Dr. Ashwini. V. Swamy
Venereology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I have a non-itchy but painful penis rash. I am a 47-year-old unmarried, not-sexually active, uncircumcised male, 5’10”, 190 pounds. I have a history of ulcerative colitis (which seems to be hereditary). This was corrected 12 years back when I received a total colectomy and pouch replacement (that is bowel removed, and new bowel constructed out of small intestine). That seems all good. For some time (five years), I have experienced a very slight pain or irritation at the base of the glans of my penis. Friction (eg., masturbation) would make it sore, but it was very slight. Some redness in the skin just below the glans, but not always. Did not even consider this a problem (and it might not be the problem, I am just mentioning it).
Six months back the glans of my penis became inflamed. This was the start of my problems. No bumps, no itchiness, no scaling skin. Just redness on the bottom half of the glans, and also the tip. It got very sore. If it was never touched, it does not hurt at all. However, it rubs the underwear during the day, and that can be very painful. Not always, but most of the time. The pain can be excruciating. I want to emphasize that the rash has never been itchy. Urinating causes no pain. I consulted my family physician and he did not know what it was but said he could treat it like a yeast infection. So he prescribed some antifungal cream with 1 % Hydrocortisone (Clotrimaderm) and when that did not do anything, suggested the 1 % HC might be getting in the way, so prescribed straight anti-fungal over the counter anti-fungal cream (all the creams I have used twice a day). No help. The 1 % HC did relieve some (a little) of the pain but did not actually fix anything.
Thinking maybe the problem was not fungal, but perhaps bacterial, my doctor then prescribed Polysporin ointment. I quite by accident bought the version of Polysporin with Lidocaine. The Polysporin also did not fix the problem, but the Lidocaine brought some relief! The pain was lessened, but as I said, the problem was not fixed. I used Lidocaine for two weeks before going back to the doctor to let him know the problem remained. He then recommended a urologist, so I got a referral to a urologist. The urologist did not know what it was but suggested two possibilities: go see a dermatologist or get a circumcision. My family doctor did not think the circumcision would help, so he referred me to a dermatologist. The dermatologist said the rash was non-contagious and non-cancerous. He prescribed me four creams which I was to try, in sequence one at a time, for a week at a time, and let him know which helped. They were Ketoderm 2 %, Fucidin 2 %, Noritate 1 %, and Hydroval. I tried each of these as directed. None of these helped. The ones with some HC 1 % relieved some of the pain, but the rash is currently as bad or worse than when the problem started. The dermatologist said there was nothing else he could do, and recommended I get another appointment with a different urologist. The dermatologist did a swab and sent it to the lab, and it came back negative. He also had earlier said it was not an STI.
As you can imagine, I am not very encouraged. My doctor does not seem to know what is up, and neither does the urologist or dermatologist. Can you give me some suggestions as to the cause and the remedy for my rash?
Hi,
Welcome to icliniq.com.
Depending on the symptoms you have mentioned, and all the treatment you have taken with no much help, I can list few possibilities though it is difficult to comment without seeing the picture.
Since it is bothering you for few months, I strongly feel this condition would need shave biopsy of skin to know the exact nature of the problem so that treatment can be targeted for the cause instead of treating it with antibacterial or antifungal or topical steroids. Hope your blood glucose is within normal limits, if not it strongly favors candidal balanitis which may not respond to only topical anti-fungal but needs oral antifungal medicine.
Patient's Query
Hi doctor,
Thank you for your prompt reply. I should have mentioned that my doctor did give me an oral antifungal medicine when I first saw him, I forgot about that. Could you explain what a shave biopsy is? That does not sound very pleasant.
Hi,
welcome back to icliniq.com.
A biopsy means taking a piece of skin for examination under the microscope after that piece of skin has been mounted on a glass slide and stained with appropriate staining agents. The microscopic details provide more information regarding the pathology that is going on in the tissue. It would say if the condition is a fungal infection or bacterial or inflammatory condition like plasma cell balanitis. There are many types of skin biopsy like:
Yes, it is not pleasant, yet it is made comfortable by giving a local numbing injection (local anesthesia-Lignocaine) so that the pain is not felt. After the skin is shaved off, the area is cauterized to prevent bleeding, later that area heals with little scar tissue. After the procedure, the area has to be treated with healing ointment to aid proper healing. Usually, for genital lesions, the biopsy is kept as last option after all topical and oral medications have been tried with no results.
Patient's Query
Thank you doctor,
That does not sound pleasant, but perhaps would be necessary. I am going to upload a picture.
Hi,
Welcome back to icliniq.com.
I saw your picture (attachment removed to protect patient identity). Considering your history and the clinical features as per the picture, I feel it is plasma cell balanitis. This needs a biopsy to rule out erythroplasia of Queyrat which is a premalignant condition. Clinically both the condition appears almost similar. Plasma cell balanitis will have a red glistening shiny surface (as in your case as per the picture) whereas erythroplasia will have well-defined margins with a velvety appearance.
Patient's Query
Hi doctor,
Thank you for the reply.
The shiny surface in the picture is due to the fact I had applied the Polysporin ointment. It is normally not so shiny. In the time since we have spoken, the condition has gotten worse. It is more tender, and the redness is more than it was. If it is the case that I have plasma cell balanitis, what does the treatment for that look like? Are we talking about creams or surgery? What is the success rate for treatment? I have made an appointment with my family doctor and I am going to ask him to pursue seeing if it is PCB. He will probably have to refer me to a dermatologist, so I will try to get a different one than I had last time. Thank you for your help.
Hi,
Welcome back to icliniq.com.
Treatment options for PCB are,
1. Topical mild steroid creams like Hydrocortisone 2.5% and Mometasone 0.1%.
2. Topical tacrolimus 0.1%.
3. Circumcision, this is considered as curative treatment option. This condition is mostly idiopathic, definite cause is unknown, probable causes attributed are friction and irritation from urine. It is a chronic condition, topical medicine are helpful but there are chances of recurrence. One more thing here to be considered is, when topical steroids are used for longer duration, it can flare up fungal infections. Hence, combination of steroid and antifungal had to be used. Circumcision, removal of prepuce, is considered curative because it is the prepuce that is causing friction and prepuce can hold urine for short period of time when it comes it contact with, causing irritation.
You have mentioned that you have more pain, and never it was itchy. Do you have pain while retracting the prepuce? Do you find it difficult to retract like does it feel tight? Do you experience difficulty while having sexual intercourse or mastrubating? Since you have mentioned that the surface is not shiny, I am thinking of another possibility it is called lichen sclerosus. This condition is painful, skin gets atrophied meaning skin thins out.
Patient's Query
Thanks for the reply doctor,
To answer your questions, I do not have pain while retracting foreskin. The foreskin itself is not really painful. It is not difficult to retract; it is naturally short so it generally always looks half retracted. I am not sure what you mean by "difficulty". I suspect the answer is no. I read up on lichen sclerosus. It is interesting that it is an auto-immune disorder, since that is in my history (ulcerative colitus). However, the symptoms of white patchy skin doesn't really sound like it, and my penis is never itchy. Would a shave biopsy confirm for sure what it is I am dealing with?
Hi,
Welcome back to icliniq.com.
Sorry, I should have been more specific. I meant pain or discomfort. Since these conditions look similar clinically, there are very few differentiating points for instance hypopigmented thin skin, glistening surface, and velvety texture. Dermoscopy is another tool which helps to see finer datails, however biopsy would be very helpful in making exact diagnosis.
Patient's Query
Hi doctor,
The pain I am feeling is almost 100% in the glans portion of the penis, not the foreskin. If the foreskin is ever sore, it is only very slight. I do think my problem might have started way back in the foreskin (maybe years ago), but the issue was so minimal I did not take serious note of it. There was a redness there, but the pain as I said was minimal to non-existent most of the time. It is when the problem grew bigger i.e. when it migrated to the glans, that the exponential growth in pain started, and when I then sought medical help. Are you saying that the two different possible conditions you listed (PCB or LS) look similar when simply looked at by a doctor, and so it is hard to tell? I ask because I am not sure what you mean when you say look similar clinically. Are you suggesting that the other techniques (the dermoscopy and the biopsy) would therefore be a great help to nailing down more exactly what is going on?
Hi,
Welcome back to icliniq.com.
We Dermatologists can make diagnosis depending the positive clinical findings that include history from the patient and morphology of the lesion.
There are many conditions in Dermatology that look similar, in such case we would list the possible diagnosis in the descending order. When I go back and see that picture you have attached, I can think of PCB, and erythroplasia of queyrat. I mentioned PCB first beacuse of shiny red surface and chronic history. But then you clarified that it is shiny because of the medicine you have applied, this makes me think other possible chronic conditions like lichen sclerosus. If I would have seen you in person, I would have been able to see the exact morphology of the lesion. Of course the picture you have sent is very clear and informative. Dermatologists use dermoscope in their routine practice. Dermoscopy helps to see certain minute features which are otherwise not seen with naked eyes like the pattern of pigment, tiny blood vessels, etc. Biopsy is usually done by Dermatologist. Biopsy gives the exact pathology of the lesion.
Patient's Query
Thank you doctor,
I was talking about our discussion with my (twin) brother, and it occurred to me that when I visited the dermatologist some months ago. He did say that whatever problem I had was something which started with the letter B and could very well have been Balanitis. When I visit my family doctor, I will ask him what the dermatologist determined. So I suspect the creams the dermatologist prescribed me were steroid based creams to deal with balanitis. You will recall I listed them, above, as Ketoderm 2%, Fuciden 2%, Noritate 1%, and Hydroval. Are you familiar with these names or are they brand names which might be different somewhere else? If someone did in fact have balanitis, would this be what would be prescribed? None of these four creams worked. When I saw him the second time, he gave me an additional prescription for three more creams, which I never tried since the first four were useless and the doctor did not seem to think these three would do any better, but I had pressed him for more options, so he prescribed them. The next three were Loprox, Bacroban, Ozanisk. Do you think it would useful for me to try these three? If the diagnosis is Balanitis, what would you recommend I do next? You listed topical tacrolimus 0.1% as an option above. Since I have tried the steroids to no effect, would that be next?
Hi,
Welcome back to icliniq.com.
Balanitis is inflammation of glans penis. Inflammation could be from various causes like infection- bacterial, fungal, viral, trauma, contact allergy to detergent, cloth, drug induced, premalignant condition or 0ther dermatogical condition like psoriasis, lichen planus, lichen sclerosus Identifying the most likely cause of balanitis is very important so that treatment can be directed to the cause. In my practice, I generally treat fungal infection first as this is the most common cause of balanitis, if it is not responding then I will consider combination of antibacterial with steroid. If still there is no response, then I suggest to undergo biopsy in that way the exact cause will be known. Those are the brand name of the creams, and I looked up the content Ketoderm is antifungal, Fuciden and Noritate are anti bacterials, Hydroval is hydrocortisone, steroid, Loprox is Ciclopirox, higher antifungal, Bactroban- Mupirocin higher antibiotic, and I could not find Ozanisk. Tacrolimus is an immunomodulator, this is helpful for inflamatory conditions like plasma cell balanitis and lichen sclerosus along with steroid.
Patient's Query
Hi doctor,
So, do you think it would be useful for me to try the additional three creams? Or do you think that is the wrong direction to go in?
Hi,
Welcome back to icliniq.com.
You can use Loprox - antifungal and Bactroban - antibacterial and there is no harm. These creams will help to treat the secondary infection if there is any.
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