Treatment of Erythroplasia of the Penis (Erythroplasia of Queyrat)
For localized erythroplasia of Queyrat (EQ), topical therapies including 5-fluorouracil or imiquimod should be first-line treatment, with CO2 laser ablation as an excellent alternative offering superior cosmetic outcomes and functional preservation compared to surgical excision. 1, 2
Understanding the Disease
Erythroplasia of Queyrat is penile intraepithelial neoplasia (carcinoma in situ) presenting as a shiny erythematous plaque on the mucosal surface of the inner prepuce and/or glans penis. 1 This condition carries the highest risk among penile intraepithelial neoplasias for progression to invasive squamous cell carcinoma, with approximately 60% of penile SCCs occurring on a background of this precursor lesion. 1
Treatment Algorithm
First-Line: Topical Therapies
Topical 5-fluorouracil is an established first-line treatment:
- Apply 5% cream for 2-4 weeks 3
- Results in clinical clearance in most cases 3
- Preserves penile anatomy and sexual function 1
Topical imiquimod 5% offers excellent non-invasive results:
- Apply three times weekly for 8 weeks 4
- Achieves complete response with excellent cosmetic outcomes 4
- Treatment response can be monitored with optical coherence tomography imaging 4
- Sustained clearance documented at 1-year follow-up 4
Second-Line: Laser Ablation
CO2 laser therapy provides the best outcomes among laser modalities:
- Achieves 81.4% complete remission after single treatment session 2
- Offers excellent cosmetic and functional results 5, 2
- Recurrence rate of approximately 26% at mean 25-month follow-up 5
- Recurrences can be successfully retreated with repeat laser therapy without requiring mutilating surgery 5
- Superior to Nd:YAG laser, which shows high recurrence rates 2
Alternative: Photodynamic Therapy
PDT with aminolevulinic acid (ALA-PDT) shows moderate efficacy:
- Achieves 58.3% complete remission rates 2
- Best suited for limited disease rather than extensive lesions 6
- One patient achieved 36-month disease-free survival 6
- Offers tumor specificity and good cosmetic results 6
- Less effective for extensive disease using current treatment parameters 6
Methyl aminolevulinate PDT (MAL-PDT) demonstrates similar results:
Surgical Options
Circumcision may be appropriate:
- For persistent disease after topical therapy 3
- When phimosis complicates medical management 1
- As adjunctive therapy following topical treatment 3
Excisional surgery (partial or total penectomy) should be reserved for:
- Invasive disease with corpora cavernosa involvement 1
- Failure of organ-preserving therapies 1
- Documented progression to invasive SCC 1
Critical Clinical Pitfalls
Do not confuse EQ with bowenoid papulosis, which presents as raised papules on the penile shaft in younger sexually active men with HPV exposure and has lower malignant potential. 1, 7 EQ has the highest risk of SCC progression among penile intraepithelial neoplasias. 1
Biopsy confirmation is mandatory before initiating treatment to distinguish in situ from invasive disease. 1 Optical coherence tomography can supplement biopsy by imaging the entire lesion to confirm non-invasive disease. 4
Avoid aggressive initial surgery when organ-preserving options remain viable, as penile-sparing approaches maintain sexual function and quality of life without compromising oncologic outcomes for in situ disease. 1, 5, 2
Surveillance Requirements
Patients treated with penile-preserving therapy require intensive follow-up:
- Clinical examination every 3-6 months for the first 2-3 years 1
- Then every 6-12 months thereafter 1
- 92% of recurrences occur within 5 years of primary treatment 1
- Patient self-examination should be emphasized given recurrence patterns 5
Higher recurrence rates are associated with: