Red Spots on the Penile Glans: Diagnosis and Management
Red spots on the glans penis require systematic evaluation to distinguish between benign conditions (pearly penile papules, physiologic variants), inflammatory dermatoses (psoriasis, lichen planus, contact dermatitis), infectious etiologies (STIs, candidiasis), and premalignant/malignant lesions (penile intraepithelial neoplasia, squamous cell carcinoma). 1, 2, 3
Initial Clinical Assessment
Examine for specific morphologic features:
- Uniform, dome-shaped papules in 1-2 rows around the corona suggest pearly penile papules, a benign variant requiring only reassurance 4
- Red, moist plaques on mucosal surfaces (glans/inner foreskin) indicate erythroplasia of Queyrat (penile intraepithelial neoplasia) 5
- Red, scaly patches on keratinized penile skin suggest Bowen's disease 5
- Smooth, shiny, red-orange solitary plaque indicates plasma cell balanitis 1
- Atrophic white patches point to lichen sclerosus 1
Diagnostic Workup Based on Presentation
For Suspected Infectious Etiology (STIs):
- Obtain Gram-stained smear of urethral exudate looking for ≥5 polymorphonuclear leukocytes per oil immersion field 5
- Perform nucleic acid amplification testing or culture for N. gonorrhoeae and C. trachomatis 5
- Order syphilis serology and offer HIV testing 5
- Examine for vesicles or ulceration suggesting herpes simplex virus 1
For Suspected Inflammatory/Neoplastic Lesions:
- Biopsy any persistent red plaque or patch before initiating treatment, as squamous cell carcinoma in situ cannot be excluded clinically despite benign appearance 5, 1
- Consider dermoscopy to aid differentiation between benign and concerning lesions 2, 3
Treatment Algorithm
Benign Variants (Pearly Penile Papules):
- Provide reassurance and education that these are normal anatomic variants with no association to STIs 4
- Reserve treatment (cryotherapy or laser) only for patients with excessive distress after counseling 4
Inflammatory Dermatoses:
- For psoriasis: Avoid typical scaling appearance expectations due to moisture and maceration in genital area; treat with low-potency topical corticosteroids 1
- For contact dermatitis: Identify and eliminate irritants (condoms, lubricants, hygiene products); manage with barrier protection and mild topical steroids 1
- For lichen sclerosus: Recognize as chronic inflammatory disease causing phimosis and meatal stenosis; requires potent topical corticosteroids and possible circumcision 1
Infectious Causes:
For genital warts (HPV 6/11):
- Consider imiquimod as first-line topical immunotherapy to induce interferon and cytokines 1
- Expect common recurrences with all treatment modalities 1
For herpes genitalis:
- Recognize as most common infectious cause of genital ulceration, often asymptomatic 1
- Initiate antiviral therapy based on clinical presentation 1
Premalignant Lesions (Penile Intraepithelial Neoplasia):
Critical distinction: Erythroplasia of Queyrat has higher malignant transformation risk than Bowen's disease 5
Risk factors to assess:
- Lack of circumcision, HPV infection, genital lichen sclerosus 5
- Consider circumcision as essential management component for most PIN cases 5
Treatment options after biopsy confirmation:
- Topical 5-fluorouracil under occlusion twice daily for 4-5 weeks achieved clearance in isolated lesions 5
- MAL-photodynamic therapy cleared 83% of patients but caused severe discomfort 5
- Surgical excision, Mohs surgery, or radiotherapy for refractory cases 5
Critical Pitfalls to Avoid
- Never assume clinical benignity excludes malignancy—biopsy persistent red plaques as lengthy misdiagnosis is common 1
- Do not overlook urethral involvement in PIN, which complicates treatment 5
- Avoid high-potency steroids chronically on genital skin, as this causes red scrotum syndrome with burning and dysesthesia 6
- Rule out testicular pathology if pain accompanies red spots, particularly testicular torsion in younger patients 5