What treatment is recommended for inflammation of the foreskin (prepuce) of the penis?

Treatment of Foreskin Inflammation (Posthitis/Balanitis)

For inflammation of the foreskin, apply clobetasol propionate 0.05% ointment once daily at night for 4 weeks, then alternate nights for 4 weeks, then twice weekly for 4 weeks before reassessment. 1

Initial Assessment and Etiology

Before initiating treatment, determine whether the inflammation is:

• Infectious (bacterial or fungal): Look for purulent discharge, fever, or signs of systemic infection 1
• Inflammatory/dermatologic: Lichen sclerosus, Zoon's balanitis, or non-specific inflammation 1, 2
• Phimosis-related: Inability to retract foreskin with chronic inflammation 1, 3

Primary Treatment: Topical Corticosteroids

The cornerstone of treatment for inflammatory foreskin conditions is ultrapotent topical corticosteroids. 1

Recommended Regimen

• Clobetasol propionate 0.05% ointment applied once daily at night for 4 weeks 1
• Then alternate nights for 4 weeks 1
• Then twice weekly for 4 weeks 1
• A 30-gram tube should last at least 12 weeks 1

Expected Outcomes

• Approximately 60% of patients achieve complete symptom remission 1
• Hyperkeratosis, ecchymoses, fissuring, and erosions should resolve 1
• Patients with ongoing disease typically require 30-60 grams annually for maintenance 1

Alternative Corticosteroid

• Mometasone furoate has also shown effectiveness if clobetasol is unavailable 1
• Betamethasone applied for 1 month achieved normal foreskin retractability in 80% of boys with phimosis 1

When Infection is Suspected

Candidal (Fungal) Balanitis

If yeast infection is suspected (white discharge, satellite lesions):

• Clotrimazole 1% cream applied twice daily for 7-14 days 1
• Miconazole 2% cream applied twice daily for 7 days 1
• Nystatin ointment applied 2-4 times daily 1

Bacterial Infection

If bacterial infection is present (purulent discharge, cellulitis):

• Mupirocin 2% ointment applied three times daily for 7-10 days 2, 4, 5
• Mupirocin is highly effective against Staphylococcus aureus and Streptococcus pyogenes, the most common bacterial pathogens 4, 5

Sexually Transmitted Infection

If urethral discharge or recent sexual exposure:

• Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days 1
• This covers both gonorrhea and chlamydia 1

Adjunctive Measures

• White soft paraffin ointment applied every 4 hours to protect inflamed tissue 1
• Gentle hygiene: Retract foreskin gently (if possible) and clean with water only 3
• Avoid irritants: No soaps, perfumed products, or harsh cleansers 6

When to Consider Circumcision

Circumcision becomes the definitive treatment when: 1, 6

• Medical therapy fails after 3 months of appropriate treatment 1
• Severe scarring or phimosis develops despite steroid therapy 1
• Recurrent infections occur (>3 episodes per year) 6
• Lichen sclerosus causes urethral involvement or severe scarring 1

Critical Pitfalls to Avoid

• Do not use testosterone cream: Despite historical use, there is no evidence base for topical testosterone in treating foreskin inflammation 1
• Do not stop steroids abruptly: Taper frequency gradually to prevent rebound inflammation 1
• Do not assume all inflammation is infectious: Most cases are inflammatory and require corticosteroids, not antibiotics 1, 6
• Do not delay treatment: Early intervention with potent topical steroids prevents progression to scarring and phimosis 1, 3

Follow-Up and Reassessment

• Reassess at 12 weeks after initiating clobetasol therapy 1
• If symptoms recur when reducing frequency, increase application frequency until resolution, then attempt to taper again 1
• Long-term maintenance with clobetasol 0.05% as needed is safe and does not increase risk of skin atrophy or malignancy with proper monitoring 1