List of Abbreviations
HIV - human immunodeficiency virus
HPV — human papillomavirus
HSV — herpes simplex virus
DNA - deoxyribonucleic acid
STI — sexually transmitted infection
ELISA - enzyme-linked immunosorbent assay
NAAT — nucleic acid amplification tests (synonym: molecular biological studies)
ICD — International Classification of Diseases
MSM — men who have sex with men
PCR — polymerase chain reaction
RCT — randomized controlled trial
RNA - ribonucleic acid
GCs – glucocorticoids
PMNL — polymorphonuclear leukocytes
** — drug is included in the VLDV list (Vital and Essential Drugs)
# — off-label (prescription of a drug outside of approved indications)
Terms and Definitions
Balanitis is inflammation of the skin of the glans penis, and posthitis is inflammation of the skin of the prepuce (when present); they usually coexist, which is defined by the term balanoposthitis.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Inflammatory, atrophic, or traumatic lesions of the glans penis and prepuce are frequently a consequence of genitourinary infections and, in 15–20% of cases, are a manifestation of systemic skin disorders such as psoriasis, lichen planus, Behçet's disease, erythroplasia of Queyrat, xerotic obliterans balanoposthitis, Zoon's plasma cell balanitis, and others [1].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The skin of the glans penis and prepuce is susceptible to various adverse mechanical and chemical impacts, as well as the influence of a number of infectious agents.
Of great importance in the development of balanoposthitis are the anatomical and physiological features of the structure of the male reproductive system, among which the function of the preputial sac stands out; due to a number of physiological reasons, it creates favorable conditions for the accumulation of smegma and contamination by aerobic and anaerobic microorganisms and viruses [1, 2, 3].
Inadequate hygiene is the most common cause of balanoposthitis. At the same time, excessive and frequent hygienic cleansing of the preputial area using antiseptic agents may contribute to the realization of pathogenic properties by opportunistic microflora and/or contamination by pathogenic microorganisms, leading to the development of an inflammatory process.
Most experts distinguish between primary and secondary balanoposthitis.
Primary balanoposthitis includes acute or allergic contact dermatitis, the development factors of which may include various locally acting medications or a reaction to the vaginal exudate of sexual partners during unprotected sex.
Activation of the aforementioned factors may occur in the presence of phimosis, a redundant prepuce, non-compliance with personal hygiene rules, as well as in patients with endocrine disorders (diabetes mellitus, myxedema, etc.).
Secondary balanoposthitis develops as a result of exposure of the prepuce and glans penis to infected urethral discharge or high-glucose urine in patients with diabetes mellitus, as well as poor personal and sexual hygiene [4, 5, 6].
Involvement of the skin of the prepuce and glans penis may be observed in various systemic skin diseases: erythroplasia of Queyrat, Zoon's plasma cell balanitis, and balanitis xerotica obliterans [7].
Among the main bacterial agents causing balanoposthitis, sexually transmitted infection (STI) pathogens are primarily distinguished, such as: Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis. In this case, balanoposthitis typically presents with urethritis caused by the listed pathogens.
Human papillomaviruses (HPVs) are a frequent etiological agent of balanoposthitis. Human papillomavirus infection is most commonly registered in unvaccinated young individuals, with the morbidity rate progressively increasing, especially among men who have sex with men. Importantly, HPV is an independent factor in the oncogenic transformation of balanoposthitis [8].
A frequent cause of balanoposthitis is herpes simplex virus types 1 and 2 (HSV-1,2) [9, 10].
Among infectious agents causing balanoposthitis that belong to the opportunistic microbiota, the following are distinguished:
fungi of the genus Candida – typical for balanoposthitis in individuals with diabetes mellitus, metabolic syndrome, and insulin resistance. Type 2 diabetes mellitus often manifests as candidal balanoposthitis, which is an indication for an endocrinological evaluation [3, 6];
aerobic and anaerobic bacteria, such as Staphylococcus aureus, Streptococcus Group A, and bacteria associated with bacterial vaginosis (Gardnerella vaginalis, Atopobium vaginae, etc.) [11–13].
1.3 Epidemiology of the Disease or Condition
Balanoposthitis is a widespread disease in men of any age group. Its lifetime prevalence is estimated to range between 12–20% of the male population [14].
Men with diabetes mellitus are at the highest risk for balanoposthitis, with 35% of them experiencing balanoposthitis [3, 15, 16].
A recent meta-analysis showed that circumcision can reduce the incidence of inflammatory diseases of the glans penis by 68% [17].
1.4 Features of Coding the Disease or Condition
According to the International Statistical Classification of Diseases and Related Health Problems Tenth Revision (ICD-10), the codes are:
N48.1 Balanoposthitis;
N51.2 Balanitis.
1.5 Classification of the disease or condition
Currently, a classification of balanoposthitis has been proposed, distinguishing between balanoposthitis caused by infectious agents and balanoposthitis as a manifestation of non-infectious etiology disorders (Table 1) [1, 3, 4, 11]. In the latter case, various precancerous conditions may also be accompanied by manifestations of balanoposthitis.
Table 1
Balanoposthitis caused by infectious agents | Balanoposthitis as a manifestation of non-infectious dermatoses | Balanoposthitis as a manifestation of precancerous conditions |
|---|---|---|
Neisseria gonorrhoae Chlamydia trachomatis Mycoplasma genitalium Trichomonas vaginalis Treponema pallidum Haemophilus ducreyi Fungi of the genus Candida spp. Streptococci Staphylococci Herpes simplex virus Human papillomavirus Bacteria associated with bacterial vaginosis: Gardnerella vaginalis, Atopobium vaginae, and other anaerobes | Lichen sclerosus et atrophicus Lichen planus Psoriasis Circinate balanitis* Zoon's balanitis Eczema Allergic reactions | Bowen's disease Bowenoid papulosis Erythroplasia of Queyrat |
* an association with chlamydial infection is hypothesized
1.6 Clinical presentation of the disease or condition
1.6 Clinical picture of the disease or condition (group of diseases or conditions) [1, 3, 4, 8–11, 18].
Subjective symptoms of balanoposthitis (complaints):
itching, burning of the skin of the glans penis and/or prepuce;
rash, plaque on the skin of the glans penis and/or prepuce;
Objective symptoms of balanoposthitis (on clinical/physical examination):
Plates/deposits (discharge)
Hyperemia and/igin edema
Erosive and/or ulcerative elements, fissures
Papules and/or pustules
Macro- or micro-lamellar desquamation
Unpleasant odor
Indirect signs of balanoposthitis:
Traces of discharge on underwear
Clinical characteristics of infectious balanoposthitis
Balanoposthitis caused by STI pathogens such as: N. gonorrhoeae, C. trachomatis, M. genitalium, T. vaginalis, typically presents in association with urethritis because the inflammatory process in the urethra spreads to the glans penis and prepuce. Urethral discharge, dysuria, and other urethral symptoms are frequently accompanied by inflammatory foci on the skin of the glans penis and the inner leaf of the prepuce.
Candidal balanoposthitis, caused by yeast-like fungi of the genus Candida spp., is characterized by itching, burning of the skin of the glans penis and prepuce, and the appearance of "cheesy" plaques or discharge from the preputial sac, the nature of which can vary from whitish mucous to purulent. Inflammatory elements may present as erythematous foci on the glans penis and the inner leaf of the prepuce, pustules, and erosions accompanied by soreness. Dry, dull red foci with a macerated surface may be present.
Aerobic balanoposthitis, caused by Streptococcus Group A, Staphylococcus aureus, and certain microorganisms of the family Enterobacteriaceae (E. coli), has a wide spectrum of manifestations: from mild erythema and edema of the skin of the glans penis and prepuce to acute clinical forms of the inflammatory process (fissure formation and pronounced edema).
Anaerobic balanoposthitis is caused by G. vaginalis, A. vaginae, Bacteroides spp., Fusobacterium spp., and certain other anaerobic microorganisms, usually associated with bacterial vaginosis (when present in female sexual partners of men with balanoposthitis). The disease manifests with foul-smelling discharge, edema, hyperemia of the glans penis and prepuce, superficial erosions, and often inguinal lymphadenitis.
Balanoposthitis in anogenital herpes infection (Herpes simplex virus) is characterized by the sequential appearance of a hyperemic focus, grouped vesicles, and subsequent erosion. The lesions have polycyclic outlines. Merging, erosions can form extensive defects with a weeping or crust-covered surface. Necrosis and ulcers occasionally form. The lesions resolve spontaneously within 2–4 weeks, leaving post-eruptive hypo- or hyperpigmented spots. The rashes may encircle the penis. Regional lymphadenitis may appear with enlargement (usually unilateral) of the inguinal lymph nodes. Anogenital localization of herpes infection manifestations in men: glans penis, shaft of the penis, corona glandis, prepuce, scrotum, thighs, buttocks.
Balanoposthitis in infection caused by human papillomavirus (Human papillomavirus, HPV) is characterized by the development of an inflammatory reaction against the background of genital warts, which are exophytic growths, most often pink or skin-colored. Typical localizations of HPV infection manifestations in men: frenulum of the penis, glans penis, corona glandis of the penis, prepuce, external urethral meatus, urethra.
Balanoposthitis in syphilis (Treponema pallidum) is characterized by the appearance of a painless erosive and ulcerative defect on the penis. In the secondary period of syphilis, roseolous-papular rashes are possible, as well as the appearance of broad condylomas. The disease is accompanied by enlargement of the inguinal lymph nodes, sometimes painful.
Balanoposthitis in chancroid (caused by Haemophilus ducreyi infection) is characterized by the appearance of a small inflammatory papule or pustule on the penis. Subsequently, a painful ulcer of irregular rounded shape forms at the site of destruction of the primary element. In balanoposthitis, the ulcer is localized on the inner layer of the prepuce, corona glandis, and glans penis. The development of painful inguinal lymphadenitis is possible, most often unilateral within 1–2 weeks of the disease. The presence of a painful ulcer and painful inguinal lymph nodes, the absence of T. pallidum upon dark-field microscopy, and negative results of serological tests for syphilis (at least 14 days after the formation of ulcerative defects) is a pathognomonic syndrome of chancroid.
Balanoposthitis in lymphogranuloma venereum (chlamydial), the causative agent of which is Chlamydia trachomatis serotypes L1, L2, L2a, L3, manifests as single or multiple grouped primary elements (papules, vesicles, superficial pustules) on the skin and/or mucous membrane at the site of invasion of the pathogen: glans and shaft of the penis, prepuce, corona glandis. The incubation period averages from 3 to 14 days (may last up to 1–2 months or more).
Circinate balanitis (circumferential inflammation of the glans penis) can be either a manifestation of a chlamydial infection or an independent disease. Clinical symptoms can appear isolated or simultaneously with other manifestations of a systemic disease: skin rashes, reactive arthritis, damage to ocular structures. Typical rashes are represented by grayish-white foci on the glans penis, tending to merge with the formation of "geographic map"-like elements with a white border.
Balanoposthitis in scabies is characterized by pruritus in the affected area, usually worsening towards evening or at night during sleep. The intensity of the rash varies from their absence to universal erythroderma. Painfulness of the rashes is characteristic of bacterial complications of scabies. Upon examination, rashes caused by the life activity of mites are detected: scabies burrows (straight or tortuous, grayish or skin-colored, slightly convex strips 0.5–1 cm long). At the blind end of the burrow, there is a small vesicle or papule. Localization of rashes on the genitalia in men: glans penis, prepuce, scrotum.
To verify infectious balanoposthitis, attention should be paid to other localizations of rashes on smooth skin and mucous membranes.
Clinical characteristics of balanoposthitis in non-infectious diseases
Psoriasis, lichen planus, lichen sclerosus, eczema localized on the penis have rather similar clinical manifestations to those on smooth skin. It is known that in 3–7% of psoriasis cases, genital localization is the only manifestation of this disease [18]. Cases of isolated penile skin lesions in lichen planus have also been described.
Nonspecific balanoposthitis. It is a chronic idiopathic disease with periods of remission and exacerbation, during which a long persistent course is possible. The disease is not associated with a specific dermatosis or infectious agent. It is characterized by a poor response to topical and oral therapy. The diagnosis is presumptive after the failure of treatment with topical glucocorticoids, antibiotics, and antimicrobial agents used in dermatology, as well as antifungal agents used in dermatology. Pathomorphological examination reveals nonspecific inflammation.
Balanoposthitis in lichen sclerosus manifests as rashes in the form of shiny, ivory or milky-white plaques on the glans penis, without signs of induration, but with phenomena of atrophy. The prepuce is often involved in the pathological process. Vesicles with hemorrhagic contents may also be noted, rarely bullae, erosions, ulcers. The prepuce may be narrowed (up to phimosis), and the external urethral meatus may also be narrowed.
Balanoposthitis in fixed drug eruption is a skin reaction to the intake of medications or the use of topical preparations, appearing on the same skin area. The etiology of fixed drug eruption is associated with the systemic use of such drugs as tetracyclines, metronidazole**, sulfonamides, etc. Topical preparations capable of causing fixed drug eruption include substances such as ethanol**, concentrated potassium permanganate solution**, antiseptics and disinfectants (topical agents for STI prevention) and/or topical contraceptives. A thorough history regarding medications taken, as well as information on previous allergic reactions, is necessary. This disease is characterized by a purple-pink shade of the spots. Zonation of the lesion coloring may occur ("target sign", as in erythema multiforme exudativum).
Rashes may vary, however, they are most often represented by erythematous elements with clear boundaries. Bullous rashes with the subsequent formation of erosions and/or ulcers may also be noted.
Allergic balanoposthitis may be associated with prior atopy or contact with various substances (spermicidal lubricant, intimate hygiene product, detergents, etc.). Of particular importance is allergy to condom latex. Rashes can be extremely diverse: from small erythematous foci to marked edema of the penile skin.
Balanoposthitis in lichen planus is characterized by polygonal, congestive red papules having a characteristic smooth surface that is shiny under lateral lighting and a slight ("umbilicated") depression in the center, localized on the glans penis or prepuce, accompanied by complaints of itching and unpleasant sensations. This is an inflammatory immunopathological disease with manifestations on the skin and mucous membranes of the genitalia and oral cavity. Etiology is unknown. Lichen planus on the genitalia and mucous membranes is a chronic disease with periods of remission and exacerbation, whereas on smooth skin, spontaneous remission is sometimes observed after 12–18 months.
The diagnosis is verified based on the clinical picture. Occasionally, a pathomorphological examination of a biopsy specimen is required, in which acanthosis and a lymphocytic infiltrate in the dermis are found.
Bowen's disease is characterized by a solitary, slowly progressive plaque of the glans penis with clear boundaries. Mild infiltration of the plaque is noted, with slight peeling, scales, and/or crusts determined on its surface. The surface of the plaque may be uneven, granular. Yellow or white scales are removed quite easily, exposing a weeping surface beneath them. The diameter of the lesions varies from a few millimeters to ten centimeters or more.
Erythroplasia of Queyrat. Typical lesions present as vivid red patches with a velvety surface and distinct borders, localized on the glans penis. Upon maceration, slightly raised whitish areas may be noted. The presence of induration in these areas strongly suggests squamous cell carcinoma. In invasive growth of erythroplasia of Queyrat, a soft-consistency nodule appears, covered with crusts and bleeding upon slight contact.
Zoon's plasma cell balanitis is characterized by the presence of erythematous, painless, orange-red plaques on the glans penis with distinct borders, polycyclic outlines, a shiny surface, and multiple bright red tiny dots on the surface resembling "cayenne pepper grains".
Complications of balanoposthitis
Phimosis (pathological) – a condition in which uncovering the glans penis is impossible or difficult due to narrowing of the foreskin. Recurrent courses of balanoposthitis can lead to cicatricial-sclerotic changes in the inner leaf of the foreskin (preputial sac) with the formation of phimosis.
Paraphimosis – entrapment of the glans penis by the ring of a narrowed foreskin that has retracted behind the glans.
It is necessary to differentiate between pathological and physiological types of phimosis. At birth, a child's foreskin is typically tightly adhered to the glans penis. In this case, physiological phimosis may develop or restriction of foreskin retraction occurs. Physiological phimosis in primary school boys is observed in 17%, while in high school students its prevalence decreases to 1.2% [19].
Pathological phimosis is a condition developing in adult males in which it is impossible to uncover the glans penis due to narrowing of the distal part of the foreskin or cicatricial changes.
It should be borne in mind that with inadequate genital hygiene, smegma may accumulate: the physiological secretion of the skin glands of the preputial sac, most often whitish-yellowish in color and of a cheesy consistency.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnostic criteria.
The diagnosis of balanoposthitis/balanitis is based on the analysis of the disease history and the results of clinical and laboratory tests.
When studying the history, it is important to determine the risk of sexually transmitted infections (STIs), and the presence or absence of urethritis. Risk is determined by age, number of sexual partners, practices of sexual relations with men, as well as the use or non-use of condoms during various types of sexual contact. When using condoms, a reaction to latex is possible.
To determine the etiology of balanoposthitis, biological material is obtained from the urethra, from the skin of the glans penis, and the preputial sac.
In all cases of candidal balanoposthitis, an examination is performed to rule out diabetes mellitus.
Given that balanoposthitis often occurs against the background of urethritis, it is necessary to examine biological material from the urethra (and from extragenital sites according to indications) for STIs (N. gonorrhoeae, C. trachomatis, M. genitalium, T. vaginalis).
In the presence of erosive and ulcerative elements, it is necessary to examine biomaterial to rule out HSV types 1 and 2, and HPV using molecular biological laboratory diagnostic methods (NAAT).
To rule out syphilis, dark-field microscopy or NAAT for the detection of Treponema pallidum is used. Serological testing for syphilis is performed with a repeat in 3 weeks if the initial result is negative, due to the possibility of a seronegative period in primary syphilis.
To rule out candidal balanoposthitis, laboratory testing for fungi of the genus Candida is carried out using microscopic, bacteriological, or molecular biological methods (NAAT), preferably with identification of the fungal species and determination of the pathogen's bacterial load.
To rule out balanoposthitis caused by aerobic or anaerobic bacteria, bacteriological or molecular biological testing (NAAT) for the corresponding groups of microorganisms is performed (preferably with determination of the pathogen's bacterial load).
In cases of prolonged, recurrent balanoposthitis of unclear etiology, a biopsy followed by pathomorphological examination may be required to rule out oncological transformation.
Indications for laboratory testing.
Subjective symptoms of balanoposthitis (complaints);
Clinical symptoms of balanoposthitis.
2.1 Complaints and Anamnesis
It is recommended that at the initial appointment, the physician ascertains from a patient suspected of having balanoposthitis/balanitis the reason for seeking care and the nature of subjective symptoms (patient complaints) [1,3,20].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comment: it is also ascertained when the symptoms of the disease appeared, the dynamics of the pathological process development, the use of systemic and/or local medications for symptoms and in connection with intercurrent diseases, the presence and nature of symptoms in the sexual partner; life history: social status, occupational hazards, somatic diseases, allergological history, alcohol consumption, drug use, smoking; sexual history: sexual orientation, age of sexual debut, marital status, presence/absence of a regular sexual partner, nature of sexual contacts – vaginal, oral, anal, date of last sexual contact; STI history: history of STIs, STI history in the sexual partner; urological history: past urological diseases, sexual dysfunction, infertility; presence of STI risk factors: age under 25, presence of multiple sexual partners and/or casual sexual contacts without barrier protection, urogenital infections in sexual partners, sexual assault, commercial sex work, homosexuality, drug use, alcohol abuse, homelessness [1,3,20].
2.2 Physical Examination
It is recommended to perform a physical examination of a patient suspected of having balanoposthitis/balanitis [3,19,21].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comment: examination of the skin of the head, torso, upper and lower extremities, skin appendages, visible mucous membranes, palpation of regional lymph nodes, abdominal palpation; palpation of the scrotum and penis, digital rectal examination of the prostate gland and seminal vesicles; examination of the skin through glass under pressure (diascopy) – in the presence of erythematous lesions.
2.3 Laboratory Diagnostics
Biological, chemical, and alimentary provocations are not used to increase the diagnostic accuracy of STIs.
It is recommended that patients with subjective and/or objective symptoms of balanoposthitis, when an infectious etiology of the disease is suspected, undergo microscopic examination of foreskin secretions to detect Treponema pallidum using dark-field microscopy of native material, Candida fungi, T. vaginalis, determine bacterial morphotypes, and assess the severity of the inflammatory process (number of PMNs) [1,4,18].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: patient preparation for microscopy is described in the clinical guidelines «Syphilis» and «Urogenital Candidiasis». If scabies is suspected, pathogen detection is also possible via microscopic examination of a skin scraping for mites.
It is recommended that patients with subjective and/or objective symptoms of balanoposthitis undergo molecular biological testing of urethral discharge for STI pathogens (Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis) to verify the pathogens [11,20].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: compliance with the conditions and timelines for the logistics of transport media with biological material is required.
It is recommended that patients with subjective and/or objective symptoms of balanoposthitis and the presence of STI risk factors, when molecular biological laboratory diagnostic methods cannot be used, undergo microbiological (culture) testing of urethral discharge for Trichomonas vaginalis (Trichomonas vaginalis); microbiological (culture) testing of urethral discharge for gonococcus (Neisseria gonorrhoeae) to verify the pathogens [22-24].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
Comments: culture testing for Neisseria gonorrhoeae and Trichomonas vaginalis is performed when molecular biological tests are unavailable.
It is recommended that patients with subjective and/or objective symptoms of balanoposthitis determine management tactics [1,3,11,20]:
1) molecular biological testing of urethral discharge for herpes simplex virus types 1 and 2 (Herpes simplex virus types 1, 2) and/or detection of herpes simplex virus types 1 and 2 DNA (Herpes simplex virus types 1, 2) in vesicular fluid or lesion scrapings by PCR;
2) molecular biological testing of biological material from the urethra for human papillomavirus (Papilloma virus);
3) laboratory testing using microbiological (culture) examination of skin scrapings for fungi (yeasts, molds, dermatophytes) or molecular biological testing of urethral discharge for Candida spp. fungi, preferably with species identification and quantitative assessment of the causative agents.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: upon verification of the diagnosis of papillomavirus infection or genital herpes, further management of patients is carried out in accordance with the relevant clinical guidelines. Determining the Candida species composition is especially important in cases of standard therapy failure.
It is recommended that patients with balanoposthitis undergo a microbiological (culture) examination of biological material from the skin of the glans penis and prepuce to determine aerobic and anaerobic bacterial microflora and assess antimicrobial drug susceptibility [1,20,25].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
Comments: external genitalia hygiene should not be performed immediately prior to collecting material from the glans penis and prepuce.
It is recommended that patients with balanoposthitis and confirmed STIs be screened for syphilis, HIV, and viral hepatitis B and C [3,18,20,26]:
1) detection of antibodies to Treponema pallidum in blood using enzyme-linked immunosorbent assay (ELISA) and non-treponemal tests (RPR, VDRL) (qualitative and semi-quantitative assay) in blood serum;
2) detection of class M and G antibodies (IgM, IgG) to human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) in blood; detection of class M and G antibodies (IgM, IgG) to human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in blood;
3) detection of hepatitis B virus surface antigen (HBsAg) (Hepatitis B virus) in blood and detection of hepatitis C virus antigen (Hepatitis C virus) in blood.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
2.4 Instrumental Diagnostics
It is recommended in selected cases, for the purpose of differential diagnosis of genital dermatoses, that patients undergo magnified skin examination (dermoscopy) [27].
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
It is recommended for the differential diagnosis of genital dermatoses in patients, as well as for the verification of precancerous conditions of the penis, to perform a pathomorphological examination of skin biopsy (surgical) material [28].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
2.5 Other Procedures
It is recommended that patients, when indicated, have an initial consultation (examination) with a urologist to verify complications and determine further management tactics [1,20,29].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: consultation with a urologist is necessary in the presence of symptoms of phimosis, paraphimosis, or urinary tract infection to clarify the diagnosis and patient management strategy.
It is recommended that patients, when indicated, have an initial consultation (examination) with a dermatovenerologist to verify genital dermatoses and STIs and determine further patient management tactics; and an initial consultation (examination) with an endocrinologist to verify endocrine disorders and determine further management tactics [1,19,29].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: suspected STI is an indication for an initial consultation (examination) with a dermatovenerologist.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
General recommendations for the treatment of balanoposthitis
Contact with soap, shower gel, shampoo, and other detergents should be avoided [5].
If there is a history of allergic reaction to latex, contact with latex products should be avoided [30].
Regardless of the initial diagnosis, the prepuce must be retracted, which leads to faster resolution of balanoposthitis clinical symptoms [1,18,29].
Balanoposthitis is frequently caused by simple intertrigo, i.e., inflammation of contacting areas of the glans penis and the inner leaf of the prepuce. In such cases, retraction of the prepuce is sufficient.
3.1 Conservative Treatment
Prior to treatment, the patient must be informed about the causes of the disease and its consequences for the health of the patient and their sexual partner(s) (see Appendix "Patient Information").
Treatment of balanoposthitis caused by an infectious agent
Treatment of balanoposthitis when STIs are identified (syphilis, gonococcal, chlamydial, trichomonal, M. genitalium infections, chancroid, HSV types 1 and 2, HPV) is carried out in accordance with the relevant clinical guidelines.
It is recommended that patients with candidal balanoposthitis use drugs of choice for the treatment of infections of the skin of the glans penis [3,20,30-33,62]:
- miconazole 2% cream, topically twice daily to the affected area for no more than 2 weeks.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
or
- natamycin 2% cream, topically 1-2 times daily to the affected area for 7 days
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
or
- clotrimazole 1% cream.
GPR BLEL 2Grade of Recommendation B (Level of Evidence 2)
Comment: topically 2-3 times daily to the affected area for no more than 2 weeks.
Alternative therapy
- fluconazole** 150 mg once orally.
GPR BLEL 2Grade of Recommendation B (Level of Evidence 2)
or
- nystatin ointment 100,000 IU/g 2 times daily to the affected area for 7 to 28 days.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: oral treatment regimens (fluconazole**) are prescribed for pronounced symptoms or in patients with diabetes mellitus. Nystatin ointment is prescribed in case of intolerance (inefficacy) of imidazole and triazole derivatives or when non-albicans Candida species are detected.
It is recommended that patients for the treatment of aerobic balanoposthitis [1,3,11,25]
- systemic antibacterial drugs in therapeutic doses depending on the sensitivity of isolated microorganisms.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: systemic antibacterial drugs are indicated for moderate to severe aerobic balanoposthitis.
Alternative therapy (ointment applied to the skin of the glans penis) [11,25,35]:
Mupirocin 2% ointment 2-3 times a day, topically for up to 10 days.
Corticosteroids combined with antibiotics.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: topical treatment should be used primarily; however, in acute inflammation, systemic antibacterial drugs may be prescribed. In mild cases, single-ingredient preparations can be used. Corticosteroids combined with antibiotics are used for mixed bacterial-fungal infections. If treatment is ineffective or balanoposthitis constantly relapses after short-term improvement, an initial consultation (examination) with a urologist is necessary to decide on surgical treatment — circumcision (circumcisio).
It is recommended that patients for the treatment of anaerobic balanoposthitis [11]:
#Metronidazole** 400–500 mg twice daily for 7 days.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Alternative therapy:
- Amoxicillin + clavulanic acid** 375 mg orally 3 times daily for 7 days.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: #Metronidazole** is ineffective when Atopobium vaginae is detected [36]. There is evidence regarding the efficacy of clindamycin** (orally) in average therapeutic doses [37]. If treatment is ineffective or balanoposthitis constantly relapses after short-term improvement, an initial consultation (examination) with a urologist is recommended to decide on surgical treatment — circumcisio.
It is recommended that patients for the treatment of circinate balanoposthitis:
Moderate-potency corticosteroids (group II) topically until symptom resolution, combined with treatment of the identified infectious agent [11,37].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: the estimated duration of drug use may vary up to 14 days. If treatment is ineffective, or if balanoposthitis constantly relapses after short-term improvement, an initial consultation (examination) with a urologist is recommended to decide on surgical treatment: circumcision (circumcisio).
Treatment of non-infectious balanoposthitis
Upon verification of a skin disease manifesting as balanoposthitis, further management of the patient is carried out in accordance with the relevant clinical guidelines.
It is recommended for the treatment of patients with balanoposthitis as a manifestation of lichen sclerosus [11,37-39]:
clobetasol ointment (containing 0.05% clobetasol propionate) 2 times a day until remission is achieved, followed by a gradual taper (no more than 4 weeks).
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: after discontinuing clobetasol treatment, it is advisable to use neutral topical hygienic products to create an environmental skin barrier (emollients). Long-term intermittent therapy with clobetasol is not recommended; surgical intervention should be considered. Additional treatment for secondary bacterial or fungal infection may be required.
Alternative therapy
- non-corticosteroid dermatitis medications.
LoR CLE 3Level of Recommendation C (Level of Evidence 3)
Comments: studies have demonstrated the efficacy of topical #pimecrolimus** 2 times daily. The duration of topical therapy on the glans penis skin may vary up to 16 weeks [11,37]. Patients with a history of genital warts and genital herpes may experience disease recurrence, of which they should be warned. The possibility of secondary infection should be kept in mind. Additional treatment options are presented in the clinical guidelines for "Lichen Sclerosus et Atrophicus".
It is recommended for the treatment of patients with balanoposthitis as a manifestation of lichen planus (topical) [11,37]:
First-line therapy:
moderate-potency corticosteroids (group II), very high-potency corticosteroids (group IV).
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Alternative therapy:
non-corticosteroid dermatitis medications.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: studies have demonstrated the efficacy of topical application of #pimecrolimus** 1% and #tacrolimus** 0.1% ointment 2 times daily. Topical therapy on the glans penis skin was applied until the resolution of rashes with subsequent tapering [11,22,35,37]. The estimated duration of topical therapy may vary up to 8 weeks. If no effect is observed, an initial consultation with a urologist should be recommended to address the issue of surgical treatment — circumcision (circumcisio). Additional treatment options are presented in the clinical guidelines for "Lichen Planus".
It is recommended for the treatment of patients with balanoposthitis as a manifestation of psoriasis using topical agents [11,25]:
moderate-potency corticosteroids (group II).
Alternative therapy:
other topical antipsoriatic drugs.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: studies have shown the efficacy of topical calcipotriol with or without moderate-potency corticosteroids (group II) / very high-potency corticosteroids (group IV); treatment is continued until the resolution of rashes. Moderate-potency corticosteroids (group II) / very high-potency corticosteroids (group IV) may cause skin atrophy and superinfection [40]. A study describes that 0.1% #tacrolimus** ointment twice daily for 8 weeks and #pimecrolimus** 2 times daily for 21 days are also effective, though they should not be used as first-line therapy [41–44].
It is recommended for the treatment of patients with balanoposthitis as a manifestation of seborrheic dermatitis [11,45–48]:
topical antifungals
or
hydrocortisone and topical antifungals.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: studies have demonstrated the efficacy of topical agents containing clotrimazole and/or low-potency corticosteroids. The latter are advisable to use in the presence of inflammatory changes.
Alternative therapy:
systemic antifungals.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: studies have described the efficacy of oral therapy with #terbinafine 250 mg/day for 6 weeks; #itraconazole 200 mg orally once daily for the first week of treatment, then 200 mg orally once daily for the first two days of each treatment month, for 3 months [45–48].
It is recommended for the treatment of patients with balanoposthitis as a manifestation of Zoon's plasma cell balanitis [11,49–53,60]:
- very high-potency corticosteroids (group IV);
- combined topical preparations: corticosteroids combined with antibiotics;
- other topical antibiotics;
- non-glucocorticoid dermatitis medications.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: depending on the disease course, medications can be applied to the glans penis skin for an extended period. In case of a secondary infection, combination products are used. Studies have demonstrated the efficacy of #mupirocin 2% ointment 2 times daily for 3 months [50]. A study has demonstrated the efficacy of topical #tacrolimus** at a dose of 0.1% twice daily for 2–4 or 5 weeks, and #pimecrolimus** 1% twice daily for 2 months [51–52]. Penile biopsy should be performed in case of atypical clinical manifestations or treatment resistance. If treatment is ineffective or relapses are frequent, an initial consultation with a urologist should be recommended to address the issue of surgical treatment — circumcision (circumcisio).
It is recommended for patients for the treatment of dermatoses in the form of allergic balanitis/balanoposthitis and fixed drug eruption [11,54,55]
First-line therapy:
hydrocortisone** 1% ointment, topically, 2 times daily until complete regression of rashes.
Alternative regimens:
systemic corticosteroids may be indicated in severe cases.
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: intravenous formulations may be used: prednisolone**, methylprednisolone**, dexamethasone**, the drug dosage and duration of treatment are determined by the physician individually depending on the severity of the disease course. Discontinuation of the offending drug (substance) that caused toxicoderma is required. Emollients—water-based creams that can be used instead of soap—may be prescribed. Topical steroids for toxic-allergic balanoposthitis are used until symptoms resolve [11,55].
It is recommended for patients for the treatment of balanoposthitis as a manifestation of penile intraepithelial neoplasia, bowenoid papulosis, Bowen's disease, or erythroplasia of Queyrat [11,56–60]:
- initial consultation with an oncologist and initial consultation with a urologist to verify the diagnosis and determine appropriate management.
Basic methods:
- surgical treatment, including Mohs micrographic surgery and circumcision;
- skin cryosurgery;
- photodynamic therapy for male genital pathology;
- laser skin tissue destruction.
Topical therapy [61]:
#imiquimod 5% cream 5 days a week for 4–6 weeks.
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
Comments: for accurate diagnosis, a skin biopsy followed by pathomorphological examination of the biopsy (surgical) skin material is required. Age, comorbidities, immune system status, and the presence of human papillomavirus infection must be taken into account [60].
3.2 Surgical Treatment
It is recommended for patients, regardless of the etiological factor of balanoposthitis, in cases of ineffective conservative therapy and frequent disease relapses, as well as phimosis, paraphimosis, or associated lichen sclerosus, to undergo surgical intervention: circumcision (circumcisio) in a urology inpatient setting [11,14,17,22].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: in case of meatal stenosis (narrowing of the external urethral meatus) in lichen sclerosus, urethral meatotomy may be indicated, and if the sclerotic process involves the urethra, urethroplasty (urethral reconstruction) is indicated. Surgical treatment (excisional surgery, laser skin tissue destruction, cryosurgery) is used when precancerous conditions are verified: erythroplasia of Queyrat, Bowen's disease, Zoon's plasma cell balanitis.
3.3 Other Treatment
Not applicable.
Pain management and dietary therapy are not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable.
5. Prevention and Dispensary Observation
It is recommended in case of detected STIs that primary prevention consisting of condom use during all types of sexual contact be implemented [20,21].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments. Patients with STIs are advised to abstain from sexual contact for seven days after they and their partners complete treatment, symptoms resolve, and negative laboratory test results for STIs are obtained.
6. Organization of Medical Care
Reporting of diagnosed STI cases
The legislation of the Russian Federation defines STI reporting forms to be completed by physicians of any specialty who diagnose an STI:
Two forms of state statistical observation: No. 9 — "Data on sexually transmitted infections, fungal skin diseases, and scabies" and No. 34 — Order of Rosstat dated December 29, 2011, No. 520 (ed. dated December 24, 2018) "On the approval of statistical tools for the organization of federal statistical observation by the Ministry of Health and Social Development of Russia over the activities of healthcare institutions."
Form No. 089/u-kv — "Notification of a patient with a newly established diagnosis of syphilis, gonococcal infection, trichomoniasis, chlamydiosis, urogenital herpes, anogenital warts, microsporia, favus, trichophytosis, foot mycosis, scabies", approved by the Russian Ministry of Health dated March 2, 2015 No. 13-2/25 On accounting form N 089/u-kv "Notification of a patient with a newly established diagnosis of: syphilis, gonococcal infection, chlamydial infections, trichomoniasis, anogenital herpesviral infection, anogenital (venereal) warts, mycosis, scabies"; to be sent within a 3-day period to the territorial dermatovenereological dispensary. The territorial dermatovenereological dispensary sends the received notifications to the head dispensary of the constituent entity of the Russian Federation monthly, no later than the 5th day of the month following the expired month.
Employees of institutions receiving this information are legally responsible for ensuring information confidentiality and maintaining medical secrecy.
7. Additional Information
Requirements for obtaining biological material for laboratory testing of STIs.
To obtain reliable laboratory results, a number of requirements are observed, which include [20,63]:
timing of obtaining biological material taking into account the use of antibacterial agents: (molecular biological studies - in 3-4 weeks using PCR of urethral discharge for sexually transmitted infection pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium);
obtaining biological material from the urethra no earlier than 3 hours after the last urination; in the presence of abundant urethral discharge – 15-20 minutes after urination;
compliance with the conditions for sample delivery to the laboratory.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Level of recommendation certainty | Level of Evidence |
|---|---|---|---|
1 | Initial appointment (examination, consultation) by a urologist or dermatovenereologist performed | C | 5 |
2 | Patient underwent diagnostic laboratory tests (microscopic, molecular biological, microbiological for STI pathogens) | C | 5 |
3 | Therapy prescribed in accordance with the clinical form of balanoposthitis (in the absence of contraindications) | C | 5 |
References
Show references
Edwards S. Balanitis and balanoposthitis: a review. Genitourin Med. 1996 Jun;72(3):155-9. doi: 10.1136/sti.72.3.155. PMID: 8707315; PMCID: PMC1195642.
Vasiliev M.M., Gomberg M.A., Kovalyk V.P., Abdumalikov R.A., Belavin A.S. On the pathology of the glans penis and prepuce // STIs. 2000. No. 4.
Balanoposthitis. A guide for physicians. Edited by K.I. Zabirov. M., -2018. -200 p. Puls Medical Universal Publishing House. ISBN 978 – 5-99052-916-8
Mavrov I.I. Sexually transmitted diseases. Encyclopedic reference book. Kiev, Moscow: AST-Press, 1994. 480 p.
Schwartz R.H., Rushton H.G. Acute balanoposthitis in young boys. // Pediatr Infect Dis J. 1996. V.15. P.176-7.
Kalra S, Chawla A. Diabetes and balanoposthitis. J Pak Med Assoc. 2016 Aug;66(8):1039-41. PMID: 27524547.
Shim TN, Ali I, Muneer A, Bunker CB. Benign male genital dermatoses. BMJ. 2016 Aug 11;354:i4337. doi: 10.1136/bmj.i4337. Erratum in: BMJ. 2016 Aug 31;354:i4729. PMID: 27514401.
Wikström A, Hedblad MA, Syrjänen S. Human papillomavirus-associated balanoposthitis--a marker for penile intraepithelial neoplasia? Int J STD AIDS. 2013 Dec;24(12):938-43. doi: 10.1177/0956462413487325. Epub 2013 Jul 19. PMID: 23970611.
Parra-Sánchez M. Genital ulcers caused by herpes simplex virus. Enferm Infecc Microbiol Clin. 2019 Apr;37(4):260-264. English, Spanish. doi: 10.1016/j.eimc.2018.10.020. Epub 2018 Dec 21. PMID: 30580877.
Patel R, Kennedy OJ, Clarke E, Geretti A, Nilsen A, Lautenschlager S, Green J, Donders G, van der Meijden W, Gomberg M, Moi H, Foley E. 2017 European guidelines for the management of genital herpes. Int J STD AIDS. 2017 Dec;28(14):1366-1379. doi: 10.1177/0956462417727194. Epub 2017 Aug 24. PMID: 28836892.
Edwards SK, Bunker CB, van der Snoek EM, van der Meijden WI. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol. 2023 Jun;37(6):1104-1117. doi: 10.1111/jdv.18954. Epub 2023 Mar 21. PMID: 36942977.
Norimatsu Y, Ohno Y. Streptococcus pyogenes balanoposthitis. IDCases. 2020 May 20;21:e00832. doi: 10.1016/j.idcr.2020.e00832. PMID: 32477873; PMCID: PMC7248656.
Burdge DR, Bowie WR, Chow AW. Gardnerella vaginalis-associated balanoposthitis. Sex Transm Dis. 1986 Jul-Sep;13(3):159-62. doi: 10.1097/00007435-198607000-00009. PMID: 3490001.
Morris BJ, Krieger JN. Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision. Int J Prev Med. 2017;8:32.
Verma SB, Wollina U. Looking through the cracks of diabetic candidal balanoposthitis! Int J Gen Med. 2011;4:511-3.
Bromage SJ, Crump A, Pearce I. Phimosis as a presenting feature of diabetes. BJU Int. 2008 Feb;101(3):338-40.
Morris BJ, Krieger JN. Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision. Int J Prev Med. 2017;8:32.
Fitzpatrick's Dermatology in General Medicine. Atlas and Synopsis. Fitzpatrick T., Johnson R., Wolf K., Polano M., Suurmond D. WORD, 1248 pp., 2007.
Hsieh TF, Chang CH, Chang SS. Foreskin development before adolescence in 2149 schoolboys. Int J Urol. 2006 Jul;13(7):968-70.
Management of patients with sexually transmitted infections: a guide for physicians / edited by V.I. Kisina. M., GEOTAR-Media, 2024. – 344 p.
Garcia MR, Leslie SW, Wray AA. Sexually Transmitted Infections. 2024 Apr 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 32809643.
Perkins OS, Cortes S. Balanoposthitis. 2022 May 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 31971711.
Jegadish N, Fernandes SD, Narasimhan M, Ramachandran R. A descriptive study of the clinical and etiological profile of balanoposthitis. J Family Med Prim Care. 2021 Jun;10(6):2265-2271. doi: 10.4103/jfmpc.jfmpc_2467_20. Epub 2021 Jul 2. PMID: 34322423; PMCID: PMC8284224.
Fornasa CV, Calabrŏ A, Miglietta A, Tarantello M, Biasinutto C, Peserico A. Mild balanoposthitis. Genitourin Med. 1994 Oct;70(5):345-6. doi: 10.1136/sti.70.5.345. PMID: 8001949; PMCID: PMC1195281.
Norimatsu Y, Ohno Y. Streptococcus pyogenes balanoposthitis. IDCases. 2020 May 20;21:e00832. doi: 10.1016/j.idcr.2020.e00832. PMID: 32477873; PMCID: PMC7248656.
Kuypers J, Gaydos CA, Peeling RW. Principles of laboratory diagnosis of STIs. In: Holmes KK et al., eds. Sexually transmitted diseases, 4th ed. New York, McGraw-Hill Medical, 2008:937–958.
Campos MA, Sousa A, Lage G, Varela P, Menezes N, Tente D, Zalaudek I, Baptista A, Rocha N. Blue-gray plaque of the penis. JAAD Case Rep. 2018 Jun 4;4(6):531-533. doi: 10.1016/j.jdcr.2017.07.026. PMID: 29872668; PMCID: PMC5986158.
Dauendorffer JN, Amici JM, Renaud-Vilmer C, Cavelier-Balloy B. Comment réaliser une biopsie du pénis ? [Surgical technique: punch biopsy for evaluation of penile dermatoses]. Ann Dermatol Venereol. 2014 Apr;141(4):308-11. French. doi: 10.1016/j.annder.2014.01.017. Epub 2014 Mar 21. PMID: 24703648.
Zabirov K.I., Kisina V.I., Khodyreva L.A. et al. Clinical and diagnostic aspects of certain forms of balanoposthitis. Consilium Medicum. 2016; 18 (7): 72–77.
Heeres J, Meerpoel L, Lewi P. Conazoles. Molecules. 2010;15(6):4129-4188. Published 2010 Jun 9. doi:10.3390/molecules15064129
Masterton G, Sengupta SM, Schofield CB. Natamycin in genital candidosis in men. Br J Vener Dis. 1975 Jun;51(3):210-12. doi: 10.1136/sti.51.3.210. PMID: 1079741; PMCID: PMC1045154.
Stary A, Soeltz-Szoets J, Ziegler C, et al. Comparison of the efficacy and safety of oral flucanoazole and topical clotrimazole in patients with candidal balanitis. Genitourin Med 1996; 72: 98–102.
Gharehbolagh SA, Fallah B, Izadi A, Ardestani ZS, Malekifar P, M Borman A, Mahmoudi S. Distribution, antifungal susceptibility pattern and intra-Candida albicans species complex prevalence of Candida africana: A systematic review and meta-analysis. PLoS One. 2020 Aug 20;15(8):e0237046. doi: 10.1371/journal.pone.0237046. PMID: 32817677; PMCID: PMC7440629.
Wu M, McIntosh J, Liu J. Current prevalence rate of latex allergy: Why it remains a problem? J Occup Health. 2016 May 25;58(2):138-44. doi: 10.1539/joh.15-0275-RA. Epub 2016 Mar 24. PMID: 27010091; PMCID: PMC5356959.
Ignatovsky A.V. Balanoposthitis: classification issues, diagnostics, and therapy approaches. Medical Alphabet. 2021; (34): 39–44. https://doi.org/10.33667/2078-5631-2021-34-39-44
De Backer E, Verhelst R, Verstraelen H, Claeys G, Verschraegen G, Temmerman M, Vaneechoutte M. Antibiotic susceptibility of Atopobium vaginae. BMC Infect Dis. 2006 Mar 16;6:51. doi: 10.1186/1471-2334-6-51. PMID: 16542416; PMCID: PMC1468414.
Wray AA, Velasquez J, Khetarpal S. Balanitis. 2022 May 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30725828.
Fistarol SK, Itin PH. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol. 2013 Feb;14(1):27-47. doi: 10.1007/s40257-012-0006-4. PMID: 23329078; PMCID: PMC3691475.
Kirtschig G, Becker K, Günthert A, Jasaitiene D, Cooper S, Chi CC, Kreuter A, Rall KK, Aberer W, Riechardt S, Casabona F, Powell J, Brackenbury F, Erdmann R, Lazzeri M, Barbagli G, Wojnarowska F. Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus. J Eur Acad Dermatol Venereol. 2015 Oct;29(10):e1-43. doi: 10.1111/jdv.13136. Epub 2015 Jul 22. PMID: 26202852.
Reynolds KA, Pithadia DJ, Lee EB, Wu JJ. Treatments for inverse psoriasis: a systematic review. J Dermatolog Treat. 2020;31(8):786–93.
Meeuwis KA, de Hullu JA, Massuger LFAG, van de Kerkhof PCM, van Rossum MM. Genital psoriasis: a systematic literature review on this hidden skin disease. Acta Derm Venereol. 2011;91(1):5–11.
Dattola A, Silvestri M, Bennardo L, del Duca E, Longo C, et al. Update of calcineurin inhibitors to treat inverse psoriasis: a systematic review. Dermatol Ther. 2018;31(6):e12728.
Husein-ElAhmed H, Gieler U, Steinhoff M. Lichen planus: a comprehensive evidence-based analysis of medical treatment. J Eur Acad Dermatol Venereol. 2019;33(10):1847–62.
Ioannides D, Vakirlis E, Kemeny L, Marinovic B, Massone C, Murphy R, et al. European S1 guidelines on the management of lichen planus: a cooperation of the European Dermatology Forum with the European Academy of Dermatology and Venereology. J Eur Acad Dermatol Venereol. 2020;34(7):1403–14.
Okokon EO, Verbeek JH, Ruotsalainen JH, Ojo OA, Bakhoya VN. Topical antifungals for seborrhoeic dermatitis. Cochrane Database Syst Rev. 2015;5:CD008138.
Vena GA, Micali G, Santoianni P, Cassano N, Peruzzi E. Oral terbinafine in the treatment of multi-site seborrheic dermatitis: a multicenter, double-blind placebo-controlled study. Int J Immunopath Pharmacol. 2005;18(4):745–53.
Tucker D, Masood S. Seborrheic Dermatitis. 2024 Mar 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 31869171.
Ghodsi SZ, Abbas Z, Abedeni R. Efficacy of oral itraconazole in the treatment and relapse prevention of moderate to severe seborrheic dermatitis: a randomized, placebo-controlled trial. Am J ClinDermatol. 2015; №16 (5): 431–437.
Tang A, David N, Horton LW. Plasma cell balanitis of zoon: response to Trimovate cream. Int J STD AIDS. 2001;12:75–8
Cohen PR. Topical mupirocin 2 % ointment for diagnosis of Zoon's balanitis and monotherapy of balanitis circumscripta plasmacellularis. Int J Dermatol. 2019;58:e114–e5
Roe E, Dalmau J, Peramiquel L, Perez M, Lopex-Lozano HE, Alomar A. Plasma cell balanitis of zoon treated with topical tacrolimus 0.1%: report of three cases. J Eur Acad Dermatol Venereol. 2007;21(2):284–5.
Bardazzi F, Antonucci A, Savoia F, Balestri R. Two cases of Zoon's balanitis treated with pimecrolimus 1 % cream. Int J Dermatol. 2008;47(2):198–201.
Dayal S, Sahu P. Zoon balanitis: A comprehensive review. Indian J Sex Transm Dis AIDS. 2016 Jul-Dec;37(2):129-138. doi: 10.4103/0253-7184.192128. PMID: 27890945; PMCID: PMC5111296.
Allergodermatoses and their treatment with correction of comorbid pathology. A guide for physicians. Romanenko I.M., Kulaga V.V., Lemeshko V.A. MIA: 2023, p. 720.
Clinical Guidelines of the Russian Society of Dermatovenereologists and Cosmetologists (RDV&K). Toxicoderma. 2020.
Morton CA, Birnie AJ, Eedy DJ. British Association of Dermatologists' guidelines for the management of squamous cell carcinoma in situ (Bowen's disease) 2014. Br J Dermatol. 2014 Feb;170(2):245-60. doi: 10.1111/bjd.12766. PMID: 24313974.
Kravvas G, Ge L, Ng J, Shim TN, Doiron PR, Watchorn R et al. The management of penile intraepithelial neoplasia (PeIN): clinical and histological features and treatment of 345 patients and a review of the literature. J Dermatolog Treat. 2022;32(2):1047–62.
Alnajjar HM, Lam W, Bolgeri M, Rees RW, Perry MJ, Watkin NA. Treatment of carcinoma in situ of the glans penis with topical chemotherapy agents. Eur Urol. 2012;62(5):923–8.
Manjunath A, Brenton T, Wylie S, Corbishley CM, Watkin NA. Topical therapy for non-invasive penile cancer (tis)—updated results and toxicity. Transl Androl Urol. 2017;6(5):803–8.
Lee MA, Cohen PR. Zoon balanitis revisited: report of balanitis circumscripta plasmacellularis resolving with topical mupirocin ointment monotherapy. J Drugs Dermatol. 2017;16:285–7.
Barad P, Fernandes J, Shukla P. Bowen's disease: A favorable response to imiquimod. Indian Dermatol Online J. 2014 Oct;5(4):546-7. doi: 10.4103/2229-5178.142570. PMID: 25396164; PMCID: PMC4228676.cir
Fedotov V.P. Topical problems of candidiasis (reflections of a mycologist-dermatovenereologist – based on literature data and own research) // Dermatovenereology. Cosmetology. Sexopathology. – 2012. – Vol. 1. – P. 103-128.
Ufimtseva M.A., Vorozheikina I.N. Non-gonococcal urethritis in military personnel: methodical recommendations for physicians. – 2016.
Appendix A1. Working Group Composition
Potekaev N.N. – Doctor of Medical Sciences, Professor, President of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European Union against STIs (IUSTI/WHO), Honorary President of the Euro-Asian Association of Dermatovenereologists (EAAD), Member of the Board of Directors of the European Academy of Dermatology and Venereology (EADV), Corresponding Member of the German Dermatological Society (DDG), Honored Doctor of the Russian Federation, Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Russian Ministry of Health, Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Moscow Healthcare Department, Director of the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department, Head of the Department of Skin Diseases and Cosmetology at the Faculty of Continuing Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health.
Gomberg M.A. – Doctor of Medical Sciences, Professor, President of the Guild of Sexually Transmitted Infection Specialists "IUSTI RU", Member of the Royal College of Physicians (RCP), Member of the American Academy of Dermatology (AAD), Member of the European Academy of Dermatology and Venereology (EADV), Senior Advisor of the International Union against Sexually Transmitted Infections (IUSTI), Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Chief Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department.
Akhvlediani N.D. – Doctor of Medical Sciences, Professor of the Department of Urology at the A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, Member of the Russian Society of Urology LLC.
Gushchin A.E. – Candidate of Biological Sciences, Member of the Microbiology Committee of the Federation of Laboratory Medicine, Member of the European Union against STIs (IUSTI/WHO), Member of the Guild of Sexually Transmitted Infection Specialists "IUSTI RU", Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Leading Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department.
Dolya O.V. – Doctor of Medical Sciences, Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European Union against STIs (IUSTI/WHO), Member of the European Academy of Dermatology and Venereology (EADV), Member of the Guild of Sexually Transmitted Infection Specialists "IUSTI RU", Deputy Director for Science at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department.
Zhukova O.V. – Doctor of Medical Sciences, Professor, Executive Director of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European Union against STIs (IUSTI/WHO), Member of the Guild of Sexually Transmitted Infection Specialists "IUSTI RU", Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Central Federal District of the Russian Ministry of Health, Chief Physician of the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department, Head of the Department of Dermatovenereology and Allergology with a Course of Immunology at the Medical Institute of the Peoples' Friendship University of Russia.
Zabirov K.I. – Doctor of Medical Sciences, Professor, Honored Doctor of the Russian Federation, Member of the Russian Society of Urology LLC.
Kisina V.I. – Doctor of Medical Sciences, Professor, Honored Scientist of the Russian Federation, Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the European Union against STIs (IUSTI/WHO), Member of the Guild of Sexually Transmitted Infection Specialists "IUSTI RU", Member of the Russian Interregional Society of Evidence-Based Medicine Specialists, Member of the Interdisciplinary Association of Reproductive Medicine Specialists (MARS), Chief Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department.
Kovalyk V.P. – Doctor of Medical Sciences, Member of the European Union against STIs (IUSTI), Member of the Guild of Sexually Transmitted Infection Specialists "IUSTI RU", Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Associate Professor, Professor of the Department of Dermatovenereology and Cosmetology at the Academy of Postgraduate Education of the Federal Scientific and Clinical Center for Specialized Medical Care and Medical Technologies of the Federal Medical-Biological Agency.
Krupinov G.E. – Doctor of Medical Sciences, Professor at the Institute of Urology and Human Reproductive Health, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Member of the Russian Society of Urology LLC.
Senina M.E. – Member of the National Alliance of Dermatovenereologists and Cosmetologists LLC, Member of the Federation of Laboratory Medicine, Junior Researcher at the Moscow Scientific and Practical Center for Dermatovenereology and Cosmetology of the Moscow Healthcare Department.
Conflict of interest: none.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
1. Dermatovenereologists;
2. Urologists.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Levels of Evidence (LE) rating scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading grades of recommendation (GoR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The clinical guideline update mechanism provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
1. Order of the Russian Ministry of Health dated November 15, 2012 No. 924n "On approval of the Procedure for the provision of medical care to the population in the profile 'dermatovenereology'.
2. Order of the Russian Ministry of Health dated November 12, 2012 No. 907n "On approval of the Procedure for the provision of medical care to the adult population in the profile 'urology'.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Balanoposthitis is inflammation of the skin of the glans penis and the inner leaf of the prepuce. The most frequent cause of balanoposthitis is poor personal hygiene of the external genitalia. Predisposing factors include narrowing of the prepuce (phimosis), sexually transmitted infections (STIs), mycoses, chronic inflammatory diseases of the urogenital system (urethritis, prostatovesiculitis), and diabetes mellitus.
Disease course. Acute balanoposthitis is accompanied by pain and burning of the skin of the glans penis and the prepuce, as well as itching. In acute balanoposthitis, the prepuce and glans penis are edematous, hyperemic, and sometimes accompanied by erosive rashes, fissures, and pustular-ulcerative lesions of the prepuce and glans penis. A chronic course is characteristic of balanoposthitis developing in sexually transmitted infections (STIs), diabetes mellitus, herpes, papillomavirus infection, and mycoses.
Treatment. Treatment of balanoposthitis depends on the stage of the disease and the underlying causes. For all forms of balanoposthitis, microscopic examination of urethral and preputial sac discharge, testing for STIs, and exclusion of chronic urogenital system diseases are necessary. Therapeutic measures consist of topical agents and, less frequently, systemic medications. Treatment of chronic balanoposthitis complicated by cicatricial changes of the prepuce consists of surgical intervention: incision or circumcision of the prepuce.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
No.