What is the appropriate management of balanitis in an adult, including first‑line topical therapy and indications for systemic treatment?

Management of Balanitis in Adults

For infectious balanitis in adults, first-line treatment is topical antifungal monotherapy (miconazole 2% cream twice daily for 7 days or tioconazole 6.5% ointment as a single application) for suspected candidal infection, with systemic fluconazole 150 mg orally reserved for severe or resistant cases. 1, 2

Initial Diagnostic Approach

Key Clinical Features to Assess

• Lesion characteristics: Examine for erythematous areas with pruritus (typical of candidal balanitis), pigmentation, induration, fixation, or ulceration (concerning for malignancy or lichen sclerosus) 1, 3
• Risk factor evaluation: Document diabetes status (10.9% of men with candidal balanitis have undiagnosed diabetes), immunocompromised state, phimosis, poor hygiene, and circumcision status [1, @11@]
• Sexual history and STI screening: Obtain Gram-stained smear of urethral exudate, nucleic acid amplification tests for N. gonorrhoeae and C. trachomatis, and syphilis/HIV serology 1

When to Biopsy

• Mandatory biopsy indications: Any lesion that is pigmented, indurated, fixed, ulcerated, or fails to respond to appropriate therapy within 2 months 1, 3
• Lichen sclerosus (balanitis xerotica obliterans) requires biopsy for definitive diagnosis due to 2-9% risk of progression to squamous cell carcinoma 4, 1

First-Line Topical Therapy

Candidal Balanitis (Most Common Infectious Cause)

• Preferred regimens 1, 2:
  • Miconazole 2% cream applied twice daily for 7 days, OR
  • Tioconazole 6.5% ointment as a single application
  • Alternative: Nystatin topical daily for 7-14 days 1
• Diabetic patients: Consider longer treatment courses (7-14 days) due to compromised immune function and optimize glycemic control [1, @11@]

Lichen Sclerosus (Balanitis Xerotica Obliterans)

• Clobetasol propionate 0.05% cream or ointment applied once to twice daily for 2-3 months 1, 2
• Use emollient as soap substitute and barrier preparation 1
• For steroid-resistant hyperkeratotic areas: Intralesional triamcinolone (10-20 mg) after biopsy excludes malignancy 1
• Requires lifelong follow-up due to malignancy risk 1

Zoon's Balanitis (Balanitis Circumscripta Plasmacellularis)

• Topical mupirocin 2% ointment twice daily has shown success as monotherapy, though evidence is limited 1, 5
• Prompt response to mupirocin is highly suggestive of this diagnosis 5

Bacterial Balanitis

• Culture-directed antibiotic therapy based on sensitivity results; avoid empiric antibiotics for clinically uninfected lesions 1, 6
• Topical mupirocin may be effective for staphylococcal infections 6

Indications for Systemic Treatment

Oral Antifungal Therapy

• Fluconazole 150 mg oral tablet as a single dose for severe or resistant candidal balanitis 1
• Consider systemic therapy when topical treatment fails after 7 days or in immunocompromised patients 1, 2

Oral Antibiotics

• Reserved for culture-confirmed bacterial infections with appropriate sensitivity testing 1, 6
• Example: Ciprofloxacin for susceptible organisms like Staphylococcus haemolyticus 6

General Measures for All Types

• Proper genital hygiene: Gentle cleansing with warm water, avoiding strong soaps, keeping area dry after washing 1, 2
• Avoid irritants: Discontinue potential contact allergens and harsh cleansers 1
• Partner evaluation: Consider treating sexual partners for recurrent candidal infections 1

Follow-Up and Recurrence Management

• Initial follow-up: Return only if symptoms persist or recur within 2 months 1, 2
• Persistent symptoms despite appropriate therapy 1, 2:
  • Obtain culture to identify specific pathogens
  • Consider alternative diagnoses: psoriasis, lichen planus, contact dermatitis, STIs
  • Screen for diabetes if not already done
  • Re-evaluate for lichen sclerosus with biopsy

Common Pitfalls to Avoid

• Do not use topical steroids for infectious balanitis: Steroids suppress local immune response and may worsen fungal infections; reserve for inflammatory conditions like lichen sclerosus 2
• Do not treat clinically uninfected lesions with antibiotics: This leads to unnecessary side effects and antibiotic resistance 1
• Do not miss lichen sclerosus: This condition is underrecognized and requires biopsy for diagnosis and long-term monitoring due to malignancy risk 1, 3
• Prolonged steroid use risks: Can cause skin atrophy, adrenal suppression, and hypopigmentation, especially in children 1, 2

Surgical Considerations

• Circumcision may be considered for recurrent balanitis, confirmed lichen sclerosus (96% success rate when limited to glans and foreskin), or phimosis failing 4-6 weeks of topical betamethasone 0.05% 1, 7
• All removed tissue must be sent for histological examination to confirm diagnosis and exclude malignancy 1