What is the treatment for pruritus (itching) on the penis?

Treatment of Penile Pruritus

For penile itching, start with topical antifungal therapy (clotrimazole or miconazole cream applied twice daily for 7-14 days) if fungal balanitis is suspected, or topical hydrocortisone 2.5% applied 3-4 times daily for inflammatory causes, while simultaneously investigating for underlying infectious, inflammatory, or systemic etiologies. 1, 2, 3

Initial Clinical Assessment

Examine the penis for specific findings that guide treatment:

• Erythematous patches with pruritus suggest fungal balanitis (most common mycotic infection of the penis, primarily Candida albicans transmitted sexually) 3
• Nodules, excoriations, or burrows indicate scabies (even isolated genital involvement without body-wide distribution) 4
• Oval-circular erythematous patches with burning pain after new medication suggest fixed drug eruption 5
• Ulcerations in immunocompromised patients warrant biopsy to exclude systemic mycosis or parasitic infection 3, 6

Rule out sexually transmitted infections, contact dermatitis from irritants, and medication-induced causes through history 1, 5

Treatment Algorithm by Etiology

Fungal Balanitis (Most Common)

Topical antifungal therapy is first-line for candidal balanitis:

• Apply clotrimazole 1% cream or miconazole 2% cream to affected area twice daily for 7-14 days 1
• Male partners of women with recurrent vulvovaginal candidiasis benefit from topical antifungal treatment to relieve balanitis symptoms 1
• Systemic treatment with fluconazole 150 mg orally is recommended for widespread dermatophytic infection or refractory candidosis 3

Inflammatory/Contact Dermatitis

Topical corticosteroids provide rapid symptom relief:

• Hydrocortisone 2.5% applied to affected area 3-4 times daily (FDA-approved for external genital itching in adults) 2, 7
• Clean area with mild soap and warm water, rinse thoroughly, and gently dry before application 2
• Avoid prolonged steroid use beyond 2 weeks to prevent skin atrophy 1

Scabies (Isolated Genital Presentation)

Ivermectin 200 μg/kg orally with repeat dose at 2 weeks treats localized scabies effectively, even in immunocompetent patients with isolated genital involvement 4

Fixed Drug Eruption

Immediate discontinuation of offending medication plus topical corticosteroids twice daily prevents generalized reactions 5

• Trimethoprim-sulfamethoxazole is a common culprit 5
• Educate patient to avoid the medication permanently 5

Adjunctive Symptomatic Therapies

For persistent pruritus despite treating underlying cause:

• Non-sedating antihistamines (fexofenadine 180 mg or loratadine 10 mg daily) provide daytime relief 8, 9
• Menthol preparations offer symptomatic relief for mild-to-moderate pruritus 8, 9, 7
• Topical doxepin limited to 8 days maximum, covering <10% body surface area, not exceeding 12g daily 8, 9

When to Investigate Further

If symptoms persist after 2 weeks of appropriate topical therapy:

• Consider skin biopsy to identify unusual fungal species (Candida glabrata, non-albicans species), systemic mycosis, or parasitic infection 1, 3, 6
• Obtain fungal culture to guide systemic antifungal selection 1, 3
• Screen for systemic causes: complete blood count, comprehensive metabolic panel, HIV serology if risk factors present 8, 7

Critical Pitfalls to Avoid

• Do not use crotamiton cream or calamine lotion (ineffective for genital pruritus) 1
• Avoid long-term sedating antihistamines except in palliative care due to dementia risk 1, 8
• Do not overlook sexual transmission: treat partners when indicated for candidal balanitis 1
• Suspect amebic ulcer in patients practicing anogenital sex with balanoposthitis resistant to antibiotics; biopsy is essential 6
• Consider immunocompromised status: nearly every fungal agent can cause penile infection in these patients, often presenting as ulceration requiring systemic therapy 3