What is the treatment for cracks on the glans penis?

Treatment of Cracks on the Glans Penis

The first-line treatment for cracks on the glans penis is ultrapotent topical corticosteroid ointment, specifically clobetasol propionate 0.05%, applied once nightly for 4 weeks, then on alternate nights for 4 weeks, followed by twice weekly for 4 weeks, as this condition is most commonly caused by lichen sclerosus. 1

Initial Diagnostic Considerations

Before initiating treatment, consider the following key features:

• Look for characteristic signs of lichen sclerosus: white atrophic patches, hyperkeratosis, ecchymoses (bruising), fissuring, and architectural changes of the glans 1
• Assess for scarring complications: phimosis, preputial adhesions, or meatal stenosis which may alter urinary stream 1
• Rule out malignancy: If lesions are papillary, nodular, ulcerous, or have failed to respond to corticosteroids after adequate trial, perform a punch or excisional biopsy to exclude squamous cell carcinoma or penile intraepithelial neoplasia 1

Treatment Algorithm

First-Line Medical Management

Apply clobetasol propionate 0.05% ointment using this specific regimen 1:

• Once daily at night for 4 weeks
• Alternate nights for 4 weeks
• Twice weekly for 4 weeks, then reassess

Expected outcomes: Hyperkeratosis, ecchymoses, fissuring and erosions should resolve, though atrophy and pallor may persist 1

A 30-gram tube should last at least 12 weeks if applied correctly 1

Maintenance Therapy

• If symptoms recur when reducing frequency, increase application frequency until symptoms resolve, then attempt to taper again 1
• Long-term intermittent use may be necessary for disease control 1

Treatment Failure Considerations

If cracks persist despite adequate corticosteroid therapy, systematically evaluate:

1. Compliance Issues 1

• Patients may be alarmed by package warnings against genital corticosteroid use
• Poor eyesight or limited mobility may prevent proper application
• Verify adequate amount is being applied to the correct site

2. Incorrect Diagnosis 1

• Perform biopsy if not previously done to exclude:
  • Lichen planus
  • Mucous membrane pemphigoid
  • Genital intraepithelial neoplasia
  • Vitiligo (though this causes no architectural change)

3. Malignant Transformation 1

• Lichen sclerosus carries a 4-5% risk of progression to squamous cell carcinoma 1
• Biopsy is mandatory if prominent lichenoid infiltrate develops, suggesting disease reactivation on long-standing chronic disease 1

Surgical Intervention

Surgery is indicated for complications, not for simple cracks 1:

• Persistent phimosis or preputial adhesions: Circumcision with perioperative topical steroids to prevent Koebnerization 1
• Meatal stenosis: May require meatoplasty if causing urinary obstruction 1

Management of Associated Symptoms

Dysesthesia (Burning Sensation)

• This represents neuropathic pain and will NOT respond to corticosteroids 1
• Try lidocaine 5% ointment first 1
• Progress to amitriptyline for unresponsive cases 1

Psychosexual Dysfunction

• Offer referral to specialist with expertise in sexual dysfunction, as these issues commonly persist despite successful treatment of skin lesions 1

Critical Pitfalls to Avoid

• Do not dismiss patient concerns about corticosteroid safety: Educate that genital skin tolerates potent steroids well when used appropriately 1
• Do not assume all glans lesions are benign: The 4-5% malignancy risk mandates biopsy for atypical or treatment-resistant lesions 1
• Do not treat dysesthesia with more corticosteroids: This represents nerve sensitization requiring different management 1
• Do not delay biopsy in treatment failures: Histological confirmation prevents missed diagnoses of lichen planus, pemphigoid, or malignancy 1