Balanoposthitis in prepubertal males

The cause of balanoposthitis and balanitis is most often a mild irritant contact dermatitis; however, in some prepubertal males, balanoposthitis or balanitis is caused by a dermatosis (most often psoriasis, less commonly lichen sclerosus). Treat balanoposthitis or balanitis caused by contact dermatitis as for contact dermatitis in the genitocrural area, including use of topical corticosteroids and avoidance of allergens and irritants. Oral corticosteroids are rarely required. Topical antibiotic creams or ointments are not effectiveThe Royal Children's Hospital (RCH), 2018.

Advise the patient (or parent or carer) on general measures such as soaking the area in warm salt water (to settle swelling and discomfort), washing with a soap substitute, and using a bland emollient (eg white soft paraffin). Oral analgesics may be neededThe Royal Children's Hospital (RCH), 2018.

Advice on washing of the area depends on whether the foreskin can be easily retracted (ie pulled back from the head of the penis). In most newborns, the foreskin cannot be retracted; over time, the foreskin separates and is able to be retracted. Retractability of the foreskin increases with age, with full retraction possible in 10% of children at 1 year, 50% at 10 years, and 99% at 17 yearsThe Royal Children's Hospital (RCH), 2018.

If the foreskin can be easily retracted, advise the patient to retract the foreskin and wash underneath when bathing or showering, then to rinse off any soap and dry under the foreskin before replacing over the head of the penisThe Royal Children's Hospital (RCH), 2018.

If the foreskin cannot be easily retracted, do not forcibly retract the foreskin for cleaningThe Royal Children's Hospital (RCH), 2018. Advise the patient to wash the genital area thoroughly.

For more information on penis and foreskin care, see the Royal Children’s Hospital clinical practice guidelines and fact sheet.

Colonisation with Candida albicans can occur in uncircumcised children or in conjunction with a nappy rash Schwartz, 1996—if Candida infection is suspected when the genital area is examined, treat as for nappy rash.

Swabs for microscopy and culture are usually not required. Uncommonly, balanoposthitis can be severe, and can be caused by a Streptococcus pyogenes (group A streptococcus) infection. The rash may also involve the perianal skin. If S. pyogenes infection is suspected, or if there are severe symptoms (eg glans penis is weeping and raw, pain during urination), take a swab of the area for microscopy and culture. If S. pyogenes infection is confirmed, treat as for a streptococcal sore throat.

If balanoposthitis persists despite treatment, take a swab of the area for microscopy and culture, and refer to a dermatologist. Skin biopsy may be required.