What is the diagnosis for a cut or abrasion on the penis foreskin in the absence of phimosis?

Diagnosis of Foreskin Cut or Abrasion Without Phimosis

A cut or abrasion on the penis foreskin in the absence of phimosis is most commonly a traumatic injury from friction, zipper injury, or minor trauma, but you must rule out lichen sclerosus, which can present with fissuring and erosions even without frank phimosis. 1

Differential Diagnosis

Primary Considerations

Traumatic injury is the most likely diagnosis when phimosis is absent, including:

• Friction injuries from sexual activity or masturbation 1
• Zipper injuries 2
• Minor cuts from clothing or scratching 1

Lichen sclerosus (LS) must be excluded, as it commonly presents with fissures and erosions before phimosis develops 1. Key features include:

• Painful fissuring at the preputial opening 1
• White, atrophic patches or hyperkeratosis 1
• Ecchymosis (bruising) that may be striking 1
• Soreness rather than itch in males 1

Secondary Considerations

• Balanitis or balanoposthitis - inflammation that can cause erosions and occurs in 4-11% of uncircumcised males 2
• Contact dermatitis from irritants or allergens 1
• Genital psoriasis - can present with fissuring 1

Diagnostic Approach

Clinical Examination Features to Document

Inspect for lichen sclerosus indicators 1:

• White, scarred, or atrophic areas on the foreskin
• Hyperkeratosis with ecchymosis
• Location and pattern of fissures (perimeatal or at preputial ring suggests LS)

Assess the injury characteristics 1:

• Size, depth, and location of the cut/abrasion
• Presence of bleeding or discharge
• Signs of infection (erythema, warmth, purulent drainage)

Evaluate for complications 1:

• Ability to retract foreskin fully
• Urinary symptoms (dysuria, poor stream)
• Pain with erections or sexual activity

When to Biopsy

A biopsy is essential when 1:

• Clinical suspicion for lichen sclerosus exists (white patches, recurrent fissuring, atrophy)
• Lesions fail to heal with conservative management
• Atypical features are present that raise concern for malignancy

A biopsy is not always practical initially and treatment can be initiated based on clinical diagnosis, but histological confirmation should be obtained if the condition persists or recurs 1.

Initial Management

For Simple Traumatic Injury

Apply topical antibiotic ointment (such as bacitracin) to prevent infection and provide temporary pain relief 3.

Advise on wound care 3:

• Keep area clean and dry
• Avoid activities that caused the injury until healed
• Monitor for signs of infection

If Lichen Sclerosus is Suspected

Initiate topical corticosteroid therapy immediately while awaiting biopsy confirmation 4:

• Apply clobetasol propionate 0.05% ointment once daily for 1-3 months 4
• Use an emollient as both soap substitute and barrier preparation 4

Common Pitfalls

• Assuming all fissures are traumatic - lichen sclerosus frequently presents with fissuring before phimosis develops, and missing this diagnosis leads to progression and eventual need for circumcision 1, 4
• Failing to obtain histology - if the lesion doesn't heal or recurs, biopsy is mandatory to exclude lichen sclerosus or penile intraepithelial neoplasia 1, 4
• Overlooking early LS signs - white patches, ecchymosis, and hyperkeratosis are early indicators that require aggressive topical steroid treatment 1