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Clinical Knowledge Summaries: Previous version ­ Balanitis

Balanitis

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

About this topic

Have I got the right topic?

Age from 1 month onwards This guidance covers the diagnosis and management of acute balanitis and acute recurrent episodes of balanitis. This guidance does not cover the diagnosis and management of chronic balanitis. There are separate CKS topics on Herpes simplex -- genital and Urethritis -- male. The target audience for this guidance is healthcare professionals working within the NHS in England, and providing first contact or primary health care. Patient information from NHS Direct is intended to be printed and given to people with this condition, and the Shared decision making sections are designed to provide a focus for discussion during the consultation about the treatment options.

Changes

Version 1.0.0, revision planned in 2010. Last revised in January 2007 July­September 2006 -- reviewed. Validated in December 2006 and issued in January 2007. This guidance has been reviewed, restructured and updated following a full literature review. A new evidence section has been added. There has been one change to the recommendations; antibiotic treatment for bacterial balanitis has been changed from flucloxacillin to penicillin.

Previous changes

October 2005 -- minor technical update. Issued in November 2005. April 2005 -- minor update. Tinaderm-M® cream (nystatin 100 000 units/g and tolnaftate 1% cream) has been discontinued. The prescription has been removed. Issued in April 2005. October 2003 -- written. Validated in December 2003 and issued in February 2004.

Update

New evidence

Evidence-based guidelines No new evidence-based guidelines since 1 March 2007. HTAs (Health Technology Assessments) No new HTAs since 1 March 2007. Economic appraisals No new economic appraisals relevant to England since 1 March 2007. Systematic reviews and meta-analyses No new systematic review or meta-analysis since 1 March 2007. Primary evidence No new high quality randomized controlled trials since 1 March 2007.

New policies

No new national policies or guidelines since 1 March 2007.

New safety alerts

No new safety alerts since 1 March 2007.

Changes in product availability

No changes in product availability since 1 March 2007.

Concise knowledge for clinical scenarios

Which scenario?

· Severe acute balanitis: Managing balanitis when there is extensive and intense erythema of the glans and foreskin associated with pain.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

·

Mild to moderate acute balanitis: Managing balanitis when erythema is less intense and extensive and associated with only mild to moderate discomfort.

Which therapy?

For all men with acute balanitis: · Assess the cause of the acute balanitis. o Refer all men with suspected urethritis, ulceration or lymphadenopathy to a genito-urinary medicine clinic (with the exception of recurrent ulceration due to herpes simplex in someone with an established diagnosis, see the CKS topic on Herpes simplex -- genital). Advise: o Avoidance of contact with any potential skin irritants such as (e.g. soap). o Keeping area clean by bathing twice daily with a weak saline solution while symptoms persist. Prescribe a mild topical corticosteroid to settle inflammation causing discomfort. In adults prescribe one of the following based upon personal preference: o Oral fluconazole o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, or sulconazole o Topical nystatin o Topical terbinafine In children prescribe one of the following based upon personal preference: o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, or sulconazole o Topical nystatin For oral treatment if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal For topical antifungals if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal We recommend that treatment with a topical antifungal should be continued for 2­3 days after clinical cure. o Note: There is no evidence to support this recommendation and expert opinion varied as to the most appropriate length of treatment. If balanitis reoccurs after a clinical cure: o Consider using the same antifungal again and continue for a further 2 weeks after clearance, or o Consider an alternative class of antifungal for 7 days and continue for 2­3 days after clinical cure o For more information on recurrent balanitis see How do I manage someone with recurrent balanitis? Prescribe a mild topical corticosteroid to settle inflammation causing discomfort. Advise avoidance of potential irritants such as: o Latex condoms/diaphragms o Lubricants o Feminine hygiene spray o Topical medications o Soaps o Antiseptics Take sub-preputial swab if clinical diagnosis is in doubt or symptoms recur. o Note: state Gardnerella on the laboratory form as this is not routinely tested for. Treat empirically with oral metronidazole for 7 days. Adjust treatment as appropriate when culture and sensitivity results become available.

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Candidal balanitis: · ·

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Irritant contact balanitis: · ·

Gardnerella-associated balanitis ·

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This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

Mild to moderate balanitis of uncertain cause · Treat with a combined topical corticosteroid and anti-candidal preparation, such as clotrimazole, econazole, ketoconazole, miconazole, sulconazole, or topical nystatin.

Practical prescribing points

For further information please see the Medicines Compendium (www.medicines.org.uk) or the British National Formulary (www.bnf.org).

Topical antifungals

· · Topical anti-candidal preparations should be applied for 2­3 days after lesions have healed. Topical corticosteroids combined with a topical anti-candidal may be used if: o There is marked inflammation o It is unclear whether a person has balanitis caused by a candidal infection or contact dermatitis Note: Treatment with a topical corticosteroid and anti-candidal combination preparation should not be for longer than 1 week. Topical terbinafine is not licensed for use in children. Topical nystatin can stain clothes yellow, which may affect compliance.

· · ·

Oral fluconazole

· · The most common adverse effects of fluconazole are gastrointestinal in nature, and include nausea, vomiting, bloating, diarrhoea, and abdominal discomfort. The effect of warfarin may be enhanced by oral fluconazole. However, this is less likely with a single dose.

Metronidazole

· · Common adverse effects include a metallic taste and gastrointestinal irritation (nausea and vomiting in particular). Some people taking oral metronidazole experience disulfiram-like reactions to alcohol (flushing, increased respiratory rate, increased pulse rate). o People taking metronidazole should be advised of the possible consequences of drinking alcohol.

Hydrocortisone

· · · Use a mild potency corticosteroid (e.g. 0.5­1% hydrocortisone) for no longer than one week. Corticosteroids should be applied to the skin in a thin layer. Localized effects of topical hydrocortisone include: o Skin atrophy o Exacerbation of skin infection

Should I refer or investigate?

Refer?

· Consider dermatology referral for: o Investigation of possible contact irritant balanitis if infective causes are excluded and the potential irritant cannot be identified o Acute balanitis that fails to respond to recommended first- and second-line treatments

Investigate?

· For people with recurrent balanitis: o Take sub-preputial swabs to confirm the diagnosis, if this is in doubt based upon clinical features. o Check blood glucose levels to exclude diabetes. o Consider arranging investigations for HIV and other causes of immunosuppression, depending on clinical suspicion. For men with suspected gardnerella-associated balanitis take sub-preputial swabs to confirm the diagnosis. Consider dermatology referral for investigation of possible irritant balanitis if infective causes are excluded and the potential irritant or allergy cannot be identified.

· ·

Follow-up advice

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

·

·

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If suspected candidal balanitis has not responded to first-line treatment within 7 days: o Review the diagnosis o Check compliance with treatment o Change to a different class of antifungal drug If suspected irritant balanitis reoccurs after stopping topical corticosteroids: o Review the diagnosis. o Review contact with potential irritants and consider referral to a dermatologist if no irritants can be identified. If suspected gardnerella-associated balanitis has not responded to treatment with metronidazole within 7 days: o Review the diagnosis with the results of sub-preputial swabs and adjust treatment according to results.

Prescriptions

Non-drug management

Advice only: washing

· · Age from 1 month onwards Advice: You should keep the area as clean as possible. Good toilet hygiene, including hand washing, is strongly recommended. Regular cleaning of the area using a weak salt solution can be soothing and help relieve discomfort. A weak salt solution can be made up by adding roughly a teaspoonful of salt to half a litre (500 ml) of warm water.

Anticandidal-only preparations Clotrimazole 1% cream

Age from 1 month onwards · · · · · Clotrimazole 1% cream. Apply to the affected area 2 to 3 times a day. Continue for 2 to 3 days after area has healed Supply 20 grams. NHS Cost £2.64 OTC Cost £4.65 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Econazole 1% cream

Age from 1 month onwards · · · · · Econazole 1% cream. Apply to the affected area twice a day. Continue for 2 to 3 days after area has healed. Supply 30 grams. NHS Cost £2.56 OTC Cost £4.51 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Ketoconazole 2% cream

Age from 1 month onwards · · · · Ketoconazole 2% cream. Apply to the affected area twice a day. Continue for 2 to 3 days after area has healed. Supply 30 grams. NHS Cost £3.54 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Miconazole 2% cream

Age from 1 month onwards · · · · Miconazole 2% cream. Apply to the affected area twice a day. Continue for 2 to 3 days after area has healed. Supply 30 grams. NHS Cost £1.93 OTC Cost £3.41 Licensed use: yes

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

·

Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Sulconazole 1% cream

Age from 1 month onwards · · · · · Sulconazole 1% cream. Apply to the affected area 2 to 3 times a day. Continue for 2 to 3 days after area has healed Supply 30 grams. NHS Cost £3.90 OTC Cost £6.87 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Terbinafine 1% cream

Age from 18 years onwards · · · · Terbinafine 1% cream. Apply to the affected area once or twice a day. Continue for 2 to 3 days after the area has healed Supply 30 grams. NHS Cost £8.76 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Nystatin 100,000units/g cream

Age from 1 month onwards · · · · Nystatin 100,000units/g cream. Apply to the affected area 2 to 4 times a day. Continue for 2 to 3 days after the area has healed. Supply 30 grams. NHS Cost £2.03 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Nystatin 100,000units/g ointment

Age from 1 month onwards · · · · Nystatin 100,000units/g ointment. Apply to the affected area 2 to 4 times a day. Continue for 2 to 3 days after the area has healed. Supply 30 grams. NHS Cost £1.63 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Topical corticosteroids Hydrocortisone 0.5% cream

Age from 1 month onwards · · · · Hydrocortisone 0.5% cream. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £0.34 Licensed use: yes Patient Information: Do not use this cream for more than 7 days

Hydrocortisone 0.5% ointment

Age from 1 month onwards · · · · Hydrocortisone 0.5% ointment. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £0.35 Licensed use: yes Patient Information: Do not apply for more than 7 days.

Hydrocortisone 1% cream

Age from 1 month onwards · · Hydrocortisone 1% cream. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £1.52

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

· ·

Licensed use: yes Patient Information: Do not use this cream for more than 7 days.

Hydrocortisone 1% ointment

Age from 1 month onwards · · · · Hydrocortisone 1% ointment. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £0.72 Licensed use: yes Patient Information: Do not use this ointment for more than 7 days.

Anticandidal + hydrocortisone preparations Clotrimazole 1% + hydrocortisone 1% cream

Age from 1 month onwards · · · · Clotrimazole 1% / Hydrocortisone 1% cream. Apply thinly to the affected area once or twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.15 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Miconazole 2% + hydrocortisone 1% cream

Age from 1 month onwards · · · · Miconazole 2% / Hydrocortisone 1% cream. Apply thinly to the affected area once or twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £1.90 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Miconazole 2% + hydrocortisone 1% ointment

Age from 1 month onwards · · · · Miconazole 2% / Hydrocortisone 1% ointment. Apply thinly to the affected area once or twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.09 Licensed use: yes Patient Information: Wash hands after applying ointment. If possible leave the affected area exposed to the air at night. This ointment only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the ointment in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Econazole 1% + hydrocortisone 1% cream

Age from 1 month to 11 years 11 months · · · · Econazole 1% / Hydrocortisone 1% cream. Apply thinly to the affected area twice a day. Use for a maximum of 5 days unless otherwise directed. Supply 30 grams. NHS Cost £2.09 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Econazole 1% + hydrocortisone 1% cream

Age from 12 years onwards

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

· · · ·

Econazole 1% / Hydrocortisone 1% cream. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.09 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Nystatin + chlorhexidine + hydrocortisone 0.5% cream

Age from 1 month onwards · · · · Nystaform HC cream. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.66 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Nystatin + chlorhexidine + hydrocortisone 1% ointment

Age from 1 month onwards · · · · Nystaform HC ointment. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.66 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This ointment only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the ointment in a line from the tip of an adults index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Timodine cream (contains nystatin + hydrocortisone 0.5%)

Age from 1 month onwards · · · · Timodine cream. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.38 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adults index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Fluconazole: single dose Fluconazole 150mg as a single dose

Age from 16 years onwards · · · · Fluconazole 150mg capsules. Take the capsule as a single dose. Supply 1 capsule. NHS Cost £1.60 OTC Cost £12.50 Licensed use: yes

Drug rationale

Drugs not included

· · · Emollients are not recommended. They help relieve pruritus but do not treat the candidal infection. Salicylic acid and undecenoate preparations are not considered suitable for fungal skin infections. Topical antibacterial products that do not contain an anti-candidal component are not recommended, as they are not effective in treating candidal infections.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

·

·

Oral antifungals other than fluconazole are not recommended. Itraconazole and ketoconazole are not licensed for the treatment of candidal balanitis, and they tend to be used in immunocompromised people and where more severe or resistant candidal infection is present. Oral terbinafine is not licensed for the treatment of candidal infection.

Drugs included

· Topical imidazole preparations (clotrimazole, econazole, ketoconazole, miconazole, and sulconazole) are recommended, as they are effective against Candida albicans. There is little evidence of difference between these preparations, and they are all licensed to treat candidal skin infections in people of all ages. Product selection will depend on prescriber/user preference. Topical nystatin preparations are also effective against C albicans. They are licensed for use in all ages. Topical combination products containing hydrocortisone 0.5% or 1% plus an anti-candidal (an imidazole or nystatin) are recommended to reduce accompanying inflammation. They should not be used for more than a week unless otherwise directed, to avoid adverse effects. A topical corticosteroid is recommended where the diagnosis of contact dermatitis is certain. Topical terbinafine cream is licensed for treating cutaneous candidiasis in adults. Ointment and cream formulations of active anti-candidals are included. Ointments are greasy preparations that are insoluble in water, are more occlusive than creams and, unlike creams, do not contain preservatives. Creams are emulsions of oil and water; they tend to be well absorbed into the skin. There is no evidence to support the use of one preparation over another. Oral fluconazole is licensed as a single-dose treatment for candidal balanitis in men over 16 years. o Note: fluconazole is available to buy as an over-the-counter preparation for this indication in those aged 16­60 years old.

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Shared decision making

· · · · · · Balanitis is common in boys and men. There are various causes, including infections and irritants. Candida (thrush) is the most common cause. Salt baths twice a day are soothing whilst treatment takes effect. Avoid soap and anything else that may sensitize the delicate skin. An anti-yeast cream or an anti-yeast tablet is the most common treatment, as most cases are caused by candida. A mild steroid cream can reduce inflammation caused by allergies or irritants. Sometimes it is used in addition to anti-yeast medication to reduce inflammation caused by infection. Antibiotics will clear balanitis when it is caused by a bacterial infection. See a doctor if symptoms do not clear within 7 days, or if they get worse. Referral may be needed if a sexually transmitted disease is suspected, or if the cause is not clear. Tips which may help to prevent some cases of balanitis include: o Wash the glans each day with just water. o If symptoms are related to condom use, use condoms designed for sensitive skin. o Wash your hands before going to the toilet if you work with chemicals that can irritate delicate skin.

· · · ·

Which therapy?

For all men with acute balanitis: · Assess the cause of the acute balanitis. o Refer all men with suspected urethritis, ulceration, or lymphadenopathy to a genito-urinary medicine clinic (with the exception of recurrent ulceration due to herpes simplex in someone with an established diagnosis, see the CKS topic on Herpes simplex -- genital). Advise: o Avoidance of contact with any potential skin irritants (e.g. soap). o Keeping area clean by bathing twice daily with a weak saline solution while symptoms persist.

·

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

Severe candidal balanitis: · · · · Check blood glucose to exclude diabetes. Take sub-preputial swab. Prescribe a mild topical corticosteroid to settle inflammation. In adults prescribe one of the following based upon personal preference: o Oral fluconazole o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, sulconazole o Topical nystatin o Topical terbinafine In children prescribe one of the following based upon personal preference: o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, sulconazole o Topical nystatin For oral treatment if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal For topical antifungals if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal CKS recommends that treatment with a topical antifungal should be continued for 2­3 days after clinical cure. o Note: there is no evidence to support this recommendation and expert opinion varies as to the most appropriate length of treatment. If balanitis reoccurs after a clinical cure: o Consider using the same antifungal again and continue for a further 2 weeks after clearance o OR, consider an alternative class of antifungal for 7 days and continue for 2­ 3 days after clinical cure o For more information on recurrent balanitis see How do I manage someone with recurrent balanitis? Prescribe a mild topical corticosteroid to settle inflammation. Swab the sub-preputial space prior to starting treatment with antibiotics. Treat with penicillin while awaiting results. Erythromycin is an alternative for people that are penicillin-sensitive. Alter treatment if indicated by the results of the culture and sensitivities.

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Acute streptococcal balanitis: · · · ·

Practical prescribing points

For further information please see the Medicines Compendium (www.medicines.org.uk) or the British National Formulary (www.bnf.org).

Topical antifungals

· · Topical anti-candidal preparations should be applied for 2­3 days after lesions have healed. Topical corticosteroids combined with a topical anti-candidal may be used if: o There is marked inflammation o It is unclear whether a person has balanitis caused by a candidal infection or contact dermatitis Note: treatment with a topical corticosteroid and anti-candidal combination preparation should not be for longer than 1 week. Topical terbinafine is not licensed for use in children. Topical nystatin can stain clothes yellow, which may affect compliance.

· · ·

Oral fluconazole

· · The most common adverse effects of fluconazole are gastrointestinal, and include nausea, vomiting, bloating, diarrhoea, and abdominal discomfort. The effect of warfarin may be enhanced by oral fluconazole. However this is less likely with a single dose.

Hydrocortisone

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

· · ·

Use a mild potency corticosteroid (e.g. 0.5­1% hydrocortisone) for no longer than one week. Corticosteroids should be applied to the skin in a thin layer. Localized effects of topical hydrocortisone include: o Skin atrophy o Exacerbation of skin infection

Erythromycin

· · · People taking astemizole, pimozide, ergotamine and dihydroergotamine should avoid taking erythromycin [BNF 52, 2006]. Common adverse effects include nausea, vomiting, abdominal discomfort, diarrhoea (antibiotic-associated colitis reported). Erythromycin can increase the plasma levels of certain other drugs (e.g. theophylline, carbamazepine) and can potentiate the effects of warfarin. A dose reduction may be required in these circumstances [BNF 52, 2006]. If erythromycin is taken with a statin, there is an increased risk of myopathy. Advise the person to stop the statin whilst erythromycin is being taken.

·

Should I refer or investigate?

Refer?

· Consider referring people who have not responded to recommended management or when there is diagnostic uncertainty.

Investigate?

· For people with severe balanitis: o Check blood glucose levels to exclude diabetes. o Consider arranging investigations for HIV and other causes of immunosuppression, depending on clinical suspicion. For people with suspected streptococcal balanitis take sub-preputial swabs to confirm the diagnosis and check bacterial sensitivities. For people with suspected candidal balanitis take sub-preputial swabs to confirm the diagnosis, if there is any doubt based upon clinical features.

· ·

Follow-up advice

· If suspected candidal balanitis has not responded to first-line treatment within 7 days: o Review the diagnosis o Check compliance with treatment o Change to a different class of antifungal drug If suspected streptococcal balanitis has not responded to treatment with first-line antibiotics within 7 days, review the diagnosis with the results of sub-preputial swabs and adjust treatment according to results.

·

Prescriptions

Non-drug management

Advice only: washing

· · Age from 1 month onwards Advice: You should keep the area as clean as possible. Good toilet hygiene, including hand washing, is strongly recommended. Regular cleaning of the area using a weak salt solution can be soothing and help relieve discomfort. A weak salt solution can be made up by adding roughly a teaspoonful of salt to half a litre (500 ml) of warm water.

Anticandidal-only preparations Clotrimazole 1% cream

Age from 1 month onwards · · · · Clotrimazole 1% cream. Apply to the affected area 2 to 3 times a day. Continue for 2 to 3 days after area has healed Supply 20 grams. NHS Cost £2.64 OTC Cost £4.65 Licensed use: yes

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

·

Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Econazole 1% cream

Age from 1 month onwards · · · · · Econazole 1% cream. Apply to the affected area twice a day. Continue for 2 to 3 days after area has healed. Supply 30 grams. NHS Cost £2.56 OTC Cost £4.51 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Ketoconazole 2% cream

Age from 1 month onwards · · · · Ketoconazole 2% cream. Apply to the affected area twice a day. Continue for 2 to 3 days after area has healed. Supply 30 grams. NHS Cost £3.54 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Miconazole 2% cream

Age from 1 month onwards · · · · · Miconazole 2% cream. Apply to the affected area twice a day. Continue for 2 to 3 days after area has healed. Supply 30 grams. NHS Cost £1.93 OTC Cost £3.41 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Sulconazole 1% cream

Age from 1 month onwards · · · · · Sulconazole 1% cream. Apply to the affected area 2 to 3 times a day. Continue for 2 to 3 days after area has healed Supply 30 grams. NHS Cost £3.90 OTC Cost £6.87 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Terbinafine 1% cream

Age from 18 years onwards · · · · Terbinafine 1% cream. Apply to the affected area once or twice a day. Continue for 2 to 3 days after the area has healed Supply 30 grams. NHS Cost £8.76 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Nystatin 100,000units/g cream

Age from 1 month onwards · · · · Nystatin 100,000units/g cream. Apply to the affected area 2 to 4 times a day. Continue for 2 to 3 days after the area has healed. Supply 30 grams. NHS Cost £2.03 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Nystatin 100,000units/g ointment

Age from 1 month onwards This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

· · · ·

Nystatin 100,000units/g ointment. Apply to the affected area 2 to 4 times a day. Continue for 2 to 3 days after the area has healed. Supply 30 grams. NHS Cost £1.63 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night.

Topical corticosteroids Hydrocortisone 0.5% cream

Age from 1 month onwards · · · · Hydrocortisone 0.5% cream. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £0.34 Licensed use: yes Patient Information: Do not use this cream for more than 7 days

Hydrocortisone 0.5% ointment

Age from 1 month onwards · · · · Hydrocortisone 0.5% ointment. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £0.35 Licensed use: yes Patient Information: Do not apply for more than 7 days.

Hydrocortisone 1% cream

Age from 1 month onwards · · · · Hydrocortisone 1% cream. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £1.52 Licensed use: yes Patient Information: Do not use this cream for more than 7 days.

Hydrocortisone 1% ointment

Age from 1 month onwards · · · · Hydrocortisone 1% ointment. Apply thinly to the affected area(s) once a day for up to 7 days. Supply 15 grams. NHS Cost £0.72 Licensed use: yes Patient Information: Do not use this ointment for more than 7 days.

Anticandidal + hydrocortisone preparations Clotrimazole 1% + hydrocortisone 1% cream

Age from 1 month onwards · · · · Clotrimazole 1% / Hydrocortisone 1% cream. Apply thinly to the affected area once or twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.15 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Miconazole 2% + hydrocortisone 1% cream

Age from 1 month onwards · · · · Miconazole 2% / Hydrocortisone 1% cream. Apply thinly to the affected area once or twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £1.90 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index

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Clinical Knowledge Summaries: Previous version ­ Balanitis

finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Miconazole 2% + hydrocortisone 1% ointment

Age from 1 month onwards · · · · Miconazole 2% / Hydrocortisone 1% ointment. Apply thinly to the affected area once or twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.09 Licensed use: yes Patient Information: Wash hands after applying ointment. If possible leave the affected area exposed to the air at night. This ointment only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the ointment in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Econazole 1% + hydrocortisone 1% cream

Age from 1 month to 11 years 11 months · · · · Econazole 1% / Hydrocortisone 1% cream. Apply thinly to the affected area twice a day. Use for a maximum of 5 days unless otherwise directed. Supply 30 grams. NHS Cost £2.09 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Econazole 1% + hydrocortisone 1% cream

Age from 12 years onwards · · · · Econazole 1% / Hydrocortisone 1% cream. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.09 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Nystatin + chlorhexidine + hydrocortisone 0.5% cream

Age from 1 month onwards · · · · Nystaform HC cream. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.66 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adult's index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Nystatin + chlorhexidine + hydrocortisone 1% ointment

Age from 1 month onwards · · · · Nystaform HC ointment. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.66 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This ointment only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the ointment in a line from the tip of an adults index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Timodine cream (contains nystatin + hydrocortisone 0.5%)

Age from 1 month onwards This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

· · · ·

Timodine cream. Apply thinly to the affected area twice a day. Use for a maximum of 7 days unless otherwise directed. Supply 30 grams. NHS Cost £2.38 Licensed use: yes Patient Information: Wash hands after applying cream. If possible leave the affected area exposed to the air at night. This cream only needs to be applied thinly. Measure ONE 'fingertip unit' by squeezing the cream in a line from the tip of an adults index finger to the first crease in the finger. ONE fingertip unit is enough to cover an area that is twice the size of a flat adult hand.

Fluconazole: single dose Fluconazole 150mg as a single dose

Age from 16 years onwards · · · · Fluconazole 150mg capsules. Take the capsule as a single dose. Supply 1 capsule. NHS Cost £1.60 OTC Cost £12.50 Licensed use: yes

Antibiotic (if indicated by sensitivities) for 5 days Erythromycin s/f suspension: 125mg four times a day

Age from 1 month to 1 year 11 months · · · Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 5 days. Supply 100 ml. NHS Cost £2.80 Licensed use: yes

Erythromycin s/f suspension: 250mg four times a day

Age from 2 years to 11 years 11 months · · · Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 5 days. Supply 100 ml. NHS Cost £3.65 Licensed use: yes

Erythromycin s/f suspension: 500mg four times a day

Age from 9 years to 11 years 11 months · · · Erythromycin ethyl succinate 500mg/5ml oral suspension sugar free. Take one 5ml spoonful four times a day for 5 days. Supply 100 ml. NHS Cost £3.38 Licensed use: yes

Erythromycin e/c tablets: 250mg four times a day

Age from 12 years onwards · · · Erythromycin 250mg gastro-resistant tablets. Take one tablet four times a day for 5 days. Supply 20 tablets. NHS Cost £1.85 Licensed use: yes

Erythromycin e/c tablets: 500mg four times a day

Age from 12 years onwards · · · Erythromycin 250mg gastro-resistant tablets. Take two tablets four times a day for 5 days. Supply 40 tablets. NHS Cost £3.70 Licensed use: yes

Penicillin V solution: 62.5mg four times a day

Age from 1 month to 11 months · · · · Phenoxymethylpenicillin 125mg/5ml oral solution. Take 2.5ml four times a day for 5 days. Supply 100 ml. NHS Cost £1.30 Licensed use: yes Patient Information: Discard any remaining medicine safely.

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Penicillin V solution: 125mg four times a day

Age from 1 year to 5 years 11 months · · · Phenoxymethylpenicillin 125mg/5ml oral solution. Take one 5ml spoonful four times a day for 5 days. Supply 100 ml. NHS Cost £1.30 Licensed use: yes

Penicillin V solution: 250mg four times a day

Age from 6 years to 11 years 11 months · · · Phenoxymethylpenicillin 250mg/5ml oral solution. Take one 5ml spoonful four times a day for 5 days. Supply 100 ml. NHS Cost £1.56 Licensed use: yes

Penicillin V tablets: 500mg four times a day

Age from 12 years onwards · · · Phenoxymethylpenicillin 250mg tablets. Take two tablets four times a day for 5 days. Supply 40 tablets. NHS Cost £4.52 Licensed use: yes

Phenoxymethylpenicillin 250mg tablets

Age from 12 years onwards · · · Phenoxymethylpenicillin 250mg tablets. Take one tablet 4 times a day for 5 days Supply 20 tablets. NHS Cost £2.26 Licensed use: yes

Drug rationale

Drugs not included

· · · · Emollients are not recommended. They help relieve pruritus but do not treat the candidal infection. Salicylic acid and undecenoate preparations are not considered suitable for fungal skin infections. Topical antibacterial products that do not contain an anti-candidal component are not recommended, as they are not effective in treating candidal infections. Oral antifungals other than fluconazole are not recommended. Itraconazole and ketoconazole are not licensed for the treatment of candidal balanitis, and they tend to be used in immunocompromised people and where more severe or resistant candidal infection is present. Oral terbinafine is not licensed for the treatment of candidal infection.

·

Drugs included

· Topical imidazole preparations (clotrimazole, econazole, ketoconazole, miconazole, and sulconazole) are recommended, as they are effective against Candida albicans. There is little evidence of difference between these preparations, and they are all licensed to treat candidal skin infections in people of all ages. Product selection will depend on prescriber/user preference. Topical nystatin preparations are also effective against C albicans. They are licensed for use in all ages. Topical combination products containing hydrocortisone 0.5% or 1% plus an anti-candidal (an imidazole or nystatin) are recommended to reduce accompanying inflammation. They should not be used for more than 1 week unless otherwise directed, in order to avoid adverse effects. A topical corticosteroid is recommended where the diagnosis of contact dermatitis is certain. Topical terbinafine cream is licensed for treating cutaneous candidiasis in adults. Ointment and cream formulations of active anti-candidals are included. Ointments are greasy preparations that are insoluble in water, are more occlusive than creams and, unlike creams, do not contain preservatives. Creams are emulsions of oil and water; they tend to be well-absorbed into the skin. There is no evidence to support the use of one preparation over another.

· ·

· · ·

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Clinical Knowledge Summaries: Previous version ­ Balanitis

·

· ·

Oral fluconazole is licensed as a single-dose treatment for candidal balanitis in men over 16 years. o Note: fluconazole is available to buy as an over-the-counter preparation for this indication in those aged 16­60 years old. Penicillin is offered as it is effective against the most likely bacterial causes of balanitis. Erythromycin is offered for people allergic to penicillin.

Shared decision making

· · · · · · · · · Balanitis is common in boys and men. There are various causes but infection with candida (thrush), or a bacterium, is the most likely cause if the symptoms came on quickly and/or are severe. Salt baths twice a day are soothing whilst treatment takes effect. Avoid soap and anything else that may sensitize the delicate skin. A mild steroid cream can reduce inflammation caused by the infection. An anti-yeast cream or an anti-yeast tablet will usually clear a candida infection. Antibiotics will usually clear a bacterial infection. See a doctor if symptoms do not clear within 7 days, or if they get worse. Referral may be needed if a sexually transmitted disease is suspected, or if the cause is not clear.

Detailed knowledge about this topic

Goals and outcome measures

Goals

· Rapid resolution of symptoms

Background information

What is it?

· Balanitis is defined as inflammation of the glans penis. Unless the person is circumcised, the inflammation usually involves the foreskin; the term balanoposthitis is therefore more correct, but is rarely used. Acute balanitis (up to a few weeks' duration) is most commonly caused by Candida. o Candidal balanitis is usually acquired from sexual intercourse with a partner with vaginal candidiasis who may or may not be symptomatic [Mayser, 1999]. Vaginal candidiasis, in contrast, is only rarely acquired by sexual intercourse. o Less common but important causes of acute balanitis include: Viral infection with herpes simplex. Gonorrhoea Syphilis Streptococcus Gardnerella Anaerobes (particularly bacteroides) may complicate other primary pathogens but their causative role in balanitis remains uncertain. Chlamydial infection. Protozoan infection with Trichomonas vaginalis. Trauma. Recurrent acute balanitis is most commonly caused by contact with irritants. Chronic balanitis (more than a few weeks' duration) and a wide range of neoplastic and inflammatory chronic skin problems may affect the skin and mucous membranes of the penis. For more information see What else might it be?

·

· ·

[English et al, 1997]

How common is it?

· · Balanitis is a common condition, although there have been no good-quality studies of the incidence of balanitis in a general practice population. The incidence of balanitis in men attending a genito-urinary clinic was reported to be 11% in one study [CEG, 2001].

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·

·

Candidal balanitis is widely reported as the most common cause for acute balanitis and is more likely [Edwards, 1996; English et al, 1997]: o In men that are uncircumcised. (Candidal balanitis almost never occurs in men who have been circumcised.) The sub-preputial space provides the necessary environment for Candida to survive and cause balanitis. o In men with diabetes. o Following antibiotics. o In men with poor genital hygiene. o In men with a phimosis. Irritant-contact balanitis has been found to be the cause in 72% of men with recurrent or chronic balanitis [Birley et al, 1993]. It is more likely: o In men with atopy o In men that wash frequently with soap o In men with mild balanitis [Fornasa et al, 1994]

How do I know my patient has it?

· Balanitis of all origins may present with [CEG, 2001]: o Symptoms of penile soreness, itch, and odour o Signs of erythema, exudate, and the inability to retract the foreskin (phimosis) Specific types of balanitis may have additional symptoms and signs. These are dealt with in How do I assess someone with balanitis?

·

What else might it be?

· Chronic dermatological conditions specific to the genitalia: o Lichen sclerosus is a chronic, progressive, sclerosing, inflammatory skin problem that most commonly affects the genital area. In men the tip of the foreskin develops a tight white ring which eventually prevents retraction of the foreskin. o Zoon's balanitis is a benign condition of uncertain origin in uncircumcised men. It presents with orange-red lesions with pinpoint redder spots on the glans and adjacent areas of foreskin. It resolves with circumcision. o Circinate balanitis is a chronic balanitis that develops in someone with Reiter's syndrome. It presents with well-demarcated erythematous plaque with a ragged white border. o Erythroplasia of Queyrat is a carcinoma. It presents with single or multiple plaques with a red, velvety appearance. o Squamous cell carcinoma of the penis. Lesions may be papillary or flat. Papillary lesions usually appear on the glans which eventually becomes necrotic and ulcerated. Flat lesions usually ulcerate early. Chronic dermatological conditions that may also affect the genitalia: o Psoriasis o Seborrhoeic dermatitis o Lichen planus o Pemphigus o Bowen's disease

·

[English et al, 1997]

Prognosis and complications

Prognosis

· The prognosis of acute balanitis depends on the underlying cause and the presence and management of any predisposing risk factors: o Candidal balanitis resolves rapidly with appropriate treatment but is more likely to recur in men with: Diabetes Poor genital hygiene A phimosis o Balanitis due to contact irritants resolves over a period of days with removal of the provoking irritant or allergen but may recur with re-exposure.

[English et al, 1997]

Complications

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Clinical Knowledge Summaries: Previous version ­ Balanitis

·

Difficulty retracting the foreskin may develop as a direct result of balanitis. This is more likely if the balanitis is chronic or recurring.

Management issues

Overview of management

· Assess a person with balanitis to determine: o The cause of the balanitis o Predisposing factors when balanitis is severe or recurrent Refer men with acute balanitis associated with ulceration, urethritis or lymphadenopathy to a genito-urinary medicine clinic. Advise washing the glans with saline solution and avoiding soaps. Prescribe 1% hydrocortisone if inflammation is causing significant discomfort. Treat candidal balanitis with either a topical antifungal cream or fluconazole, depending on patient preference. Advise men with irritant or allergic contact balanitis to avoid likely irritants and allergens. Treat men with gardnerella-associated balanitis with metronidazole. Treat streptococcal balanitis with penicillin or erythromycin in people who are penicillin sensitive. Assessment of men with severe or recurrent balanitis involves a pubertial swab for exclusion of diabetes. Consider assesment and treatment of the sexual partner if a man has recurrent balanitis due to Candida albicans or Gardnerella.

· · · · · · · · ·

How do I assess someone with balanitis?

The management of balanitis is dependant on an assessment of the likely cause: · Assess the duration of the balanitis: o Acute balanitis generally has a rapid onset and lasts between a few days and a few weeks. o Chronic balanitis generally has an insidious onset and may have been present for weeks or months. Assess for ulceration, urethritis or inguinal lymphadenopathy: o Ulceration may be painful or painless and may be accompanied by general malaise. Ulceration may occur on the glans, foreskin or shaft of the penis. Ulcers have an edge and a distinct red base of exposed underlying tissue which distinguishes them from superficial erosions. o Urethritis presents with dysuria and urethral discharge with erythema predominant around the urethral meatus. Urethral discharge may only be noticed as staining on underwear or with 'milking' of the urethra. o Inguinal lymphadenopathy may be caused by any condition that causes ulceration or urethritis. Assess the severity of the balanitis and distinguish severe from mild to moderate balanitis: o Severe balanitis has extensive and intense erythema of the glans and foreskin associated with pain. o Mild to moderate balanitis is diagnosed when erythema is less intense and extensive (associated with only mild to moderate discomfort). Assess for predisposing factors when balanitis is recurrent: o Check blood glucose to exclude diabetes [Mayser, 1999]. o After excluding diabetes consider investigating the sexual partner for vaginal candidiasis and bacterial vaginosis if recurrent episodes of balanitis are distressing.

·

·

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[Edwards, 1996, English et al, 1997, CEG, 2001]

Assessing the cause of acute mild to moderate balanitis

· The cause of acute mild to moderate balanitis is determined by: o The clinical features o The odour o Swabbing of the sub-preputial space if clinical diagnosis is in doubt. Candidal balanitis is the most common cause of acute balanitis [Mayser, 1999]: o Erythema on the undersurface of the foreskin and glans, sparing the area around the urethral meatus. Small, eroded papules may be present.

·

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Clinical Knowledge Summaries: Previous version ­ Balanitis

·

·

A white cheese-like matter, that can be rubbed off easily, covers the areas that are erythematous. o The sexual partner may have symptoms of vaginal candidiasis. o The diagnosis is usually made on clinical features but may be confirmed by sub-preputial swab for fungal culture. Irritant contact balanitis is common and probably under-recognized [English et al, 1997; Waugh, 1998]: o Erythema may extend onto the skin of the shaft of the penis. o Erythema may be associated with oedema. o There may be a history of contact with potential irritants or allergens. o Potential sources of irritants and allergens include latex condoms/diaphragms, lubricants, feminine hygiene spray, douches, topical medications, and soaps. Gardnerella-associated balanitis [Kinghorn et al, 1982]: o Balanitis is associated with a fishy odour and a sub-preputial mucoid discharge. o The sexual partner may have a history of bacterial vaginosis. o The diagnosis is usually made on clinical grounds, but may be confirmed by sub-preputial swab specifically stating Gardnerella (as anaerobes are not routinely tested for).

o

Assessing the cause of acute severe balanitis

· The cause of acute severe balanitis is determined by: o The clinical appearance o Checking the blood glucose of someone not known to have diabetes o Swabbing the sub-preputial space Streptococcal infections [Orden et al, 1996]: o Typically presents with a rapid onset of severe erythema and pain which is usually accompanied by a purulent exudate. o This exudate is distinguished clinically from the exudate caused by urethritis by examining the pattern of erythema on the glans. Urethritis is suspected when there is dysuria and the erythema is predominantly around the urethral meatus. o Confirm the diagnosis by sub-preputial swab for bacterial culture. Candida albicans infection in people with diabetes presents with typical features of candidal balanitis but of unusual severity [Mayser, 1999]: o Erythema on the undersurface of the foreskin and glans, sparing the area around the urethral meatus. Small, eroded papules may be present. o A white cheese-like matter, that can be rubbed off easily, covers the areas that are erythematous. o The sexual partner may have symptoms of vaginal candidiasis. o The diagnosis is usually made on clinical features but may be confirmed by sub-preputial swab for fungal culture.

·

·

Assessing the cause of acute balanitis associated with ulceration, urethritis, or lymphadenopathy.

With the exception of recurrent ulceration due to an established diagnosis of herpes simplex, refer all men with acute balanitis and suspected urethritis, ulceration, or lymphadenopathy to a genito-urinary medicine clinic for further assessment and management. · Ulceration is most commonly caused by: o Herpes simplex o Syphilis Urethritis may be caused by: o Gonorrhoea o Chlamydia o Trichomonas Inguinal lymphadenopathy may be caused by any condition that causes ulceration or urethritis. Occasionally gonorrhoea may present with acute balanitis and lymphadenopathy without urethritis.

·

·

[McCormack and Rein, 1995; English et al, 1997]

How do I manage someone with acute mild to moderate balanitis?

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Clinical Knowledge Summaries: Previous version ­ Balanitis

·

Assess the cause of mild to moderate balanitis: o Candidal balanitis o Irritant contact balanitis o Gardnerella-associated balanitis o Uncertain cause

How should I treat acute candidal balanitis?

Advise all men with balanitis to: o o Avoid contact with any potential skin irritants such as soap Keep area clean by bathing twice daily with a weak saline solution while symptoms persist

Eradicate candidal infection: · The topical imidazoles, nystatin, terbinafine, and oral fluconazole are widely recommended treatments for candidal balanitis [Hay and Moore, 2004]: o There is no evidence of superiority of any one of these treatments. Choice of treatment is therefore based upon individual preference and licence agreements. o Oral fluconazole is used as a single treatment. In one study it was preferred to topical treatment by approximately 80% of men requiring treatment for candidal balanitis [Stary et al, 1996]. o Oral fluconazole is no tlicnesed for children under 16 years and topical terbinafine are not licensed for treatment of children under 18 years [BNF 52, 2006]. In adults prescribe one of the following based upon personal preference: o Oral fluconazole o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, sulconazole o Topical nystatin o Topical terbinafine In children prescribe one of the following based upon personal preference: o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, sulconazole o Topical nystatin For oral treatment if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal For topical antifungals if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal CKS recommends that treatment with a topical antifungal should be continued for 2­3 days after clinical cure. o Note: there is no evidence to support this recommendation and expert opinion varied concerning the most appropriate length of treatment. If balanitis reoccurs after a clinical cure: o Consider using the same antifungal again and continue for a further 2 weeks after clearance. o OR, consider an alternative class of antifungal for 7 days and continue for 2­ 3 days after clinical cure. o For more information on recurrent balanitis see How do I manage someone with recurrent balanitis? Settle inflammation causing discomfort with a mild topical corticosteroid for no longer than a week: o There are no studies evaluating the role of topical corticosteroids, but they are widely recommended for the treatment of candidal balanitis where there is marked inflammation [CEG, 2001]. o A topical anti-candidal and corticosteroid combination preparation may be used. o A topical hydrocortisone 1% may be used when treating adults with oral fluconazole.

·

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·

·

·

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How should I treat acute irritant contact balanitis?

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Clinical Knowledge Summaries: Previous version ­ Balanitis

·

· ·

Anyone with balanitis should be advised to: o Avoid contact with any potential skin irritants (e.g. soap). o Keep area clean by bathing twice daily with a weak saline solution while symptoms persist. Treat with topical 1% hydrocortisone for one week, to settle the inflammation of acute balanitis. Advise avoidance of potential irritants such as: o Latex condoms/diaphragms o Lubricants o Feminine hygiene spray o Topical medications o Soaps o Antiseptics

[English et al, 1997; CEG, 2001]

How should I treat acute Gardnerella-associated balanitis?

· Anyone with balanitis should be advised to [CEG, 2001]: o Avoid contact with any potential skin irritants (e.g. soap). o Keep area clean by bathing twice daily with a weak saline solution while symptoms persist. Treat empirically with oral metronidazole for 7 days. Take sub-preputial swab if clinical diagnosis is in doubt or symptoms are recurrent. o Note: state Gardnerella on the laboratory form as this is not routinely tested for. Adjust treatment as appropriate when culture and sensitivity results become available.

· ·

·

[Waugh, 1998]

How should I treat acute balanitis when the cause cannot be determined?

· Anyone with balanitis should be advised to: o Avoid contact with any potential skin irritants (e.g. soap). o Keep area clean by bathing twice daily with a weak saline solution while symptoms persist [CEG, 2001]. Irritant contact or candidal infection are the most likely causes of balanitis [Edwards, 1996]. Therefore, clinical features alone cannot, in many cases, determine the cause of balanitis. Treat with a combined topical corticosteroid and anti-candidal preparation, such as clotrimazole, econazole, ketoconazole, miconazole, sulconazole or topical nystatin. If the balanitis recurs after stopping treatment, review the diagnosis and consider taking sub-preputial swabs before initiating further treatment.

·

·

·

How do I manage severe acute balanitis?

· Assess the cause of the severe acute balanitis and distinguish: o Severe acute Streptococcal balanitis o Severe acute candidal balanitis in someone with diabetes

Suspected streptococcal balanitis

· Anyone with balanitis should be advised to: o Avoid contact with any potential skin irritants (e.g. soap). o Keep area clean by bathing twice daily with a weak saline solution while symptoms persist [CEG, 2001]. Swab the sub-preputial space prior to starting empirical treatment with antibiotics. Treat empirically with penicillin whilst awaiting results. Erythromycin is an alternative for people that are penicillin-sensitive [Edwards, 1996]. Treat with topical 1% hydrocortisone to settle the inflammation [CEG, 2001]. Alter treatment if indicated by the results of the culture and sensitivities.

· · · ·

Severe candidal balanitis

General measures for all men with acute severe candidal balanitis: · Advise all men with balanitis to [CEG, 2001]:

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Clinical Knowledge Summaries: Previous version ­ Balanitis

· · ·

Avoid contact with any potential skin irritants (e.g. soap). Keep area clean by bathing twice daily with a weak saline solution while symptoms persist. Check blood glucose if they are not known to be diabetic [Mayser, 1999]. Take a sub-preputial swab. The topical imidazoles, nystatin, terbinafine, and oral fluconazole are widely recommended treatments for candidal balanitis [Hay and Moore, 2004]. o There is no evidence of superiority of any one of these treatments. The choice of treatment is therefore based upon individual preference and licence agreements. o Oral fluconazole is used as a single treatment. In one study it was preferred to topical treatment by approximately 80% of men requiring treatment for candidal balanitis [Stary et al, 1996]. o Oral fluconazole is not licensed for children under 16 years and topical terbinafine is not licensed for treatment of children under 18 years [BNF 52, 2006]. In adults prescribe one of the following based upon personal preference: o Oral fluconazole o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, or sulconazole o Topical nystatin o Topical terbinafine In children prescribe one of the following based upon personal preference: o A topical imidazole -- clotrimazole, econazole, ketoconazole, miconazole, sulconazole o Topical nystatin For oral treatment if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal For topical antifungals if candidal balanitis has not cleared within 7 days: o Review the diagnosis o Check compliance with treatment o Prescribe a different class of antifungal CKS recommends that treatment with a topical antifungal should be continued for 2­3 days after clinical cure. o Note: There is no evidence to support this recommendation and expert opinion varies as to the most appropriate length of treatment. If balanitis recurs after a clinical cure: o Consider using the same antifungal again and continue for a further 2 weeks after clearance, or o Consider an alternative class of anti-fungal for 7 days and continue for 2­3 days after clinical cure. o For more information on recurrent balanitis see How do I manage someone with recurrent balanitis? Settle inflammation causing discomfort with a mild topical corticosteroid for no longer than a week [CEG, 2001]. o There are no studies evaluating the role of topical corticosteroids, but they are widely recommended for the treatment of candidal balanitis where there is marked inflammation. o A topical anti-candidal and corticosteroid combination preparation may be used. o A topical hydrocortisone 1% may be used when treating adults with oral fluconazole.

o o

Eradicate candidal infection:

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How do I manage someone with acute balanitis associated with ulceration, urethritis, or lymphadenopathy?

· · For management of a recurrent ulceration due to herpes simplex in someone with an established diagnosis see the CKS topic on Herpes simplex -- genital. Refer all other men with acute balanitis and suspected urethritis, ulceration, or lymphadenopathy to a genito-urinary medicine clinic for further assessment and management.

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Clinical Knowledge Summaries: Previous version ­ Balanitis

How do I manage someone with recurrent balanitis?

Assess a person with recurrent balanitis to determine: · · · · · · · · · The cause of the balanitis Any predisposing risk factors that have caused a recurrence Take sub-preputial swab, if not already taken How do I manage someone with acute balanitis associated with ulceration, urethritis, or lymphadenopathy? How do I manage severe acute balanitis? How do I manage someone with acute mild to moderate balanitis? Diabetes see the CKS topic on Diabetes Type 2 -- blood glucose management. A partner who is found to have vaginal candidiasis or bacterial vaginosis see the CKS topics on Candida -- female genital and Bacterial vaginosis. Possible irritant or allergic contact balanitis: o Review and advise avoidance of possible exposure to irritants or allergens including [English et al, 1997]: Latex condoms/diaphragms Lubricants Feminine hygiene spray Topical medications Soaps Antiseptics o When the potential irritant or allergen cannot be identified or avoided, consider referral for specialist assessment and management.

Manage the acute episode depending on the cause of the acute balanitis. See:

Manage the cause of the recurrence. For men with:

Medicines management

Topical antifungals

Which topical antifungal should I offer?

· Topical first line anti-candidal treatments include the imidazole antifungals (clotrimazole, econazole, ketoconazole, miconazole, and sulconazole) or nystatin [BNF 52, 2006]. Topical terbinafine may be used as an alternative for adults only, as it is not licensed for use in children [ABPI Medicines Compendium, 2000]. Topical corticosteroids combined with a topical anti-candidal may be used if: o There is marked inflammation o It is unclear whether a person has balanitis caused by a candidal infection or contact dermatitis If balanitis recurs after a clinical cure: o Consider using the same antifungal again, or o Consider an alternative class of antifungal

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How long should a topical antifungal be used for?

· Treatment with a topical antifungal should be continued for 2­3 days after clinical cure. o Note: there is no evidence to support this recommendation and expert opinion varied as to the most appropriate length of treatment. If balanitis recurs after a clinical cure: o Consider using the same antifungal again and continue for a further 2 weeks after clearance, or o Consider an alternative class of antifungal for 7 days and continue for 2­3 days after clinical cure Treatment with a topical corticosteroid and anti-candidal combination preparation should be for no longer than 1 week [BNF 52, 2006].

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What adverse effects are associated with topical antifungals?

· Topical nystatin can stain clothes yellow, which may affect compliance.

Oral antifungals

Which oral antifungal should I use?

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Clinical Knowledge Summaries: Previous version ­ Balanitis

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Fluconazole 150 mg given as a single dose is the only oral antifungal preparation that is licensed specifically for the treatment of candidal balanitis [ABPI Medicines Compendium, 2004].

What are the adverse effects of fluconazole?

· The most common adverse effects of fluconazole are gastrointestinal in nature and include nausea, vomiting, bloating, diarrhoea, and abdominal discomfort [Micromedex, 2007].

What drug interactions can occur with fluconazole?

· · · The effect of warfarin may be enhanced by oral fluconazole. However, this is less likely with a single dose. Sulphonylureas increase plasma concentration -- monitor for possible hypoglycaemic episodes. Immunosuppressants increase plasma concentration of cyclosporin and tacrolimus -- monitor for possible toxicity.

[ABPI Medicines Compendium, 2004].

Metronidazole

What are the adverse effects?

· Common adverse effects include a metallic taste and severe gastrointestinal irritation (nausea and vomiting in particular). These are more common at higher doses [ABPI Medicines Compendium, 2006].

What drug interactions can occur with metronidazole?

· Some people taking oral metronidazole experience disulfiram-like reactions to alcohol (flushing, increased respiratory rate, increased pulse rate). Although there is no conclusive evidence to support an interaction between metronidazole and alcohol, people taking metronidazole should be advised of the possible consequences of drinking alcohol [Baxter, 2006]. Warfarin dose may need to be reduced when given with metronidazole. Prothrombin times should be monitored. Lithium retention accompanied by evidence of possible renal damage has been reported in patients treated simultaneously with lithium and metronidazole. Lithium treatment should be tapered or withdrawn before administering metronidazole. Plasma concentrations of lithium, creatinine, and electrolytes should be monitored in patients under treatment with lithium while they receive metronidazole.

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[ABPI Medicines Compendium, 2006]

Erythromycin

Who should avoid taking erythromycin?

· People taking astemizole, pimozide, ergotamine, and dihydroergotamine [BNF 52, 2006].

What are the adverse effects of erythromycin?

· · Common adverse effects include nausea, vomiting, abdominal discomfort, and diarrhoea (antibiotic-associated colitis reported). Cardiac arrhythmias have been reported very rarely in patients receiving erythromycin therapy.

[ABPI Medicines Compendium, 2002]

What drug interactions can occur with erythromycin?

· Erythromycin can increase the plasma levels of certain other drugs (e.g. theophylline, carbamazepine) and can increase the effects of warfarin. A dose reduction may be required in these circumstances [BNF 52, 2006]. If erythromycin is taken with a statin, there is an increased risk of myopathy. Advise the person to stop the statin whilst erythromycin is being taken.

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Topical corticosteroids

Which topical corticosteroid should I offer?

· · Use a mild potency corticosteroid (0.5­1% hydrocortisone). It is rarely necessary to use a more potent corticosteroid than 1% hydrocortisone.

Should I use an ointment or a cream?

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Clinical Knowledge Summaries: Previous version ­ Balanitis

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The choice regarding whether to use an ointment or a cream will depend largely on personal preference. o We found no clinical trials comparing ointment and cream formulations of topical corticosteroids in the management of balanitis.

How long should a corticosteroid be used for?

· The topical corticosteroid should be applied until the inflammation has cleared, but for no longer than a week (in order to minimize adverse effects) [BNF 52, 2006].

How much topical corticosteroid should be applied?

Corticosteroids should be applied to the skin in a thin layer. As a practical guide, the quantity of topical corticosteroid to apply is often expressed in terms of fingertip units (FTUs) [MeReC, 1999]. o One FTU is roughly equivalent to the amount of cream or ointment that can be squeezed from a tube with a standard nozzle onto an adult index finger from the tip of the finger to the first crease. FTUs should be used together with body charts that show the number of FTUs required to cover each area of a child's or an adult's body. As a rough guide, one FTU of topical corticosteroid is sufficient to treat a skin area approximately twice that of the flat of the hand with the fingers together. A demonstration of the use of the FTU should be backed up with written information. To avoid applying excess corticosteroid to the applying fingertip, advise the person either to wash the fingertip after application or to use a polythene sleeve or cotton bud to apply the corticosteroid.

o o

o o

What are the adverse effects of corticosteroids?

Adverse effects of topical corticosteroids can be divided into: Localized effects, such as skin atrophy and exacerbation of skin infection. Systemic effects, such as hypophyseal-pituitary-adrenal (HPA) suppression which may lead to growth retardation. The risk of adverse effects increases with the potency of the topical corticosteroid, duration of use, and area of application (e.g. thin skin on the face and flexures). Adverse effects are most likely with potent or very potent topical corticosteroids when used in large quantities for prolonged periods. Mildly and moderately potent topical corticosteroids used for short periods are rarely associated with adverse effects. Skin atrophy is much more likely with potent and very potent topical corticosteroids. o For the skin on the trunk and limbs, thinning of the skin may occur within 1­ 3 weeks of starting a potent or very potent topical corticosteroid, but reverses within 4 weeks if treatment is stopped. o There is little risk of skin thinning with mild to moderate topical corticosteroids when used for up to 4 weeks. o o

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[MeReC, 1999; DTB, 2003]

Supporting evidence

There is little published evidence regarding the treatment of balanitis.

Evidence on antifungals

· The topical imidazoles, nystatin, terbinafine, and oral fluconazole are widely recommended treatments for candidal balanitis [Hay and Moore, 2004]. o These recommendations are made by extrapolating evidence of the effectiveness of these treatments for candidiasis of the skin, toenails, and perineum in infants. The comparative effectiveness of treatments has only been studied in one good quality trial [Stary et al, 1996]. It found that oral fluconazole is as effective as topical clotrimazole in the treatment of candidal balanitis: o A randomized, open-label, multicentre study (n = 157) that included men with either mild, moderate, or acute balanitis compared the efficacy of a single oral 150 mg fluconazole with topical clotrimazole applied twice daily for 7 days. o At short term (days 8­11) follow-up 132 men were assessed.

·

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Balanitis

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Clinical cure (disappearance of all clinical signs and symptoms) or improvement was achieved in 92% of men taking fluconazole and in 91% of men using topical clotrimazole. Mycological cure was achieved 78% of men receiving fluconazole and 83% of men using topical clotrimazole.

Evidence on topical steroids

· · We found no well-designed studies evaluating the effectiveness of topical corticosteroids for treating balanitis. Randomized controlled trials of topical corticosteroids compared with a placebo suggest a large treatment effect for atopic eczema (for further information see the CKS topic on Eczema -- atopic). Clinical experience suggests that similar benefits occur when topical corticosteroids are used to treat balanitis.

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References

NHS staff in England can link, free of charge, from references to the full text journal articles by clicking on [NHS Athens Full-text]. You will need an NHS Athens password to access these resources. Click here for Athens registration. All references with links to [Free Full-text] are freely available online to users in England and Wales. This includes the full text of Department of Health papers and Cochrane Library reviews. 1 ABPI Medicines Compendium (2000) Summary of product characteristics for Lamisil cream. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Accessed: 10/10/2006]. ABPI Medicines Compendium (2002) Summary of product characteristics for Erythrocin 500. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Accessed: 09/10/2006]. ABPI Medicines Compendium (2004) Summary of product characteristics for Diflucan 150 capsules. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Accessed: 04/10/2004]. ABPI Medicines Compendium (2006) Summary of product characteristics for Flagyl tablets 200mg and 400mg. Electronic Medicines Compendium. Datapharm Communications Ltd. www.emc.medicines.org.uk [Accessed: 09/10/2006]. Baxter, K. (Ed.) (2006) Stockley's drug interactions: a source book of interactions, their mechanisms, clinical importance and management. 7th edn. London: Pharmaceutical Press. Birley, H.D., Walker, M.M., Luzzi, G.A. et al. (1993) Clinical features and management of recurrent balanitis: association with atopy and genital washing. Genitourinary Medicine 69(5), 400-403. BNF 52 (2006) British National Formulary. 52nd edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain. CEG (2001) National guideline on the management of balanitis. Clinical Effectiveness Group (Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). www.bashh.org [Accessed: 08/08/2006]. [Free Full-text] DTB (2003) Topical steroids for atopic dermatitis in primary care. Drug & Therapeutics Bulletin 41(1), 5-8. [Abstract] Edwards, S. (1996) Balanitis and balanoposthitis: a review. Genitourinary Medicine 72(3), 155-159. English, J.C., Laws, R.A., Keough, G.C. et al. (1997) Dermatoses of the glans penis and prepuce. Journal of the American Academy of Dermatology 37(1), 1-24. Fornasa, C.V., Calabro, A., Miglietta, A. et al. (1994) Mild balanoposthitis. Genitourinary Medicine 70(5), 345-346. Hay, R.J. and Moore, M.K. (2004) Mycology. In: Burns, T., Breathnach, S., Cox, N. and Griffiths, C. (Eds.) Rook's textbook of dermatology. 7th edn. Oxford: Blackwell Science. 31.1-31.101. Kinghorn, G.R., Jones, B.M., Chowdhury, F.H. and Geary, I. (1982) Balanoposthitis associated with Gardnerella vaginalis infection in men. British Journal of Venereal Diseases 58(2), 127-129. Mayser, P. (1999) Mycotic infections of the penis. Andrologia 31(Suppl 1), 13-16. McCormack, W.M. and Rein, M.F. (1995) Urethritis. In: Mandell, G.L., Douglas, R.G. and Bennett, J.E. (Eds.) Mandell, Douglas and Bennett's principles and practice of infectious diseases. 4th edn. New York: Churchill Livingstone. 1063-1072. MeReC (1999) Using topical corticosteroids in general practice. MeReC Bulletin 10(6), 2124. [Free Full-text]

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Clinical Knowledge Summaries: Previous version ­ Balanitis

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Micromedex (2007) MICROMEDEX [CD-ROM]. (vol 131, 1st quarter 2007). Thomson Healthcare. Orden, B., Martin, R., Franco, A. et al. (1996) Balanitis caused by group A beta-hemolytic streptococci. Pediatric Infectious Disease Journal 15(10), 920-921. Stary, A., Soeltz-Szoets, J., Ziegler, C. et al. (1996) Comparison of the efficacy and safety of oral fluconazole and topical clotrimazole in patients with candida balanitis. Genitourinary Medicine 72(2), 98-102. Waugh, M.A. (1998) Balanitis. Dermatologic Clinics 16(4), 757-762.

Patient information

Patient information from NHS Direct: · · Balanitis Thrush, men

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