How to treat balanitis that does not go away despite trying multiple medications?

Hello,

Welcome to icliniq.com.

I understand your concern.

• It looks more like candidal balanoposthitis, a kind of superficial fungal infection. You had used mostly topical steroids except once when you used Miconazole. Tacrolimus is not also indicated in this.
• It presents superficial fragile pustules which rupture to form red bumps or superficial bright erythema.
• It is not considered a typical sexually transmitted condition, as it can happen without sexual contact too. Yet I would suggest treating the partner with Fluconazole if sexually active.
• This condition is also more common in diabetics, so please get your blood sugar levels checked once.

I would suggest you the following medications after consulting with your physician:

1. Tablet AF-150 (Fluconazole) 1 tablet once per week for two weeks.

2. Tablet Levosiz (Levocetrizine) 5 mg once a day.

3. Candid (Clotrimazole) cream apply twice a day.

Do it for two weeks, and also get your blood sugar test done. Then follow back.

Take care.

Hope this helps.

Kind regards.

Hello,

Welcome back to icliniq.com.

I understand your concern.

Resistance in candidal balanoposthitis is common these days. The use of topical steroids can also exaggerate that. When topicals are not working, a short course of oral Itraconazole is suggested. KOH (potassium hydroxide) preparations do not always show yeast. Although it is also suggested in a single dose, I have seen better results with a short course. I would suggest you take the following medications after consulting with your physician for one week and then follow back:

1. Capsule Itraconazole 100 mg twice a day.

2. Cream Luliconazole apply once at night.

3. Use a mild cleanser like Cetaphil cleanser (water and Glycerine) for sensitive skin to wash the affected area.

4. Tablet Levocetrizine 5 mg once a day.

Skip the last prescription, then follow up after one week. Avoid using any other topical preparations for now.

Take care.

Hope this helps.

Kind regards.

Hello,

Welcome back to icliniq.com.

Thanks for providing more clinical photographs (the attachment is hidden to protect the patient's identity).

As you say you have used steroids, antifungal, as well as Tacrolimus without much improvement, I will still suggest you use Itraconazole for a short course. Another thing is, Isotretinoin itself can rarely also irritate the mucosa and can lead to balanitis. Using only moisturizer should help if Isotretinoin is the culprit here.

Do you find any correlation between the two? I mean, is balanitis started after starting Isotretinoin? If you can not stop it for medical reasons, just try a mild cleanser along with a moisturizer.

I will suggest against the use of topical steroids as I do not see any indication as of now. Too many creams can also lead to allergic contact dermatitis, even steroids.

Take care.

Kind regards.

Hello,

Welcome back to icliniq.com.

I understand your concern.

The most likely diagnosis, as I told you earlier, is candidal balanoposthitis. That is why topical antifungal like Miconazole helps. But some cases are not easily treated by topical alone. If Miconazole helps, use it, but also take oral Itraconazole 100 mg twice a day for seven days initially, and extend up to two weeks to prevent the recurrence. My diagnosis remains candida, which is a superficial fungus, and the response to Miconazole supports it to some extent. I have seen a few cases who did not respond to topical Clotrimazole or oral Fluconazole but had a very good response to oral Itraconazole without further recurrence. No other condition presents like this. Also, if you are sexually active, treatment of a partner is suggested, though it is not a typical STD (sexually transmitted disease). If not, just follow the Itraconazole regimen. And I understand it can be very frustrating. Just give Itraconzole a try after consulting with your physician and follow up after one week.

Take care.

Hope this helps.

Kind regards.

Hello,

Welcome back to icliniq.com.

I understand your concern. Could you please send me the swab report? I could not determine which bacteria were found. Please do not be too anxious. Have you started taking oral Itraconazole? Kindly send the swab report or provide the impressions here.

Thank you.

Hello,

Welcome back to icliniq.com.

Anaerobic balanoposthitis is indeed a rare condition, but if the culture confirms it, treatment is necessary. If the cream is causing excessive dryness, you can request oral Metronidazole (the same medication in oral form). Your doctor should have no issue prescribing the oral version, especially if the topical treatment is causing irritation. Typically, a seven-day course of oral Metronidazole yields good results. In the meantime, you can use a moisturizer in conjunction with the cream to alleviate dryness.

Thank you.

Hello,

Welcome back to icliniq.com.

You should discontinue the cream you have been using as it may be causing irritation, and for now, apply nothing except moisturizer. As I mentioned before, consult your general practitioner and request the oral form of this medication since you cannot tolerate the topical one. Given the positive culture for anaerobic bacteria, try a week-long course of oral Metronidazole at the very least. The burning sensation should improve once you stop the cream. In the meantime, you can use Miconazole with a moisturizer for symptomatic relief.

Take care.

Hello,

Welcome back to icliniq.com.

Yes, you can take these medications if you do not have any known cardiac conditions. Anxiety, in itself, is not a contraindication.

I hope your queries are resolved and any further queries are welcome. Thank you.