What is the appropriate evaluation and management of a foreskin lesion?

Evaluation and Management of Foreskin Lesions

A foreskin lesion requires immediate visual inspection with documentation of morphology, size, and location, followed by biopsy for any persistent, atypical, or suspicious lesion to exclude malignancy and confirm the diagnosis. 1

Initial Clinical Assessment

Physical Examination Priorities

• Document the exact location (prepuce, coronal sulcus, glans, shaft), morphology (papular, nodular, ulcerated, flat, white plaques, erythematous patches), size in millimeters, and number of lesions 1
• Assess foreskin retractability to determine if phimosis is present, as inability to fully examine the glans increases risk of undetected pathology by 25-60% 2
• Look for specific features including white atrophic plaques, gray-white discoloration, hyperkeratosis, erosions, fissures, ecchymosis, or verrucous changes 1
• Examine the entire genital region including meatus, shaft, scrotum, and perianal area to determine if this is an isolated lesion or part of systemic disease 2

Key Differential Diagnoses

The most common foreskin lesions fall into distinct categories:

Lichen Sclerosus (LS):

• Presents as porcelain-white plaques with atrophic, thinned skin that may have follicular dells and ecchymosis 1
• Causes phimosis in 30% of adult cases and is found in 14-100% of children with phimosis 1
• Carries a 2-9% risk of malignant transformation to squamous cell carcinoma, with some studies reporting up to 50% of penile SCC associated with LS 1, 2
• May involve the urethral meatus leading to stenosis and obstructive symptoms 1

Penile Intraepithelial Neoplasia (PeIN) / Carcinoma in Situ:

• Appears as persistent erythematous patches or hyperkeratotic areas that do not heal 1
• May be HPV-related (50% of cases, especially HPV 16) or non-HPV-related 1
• Can progress to invasive carcinoma in 2.6-13% despite treatment 1

Inflammatory Dermatoses:

• Psoriasis presents with well-demarcated erythematous plaques but typically lacks the silvery scale seen elsewhere due to moisture 3
• Zoon balanitis shows smooth, shiny, red-orange plaques and occurs exclusively in uncircumcised men 3

Biopsy Indications (Mandatory)

Perform biopsy immediately if: 1

• Any persistent hyperkeratosis, erosion, or erythema that does not resolve
• Atypical features or diagnostic uncertainty
• Failure to respond to adequate treatment (4-6 weeks for inflammatory conditions)
• New warty or papular lesions in a patient with known LS
• Any suspicion of neoplastic change
• Before initiating nonsurgical treatment (topical agents, laser, radiotherapy)
• Pigmented areas to exclude melanocytic proliferation

The biopsy provides histological confirmation and rules out coexistent malignancy, which is critical because clinical appearance alone is insufficient for diagnosis 1

Management Based on Diagnosis

For Lichen Sclerosus

First-line treatment: 4

• Clobetasol propionate 0.05% ointment applied once daily for 1-3 months to affected foreskin and tight preputial ring
• Add emollient as soap substitute and barrier preparation
• Expect 60% complete symptom resolution with disappearance of hyperkeratosis, fissuring, and erosions (though pallor and scarring may persist)

Follow-up and maintenance: 4

• Reassess at 3 months after initial treatment course
• If symptoms recur when reducing frequency, increase application until resolution, then taper cautiously
• Most patients with ongoing disease require 30-60g annually for maintenance
• Long-term ultrapotent steroid use is safe without evidence of significant steroid damage 4

Surgical intervention: 4

• Reserve circumcision for cases with no response after adequate 1-3 month trial of topical steroids
• Always send excised foreskin for histological examination to exclude penile intraepithelial neoplasia
• Continue topical clobetasol post-operatively to prevent Koebnerization (disease reactivation from surgical trauma)

Surveillance: 2, 5

• Lifelong monitoring every 6-12 months even when asymptomatic due to malignancy risk
• Biopsy any new suspicious areas immediately

For Penile Intraepithelial Neoplasia (Tis, Ta)

Penile-preserving options: 1

• Topical imiquimod 5% or 5-fluorouracil cream (response rates 40-100% for imiquimod, 48-74% for 5-FU; recurrence rates 20% and 11% respectively)
• Wide local excision (including Mohs surgery) provides advantage of complete histopathological staging and detects areas of invasion (up to 20% harbor invasive disease)
• CO2 or Nd:YAG laser ablation (response rates 52-100%, recurrence 7-48%)
• Complete glansectomy for extensive disease

Critical caveat: Treatment effects must be clinically assessed and biopsied if doubt exists, as insufficient responses and recurrences may signify underlying invasive disease 1

Surveillance: 1

• Clinical exam every 3 months for first 2 years
• Every 6 months for next 3 years
• Every 12 months thereafter

For Invasive Penile Cancer (T1 or higher)

Immediate referral to urologic oncology for staging and treatment planning 1

• Perform MRI of penis if uncertainty regarding corporal invasion or feasibility of organ-sparing surgery
• Inguinal ultrasound with fine-needle aspiration of sonographically abnormal nodes if surgical staging planned
• Dynamic sentinel node biopsy or inguinal lymph node dissection for T1b or higher disease

Common Pitfalls to Avoid

• Never diagnose LS on clinical grounds alone without biopsy when there is any diagnostic uncertainty or atypical features 1
• Do not dismiss white plaques as benign without histological confirmation, as pseudohyperplastic SCC frequently originates in LS fields 1
• Avoid referring for circumcision without adequate trial of topical steroids (1-3 months for adults, 4-6 weeks for children) 4
• Do not assume circumcision cures LS, as 50% of men continue to have lesions post-circumcision and require ongoing topical therapy 1, 4
• Never ignore patient concerns about package insert warnings against anogenital corticosteroid use; provide proper education that appropriately dosed long-term use is safe 4
• Ensure adequate medication amount is applied to the correct site, as obesity or severe phimosis may make application difficult 4

Special Populations

Children: 1

• Ecchymosis may be striking and potentially mistaken for sexual abuse, though LS confirmation does not exclude coincident abuse
• Biopsy is not always practical; initiate treatment without histological confirmation if clinical features are typical
• Use betamethasone 0.05% twice daily for 4-6 weeks (80-90% achieve normal retractability)
• For confirmed or suspected LS in children, use ultrapotent clobetasol 0.05% as medium-potency steroids are insufficient 4

Uncircumcised men: 1, 6

• Age-adjusted odds ratio for all penile skin diseases is 3.24 times higher with presence of foreskin
• LS, penile SCC, and HPV are all more common in uncircumcised men
• Circumcision protects against inflammatory dermatoses, possibly by preventing Koebnerization or reducing infectious agents