Differentials
Eczema and dermatitis
SIGNS / SYMPTOMS
Characterized by erythematous scaly plaques. Pruritus is often a prominent sign.
INVESTIGATIONS
Diagnosis is clinical.
Atopic dermatitis
SIGNS / SYMPTOMS
Characterized by erythematous scaly patches and lichenified plaques. Pruritus is a prominent finding. Additional areas of involvement include the hands, ankles/feet, and flexural areas.
INVESTIGATIONS
Diagnosis is clinical.
Biopsy usually not necessary but may be warranted in atypical cases.
A high serum IgE level strengthens clinical suspicion of the presence of the atopic tendency.
Seborrheic dermatitis
SIGNS / SYMPTOMS
Lesions with slight erythema, slight to moderate scaling, and often perifollicular or frank follicular involvement.
Other commonly affected areas include scalp, ears, glabella and brows, nasolabial folds, axillae, chest, back, and groin. Slight dandruff, mild scaling of the eyebrows, or scaling lesions in the axillae or on the chest may be present.
Patients typically complain of the cosmetic insult rather than of itch, which may be mild.
INVESTIGATIONS
Diagnosis is clinical (and includes noting response to treatment).
Biopsy usually not necessary but may be warranted in atypical cases.
Irritant contact dermatitis
SIGNS / SYMPTOMS
Characterized by erythematous, scaly patch or plaque corresponding to site of application of irritant.
INVESTIGATIONS
Diagnosis is clinical based on history, examination, and trial of treatment (i.e., avoiding presumed irritant).
Allergic contact dermatitis
SIGNS / SYMPTOMS
Symptoms are pain, burning, or itching.
Signs include erythema, swelling, vesiculation and exudation, or erythematous scaling and lichenification, depending on severity. These appear about 1 week after first contact with allergen, if previously unsensitized, or within hours to 1-2 days if sensitized.
This is a relatively uncommon cause of balanoposthitis.
INVESTIGATIONS
Management relies on the identification of the potential allergen and likely source, and then avoidance. There may be clues to the inciting factors at presentation, but subsequent patch testing to identify allergen(s) is required.[46]
Psoriasis
SIGNS / SYMPTOMS
Presents with variably itchy, silvery-scaled erythematous patches or plaques in circumcised men. Scale is absent from lesions on the glans penis or in the preputial sac of uncircumcised men, because of the mucosal site.
Identifying other areas of involvement can help with the diagnosis of psoriasis. Commonly involved areas include the scalp, ears, umbilicus, sacrum, natal cleft, and nails.
Psoriatic balanoposthitis can be part of the spectrum of inverse-pattern psoriasis (with intertriginous and flexural site disease involvement) and may be associated with intertriginous disease of the axillae, natal cleft, gluteal folds, and groin.
Bowen disease and extramammary Paget disease may be misdiagnosed as psoriasis when there are single or several foci on the penile shaft and/or in the groin.
INVESTIGATIONS
Diagnosis is usually clinical; sometimes a biopsy is necessary, to exclude Zoon balanitis, lichen planus, erythroplasia of Queyrat, or Kaposi sarcoma in uncircumcised patients with solitary mucosal lesions.
Reactive arthritis (Reiter disease)
SIGNS / SYMPTOMS
Skin lesions may be similar to those of psoriasis. Patients may present with features of both psoriasis and Reiter syndrome.
Classically, patients with reactive arthritis have thickened yellow palms and soles with a cobblestone appearance, with or without pustular lesions (keratoderma blenorrhagica); and characteristic involvement of the penis (circinate balanitis), which, when severe, can result in balanoposthitis.
INVESTIGATIONS
Diagnosis is clinical.
Presence of HLA-B27 in the proper clinical context can support the diagnosis.
Lichen sclerosus
SIGNS / SYMPTOMS
Men may be asymptomatic. Atrophic white patches (leukoderma) or plaques are most commonly seen. The lesions can also present as hypertrophic or lilac-colored, slightly scaly lichenoid patches or plaques with telangiectasia and sparse purpura. Zoonoid inflammatory patches are common.
Patients may report symptoms signifying sexual dysfunction or dyspareunia (itching, burning, pain, bleeding, tearing, splitting, hemorrhagic blisters), discomfort with urination, and narrowing of the urinary stream and/or concerns about the changing anatomy of their genitalia.[12][47][48][49][50][51]
Other presentations include nonretractile foreskin, paraphimosis, and urinary retention (even renal failure). The signs may be subtle with meatal narrowing and slight tightening of the prepuce (with retraction still possible) due to sclerotic plaques and bands.
Severe changes due to the lichen sclerosus and associated nonspecific or Zoonoid balanoposthitis include constrictive posthitis, adhesions, loss of anatomic definition, and dissolution or effacement of the normally sharply defined architectural features (e.g., frenulum and the coronal sulcus). Overt changes of Zoon balanitis may be more florid than the underlying lichen sclerosus.
Other urologic complications include balanoposthitis, adhesions, phimosis, paraphimosis, posthitis, balanitis xerotica, and cancer.
Postinflammatory hyperpigmentation is occasionally seen.
INVESTIGATIONS
Most cases can be diagnosed clinically.
If there is clinical doubt, a biopsy should be done. A biopsy is mandatory if a lesion or part of a lesion is eroded or verrucous (warty).
Zoon balanitis
SIGNS / SYMPTOMS
Well-demarcated, glistening, moist, shiny, bright-red or brown patches involving the glans and mucosal prepuce. The urethra (fossa navicularis) may also be involved. The lesions may demonstrate dark red stippling (cayenne pepper spots) and purpura with hemosiderin deposition.
Atypical or unusual morphology should be viewed with suspicion and biopsied.
INVESTIGATIONS
Screening for STDs is usually mandatory in patients with penile lesions presumed to represent Zoon balanitis.
When Zoon balanitis is suspected, underlying lichen sclerosus must be suspected.
A targeted biopsy should be avoided except to exclude penile intraepithelial neoplasia (PeIN). If performed, the pathologist should be encouraged to look for concomitant disease (e.g., lichen sclerosus and PeIN), especially in the foreskin specimen following circumcision.
Nonspecific balanoposthitis
SIGNS / SYMPTOMS
Nonspecific balanoposthitis is a diagnosis of exclusion and probably not common.
Candidiasis may be present as a secondary opportunistic phenomenon rather than as a primary cause of disease in most, if not all, cases.
Preputial dysfunction is the probable cause, and in many cases lichen sclerosus will eventually be found as the underlying morbid state.
INVESTIGATIONS
Diagnosis of exclusion.
Gonorrhea
SIGNS / SYMPTOMS
Erythematous patches may be well demarcated and look very similar to Zoon balanitis.
Meatal, preputial, and penile edema and, less commonly, painful lymphadenopathy may be present.
INVESTIGATIONS
Diagnosed by stained smear of urethral swab positive for Neisseria gonorrhoeae. Confirmed by culture or nucleic acid amplification tests.
Candidiasis
SIGNS / SYMPTOMS
Burning and soreness are more likely than itch. The glans may be eroded. Coalescent red patches or plaques involve the folds, often with superficial erosions.
INVESTIGATIONS
Diagnosis is clinical and supported by direct demonstration of the budding forms of the yeast and pseudohyphae in a KOH preparation with India ink. Microbiologic culture is confirmatory.
If candidiasis is diagnosed, a clinical search for an underlying dermatologic or medical cause should follow, as signs due to Candida may be more obvious than those of the underlying cause.
Carcinoma in situ/penile intraepithelial neoplasia (PeIN)
SIGNS / SYMPTOMS
Persistent leukoplakia, erythroplasia, clustered pigmented papules.[25]
Use of this content is subject to our disclaimer