How should I manage a small red irritated spot just below the glans penis in a 30‑year‑old man?

Management of Small Red Irritated Spot Below the Glans Penis in a 30-Year-Old Man

The most likely diagnosis is candidal balanitis, and you should start with topical clotrimazole 1% cream or miconazole 2% cream applied to the glans 1-3 times daily for 7-14 days. 1

Immediate Red Flag Assessment

Before treating as simple balanitis, rapidly exclude emergencies:

• Rule out Fournier gangrene if the patient has fever, severe pain, skin crepitus, or rapidly spreading necrosis—this requires immediate surgical debridement and broad-spectrum antibiotics 1
• Assess for penile fracture if there was trauma during intercourse with a cracking sound, immediate detumescence, and ecchymosis—this needs urgent surgical exploration 1
• Check the urethral meatus for blood, which suggests urethral injury requiring urological evaluation 1

First-Line Treatment: Candidal Balanitis

Since this is the most common cause of localized redness and irritation in young men:

• Apply clotrimazole 1% cream or miconazole 2% cream to the affected area 1-3 times daily for 7-14 days 1, 2
• Alternative topical options include terconazole 0.4% cream for 7 days or tioconazole 6.5% ointment as a single application 1
• Consider oral fluconazole 150 mg as a single dose if the infection is more widespread or recurrent 1
• Treat sexual partners if infections recur, as partners may develop symptomatic balanitis 1

When to Suspect Bacterial Infection Instead

Switch to antibiotics if you see purulent discharge, severe inflammation, or sexually transmitted infection risk factors:

• For men under 35 years: Give ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days 1
• For men 35 years or older: Give ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1
• Obtain cultures before starting antibiotics: Gram stain of any discharge and NAAT testing for N. gonorrhoeae and C. trachomatis 1
• Reassess at 3 days: If no improvement, consider abscess requiring drainage or atypical organisms 1

Consider Lichen Sclerosus If Presentation Is Atypical

If the lesion appears as a white or grayish-white atrophic patch rather than simple erythema:

• Lichen sclerosus typically affects the glans, coronal sulcus, frenulum, and prepuce with porcelain-white plaques, though early disease may show only mild erythema 1, 3
• Itching is usually NOT prominent in lichen sclerosus, unlike fungal infections 4
• First-line treatment is clobetasol propionate 0.05% ointment applied once daily for 1-3 months, plus emollient as soap substitute 3
• Perform a biopsy if there is persistent hyperkeratosis, erosion, failure to respond to treatment, or any suspicion of malignancy 4, 3
• Long-term monitoring is mandatory every 6-12 months due to 2-9% risk of malignant transformation 4, 3

Adjunctive Measures for All Patients

• Abstain from sexual activity until treatment is completed and symptoms resolve 1
• Avoid irritants: Reduce soap washing, and review all personal products including lubricants, condoms, lotions, and hygiene sprays that may cause irritant or allergic contact dermatitis 5
• Maintain gentle hygiene: Excessive washing can worsen balanitis ("over-treatment balanitis") 6

Critical Pitfalls to Avoid

• Do not delay surgical consultation if you suspect Fournier gangrene, penile fracture, or abscess formation 1
• Do not use over-the-counter antifungal preparations indefinitely without confirming the diagnosis if symptoms persist beyond 2 months or worsen during treatment 1
• Do not forget to evaluate and treat sexual partners for sexually transmitted causes to prevent reinfection 1
• Do not miss early malignancy: Erythroplasia of Queyrat (penile carcinoma in situ) can present as a persistent erythematous patch that mimics benign inflammation—biopsy any lesion that fails to respond to standard treatment within 3-4 weeks 4, 3, 7