What are the possible causes and treatments for itching on the penis?

Penile Itching: Causes and Treatment

For penile itching, first rule out infectious causes (candida, scabies, STIs) and inflammatory dermatoses (lichen sclerosus, psoriasis, contact dermatitis), then treat with targeted therapy based on the specific diagnosis—over-the-counter hydrocortisone 1% can provide symptomatic relief for mild irritant dermatitis while awaiting definitive diagnosis. 1

Immediate Diagnostic Priorities

Exclude Infectious Causes First

• Candida balanitis is among the most common infectious causes, particularly in uncircumcised men, presenting with erythema, white patches, and satellite lesions 2, 3
• Scabies can present as isolated genital itching with nodules on the scrotum and excoriations, even without body involvement—microscopic examination of skin scrapings is diagnostic 4
• Herpes simplex virus is the most common infectious cause of genital ulceration and may present with itching before vesicles appear 3
• HPV infection (condyloma acuminatum) typically presents with visible warts but may cause pruritus 3

Identify Inflammatory Dermatoses

• Lichen sclerosus presents as porcelain-white plaques on the glans penis, coronal sulcus, and prepuce, though itch is NOT a prominent symptom in men (unlike women) 5
• Psoriasis on the penis appears atypical without the characteristic scale due to moisture and maceration—look for psoriatic plaques elsewhere on the body 2, 3
• Contact dermatitis (allergic or irritant) may result from condoms, lubricants, soaps, or excessive hygiene ("over-treatment balanitis") 2, 3
• Lichen planus frequently involves the penis as part of generalized cutaneous disease 2, 6

Systematic Examination Approach

Key Clinical Features to Document

• Distribution: glans only, shaft, scrotum, perianal area 5
• Appearance: erythema, white patches, scaling, nodules, ulceration, vesicles 2, 3
• Associated symptoms: pain, discharge, dysuria, bleeding, foul odor 5
• Timing: constant vs. intermittent, nocturnal worsening (suggests scabies) 4
• Sexual history: new partners, condom use, partner symptoms 3
• Hygiene practices: excessive washing, new products 2, 3

Essential Investigations

• Microscopic examination of skin scrapings for scabies mites if nodules or excoriations present 4
• Fungal culture or KOH preparation if candida suspected 2, 3
• Biopsy is mandatory if lesions persist despite treatment, appear atypical, or raise concern for malignancy 5, 7
• STI screening including syphilis serology if ulceration present 7

Treatment Algorithm

For Confirmed Candida Balanitis

• Topical antifungal cream (clotrimazole, miconazole) applied twice daily for 7-14 days 3
• Address predisposing factors: diabetes control, hygiene education, consider circumcision if recurrent 3

For Confirmed Scabies

• Ivermectin 200 μg/kg orally, repeated after 2 weeks is highly effective and likely the treatment of choice 4, 3
• Treat all household contacts simultaneously 4

For Contact Dermatitis (Irritant or Allergic)

• Hydrocortisone 1% cream applied to affected area 3-4 times daily provides symptomatic relief 1
• Identify and eliminate the offending agent (soaps, lubricants, condoms) 3
• Avoid excessive washing and use gentle cleansers 2

For Lichen Sclerosus (If Confirmed by Biopsy)

• Potent topical corticosteroids are first-line treatment 5, 7
• Long-term follow-up required due to malignancy risk in adults 5

For Psoriasis

• Topical corticosteroids (moderate to potent strength) 3
• Avoid irritants and maintain good hygiene 3

Critical Red Flags Requiring Urgent Evaluation

Suspect Malignancy If:

• Persistent ulcer or plaque despite appropriate treatment 7
• Irregular borders, induration, or fungating appearance 5, 7
• Age >50 years with new lesion, especially with risk factors (phimosis, HPV, tobacco, lichen sclerosus) 5, 7
• Biopsy mandatory to exclude squamous cell carcinoma, erythroplasia of Queyrat, or Bowen's disease 3, 7

Other Urgent Concerns:

• Acute testicular pain with penile symptoms—rule out testicular torsion, epididymo-orchitis 8, 9
• Systemic symptoms (fever, weight loss, lymphadenopathy) suggest infection or malignancy 5, 9

Common Pitfalls to Avoid

• Do not assume isolated genital itching is benign—scabies can present without body involvement 4
• Do not treat empirically beyond initial therapy without tissue diagnosis if lesions persist 7
• Do not overlook excessive hygiene as a cause of irritant dermatitis 2, 3
• Do not miss lichen sclerosus in men with phimosis—30% of adult phimosis may be due to lichen sclerosus 5
• Biopsy is essential when diagnosis is uncertain or lesions fail to respond to treatment 5, 7