Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

atopic eczema

1st line – topical corticosteroid + supportive measures

Back
ACUTE
|
atopic eczema
1st line – 

topical corticosteroid + supportive measures

Use the lowest-potency topical corticosteroid capable of containing disease.

Hydrocortisone is a low-potency topical corticosteroid and is used for mild cases. Triamcinolone is a moderate-potency topical corticosteroids used in moderate/severe cases.

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1][33]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Consider – oral antihistamine

Back
ACUTE
|
atopic eczema
|
with significant pruritus
Consider – 

oral antihistamine

Treatment recommended for SOME patients in selected patient group

Oral antihistamines are useful for patients with significant pruritus.

Hydroxyzine is commonly used, but may cause sedation. Nonsedating options include cetirizine, fexofenadine, and loratadine.

Primary options

hydroxyzine: 25-50 mg orally every 6-8 hours when required

OR

cetirizine: 5-10 mg orally once daily when required

OR

fexofenadine: 60 mg orally twice daily when required, or 180 mg orally once daily when required

OR

loratadine: 10 mg orally once daily when required

seborrheic dermatitis

1st line – supportive measures

Back
ACUTE
|
seborrheic dermatitis
1st line – 

supportive measures

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]​

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]​

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Plus – topical antifungal

Back
ACUTE
|
seborrheic dermatitis
|
with significant erythema/inflammation
Plus – 

topical antifungal

Treatment recommended for ALL patients in selected patient group

Topical antifungals (e.g., ketoconazole, miconazole, clotrimazole) in conjunction with mild or moderately potent topical corticosteroids may be used for more severe cases (i.e., those with significant erythema/inflammation).[1]​ The corticosteroids are typically applied for 2-3 weeks, while the antifungal agent is used until active skin disease resolution is seen.

Seborrheic dermatitis is a chronic, frequently recurrent condition, so these medications will likely be used intermittently over an extended time period.

Primary options

ketoconazole topical: (2%) apply to the affected area(s) once daily

OR

miconazole topical: (2%) apply to the affected area(s) twice daily

OR

clotrimazole topical: (1%) apply to the affected area(s) twice daily

Consider – topical corticosteroid

Back
ACUTE
|
seborrheic dermatitis
|
with significant erythema/inflammation
Consider – 

topical corticosteroid

Treatment recommended for SOME patients in selected patient group

Topical corticosteroids should be used only for more severe flare-ups with marked inflammation and erythema. Limit use to periods of 2-3 weeks.

When the disease flare-up is under control, the topical corticosteroids should be discontinued and the ketoconazole cream continued as needed (i.e., until skin disease resolution is seen).

Seborrheic dermatitis is a chronic, frequently recurrent condition, so these medications will likely be used intermittently over an extended time period.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

Consider – topical calcineurin inhibitor

Back
ACUTE
|
seborrheic dermatitis
|
with significant erythema/inflammation
Consider – 

topical calcineurin inhibitor

Treatment recommended for SOME patients in selected patient group

Topical calcineurin inhibitors are an alternative to topical corticosteroids. Use until active skin disease resolution is seen.

Seborrheic dermatitis is a chronic, frequently recurrent condition, so these medications will likely be used intermittently over an extended time period. Be wary of extended use of these drugs in the uncircumcised male.

Primary options

pimecrolimus topical: (1%) apply sparingly to the affected area(s) twice daily

OR

tacrolimus topical: (0.03 or 0.1%) apply sparingly to the affected area(s) twice daily

Plus – oral azole antifungal under specialist direction

Back
ACUTE
|
seborrheic dermatitis
|
with concomitant seborrheic folliculitis or HIV infection
Plus – 

oral azole antifungal under specialist direction

Treatment recommended for ALL patients in selected patient group

Indicated in cases with concomitant seborrheic folliculitis or in HIV infection.

Carry out treatment under the guidance of a dermatologist or infectious disease specialist.

irritant contact dermatitis

1st line – irritant avoidance + supportive measures + topical corticosteroid

Back
ACUTE
|
irritant contact dermatitis
1st line – 

irritant avoidance + supportive measures + topical corticosteroid

Identification and avoidance of/reduction in exposure to irritants.[1]​ Management is directed at education and behavior modification.

Low- to medium-potency topical corticosteroid ointments reduce symptoms. Hydrocortisone is a low-potency topical corticosteroid useful for mild disease. Triamcinolone is a medium-potency corticosteroid useful for moderate disease. Limit use to 2-3 weeks.

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Consider – oral antihistamine

Back
ACUTE
|
irritant contact dermatitis
|
with significant pruritus
Consider – 

oral antihistamine

Treatment recommended for SOME patients in selected patient group

Oral antihistamines are useful for patients with significant pruritus.

Hydroxyzine is commonly used, but may cause sedation. Nonsedating options include cetirizine, fexofenadine, and loratadine.

Primary options

hydroxyzine: 25-50 mg orally every 6-8 hours when required

OR

cetirizine: 5-10 mg orally once daily when required

OR

fexofenadine: 60 mg orally twice daily when required, or 180 mg orally once daily when required

OR

loratadine: 10 mg orally once daily when required

allergic contact dermatitis

1st line – allergen avoidance + supportive measures + topical corticosteroid

Back
ACUTE
|
allergic contact dermatitis
1st line – 

allergen avoidance + supportive measures + topical corticosteroid

Avoidance of allergen(s) identified in history or confirmed by patch testing.

Low- to medium-potency topical corticosteroid ointments reduce symptoms. Hydrocortisone is a low-potency topical corticosteroid useful for mild disease. Triamcinolone is a medium-potency corticosteroid useful for moderate disease. Limit use to 2-3 weeks.

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Consider – oral antihistamine

Back
ACUTE
|
allergic contact dermatitis
|
with significant pruritus
Consider – 

oral antihistamine

Treatment recommended for SOME patients in selected patient group

Oral antihistamines are useful for patients with significant pruritus.

Hydroxyzine is commonly used, but may cause sedation. Nonsedating options include cetirizine, fexofenadine, and loratadine.

Primary options

hydroxyzine: 25-50 mg orally every 6-8 hours when required

OR

cetirizine: 5-10 mg orally once daily when required

OR

fexofenadine: 60 mg orally twice daily when required, or 180 mg orally once daily when required

OR

loratadine: 10 mg orally once daily when required

Consider – wet soaks

Back
ACUTE
|
allergic contact dermatitis
|
severe with exudate/weeping
Consider – 

wet soaks

Treatment recommended for SOME patients in selected patient group

Aluminum acetate soaks are a helpful treatment adjunct in cases of severe acute contact dermatitis with exudate/weeping. They can be used until active skin disease resolution is seen.

Primary options

aluminum acetate topical: apply towel soaked in solution to affected area(s) for 20-30 minutes twice daily

psoriasis

1st line – topical corticosteroid or topical calcineurin inhibitor or topical vitamin D analog + supportive measures

Back
ACUTE
|
psoriasis
1st line – 

topical corticosteroid or topical calcineurin inhibitor or topical vitamin D analog + supportive measures

Use hydrocortisone, a low-potency topical corticosteroid, for mild disease and triamcinolone, a medium-potency topical corticosteroid, for moderate disease. Limit use to 2-3 weeks.

Topical calcineurin inhibitors or the vitamin D analog calcipotriene can be used as an alternative to topical corticosteroids, (and to avoid potential skin atrophy).[1]​ They are used until active skin disease resolution is seen. Be wary of extended use of these drugs in the uncircumcised male.

Avoid strong crude tar preparations at anogenital sites, as the skin at these sites tends to absorb topical agents, leading to a heightened risk of genital cancer.

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Secondary options

pimecrolimus topical: (1%) apply sparingly to the affected area(s) twice daily

OR

tacrolimus topical: (0.03 or 0.1%) apply sparingly to the affected area(s) twice daily

OR

calcipotriene topical: (0.005%) apply sparingly to the affected area(s) twice daily

More

Plus – specialist systemic treatment

Back
ACUTE
|
psoriasis
|
severe systemic disease
Plus – 

specialist systemic treatment

Treatment recommended for ALL patients in selected patient group

Use systemic treatment with acitretin, methotrexate, cyclosporine, or biologic agents (e.g., etanercept). Carry out treatment under the guidance of a dermatologist.

reactive arthritis (Reiter disease)

1st line – topical corticosteroid or topical calcineurin inhibitor + supportive measures

Back
ACUTE
|
reactive arthritis (Reiter disease)
1st line – 

topical corticosteroid or topical calcineurin inhibitor + supportive measures

Use hydrocortisone, a low-potency topical corticosteroid, for mild disease and triamcinolone, a medium-potency topical corticosteroid, for moderate disease. Limit use to 2-3 weeks.

Topical calcineurin inhibitors can be used as an alternative to topical corticosteroids (and to avoid potential skin atrophy).[1]​ They are used until active skin disease resolution is seen. Be wary of extended use of these drugs in the uncircumcised male. 

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Secondary options

pimecrolimus topical: (1%) apply sparingly to the affected area(s) twice daily

OR

tacrolimus topical: (0.03 or 0.1%) apply sparingly to the affected area(s) twice daily

Plus – oral retinoids under specialist direction

Back
ACUTE
|
reactive arthritis (Reiter disease)
|
with HIV infection
Plus – 

oral retinoids under specialist direction

Treatment recommended for ALL patients in selected patient group

Oral retinoids can be particularly useful, especially in HIV infection. Carry out treatment under the guidance of a dermatologist or infectious disease specialist.

lichen sclerosus

1st line – topical corticosteroid ± antibiotic/antifungal

Back
ACUTE
|
lichen sclerosus
1st line – 

topical corticosteroid ± antibiotic/antifungal

Apply clobetasol, a high-potency topical corticosteroid, until resolution of active skin disease.[1]​ Its use induces remodeling of the affected mucosa, relieves phimosis, improves the histologic signs, and can avoid the need for circumcision. 

Avoid topical calcineurin inhibitors such as tacrolimus ointment and pimecrolimus cream.[55][56]

Add antibiotics and antifungals as indicated by specific findings of diagnostic testing.

Primary options

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

2nd line – surgery-circumcision

Back
ACUTE
|
lichen sclerosus
2nd line – 

surgery-circumcision

Surgical interventions range from circumcision, frenuloplasty, and meatotomy to sophisticated plastic repair, depending on the clinical presentation and the site of greatest disease impact on the organ.

Complete circumcision is the preferred treatment because all affected tissue is removed and any secondary involvement of the glans usually regresses or resolves after the procedure.

gonorrhea

1st line – antibiotic

Back
ACUTE
|
gonorrhea
1st line – 

antibiotic

Treat patients with recommended antibiotics for gonorrhea.[52][53][54] See Gonorrhea infection.

Plus – supportive measures

Back
ACUTE
|
gonorrhea
Plus – 

supportive measures

Treatment recommended for ALL patients in selected patient group

Advise patients to: pay attention to personal hygiene; avoid irritants such as antibacterial soaps and overwashing of the genital area; and avoid genital contact with common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).

Use of soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed is indicated.

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

candidiasis

1st line – identify underlying disease + topical antifungal + supportive measures

Back
ACUTE
|
candidiasis
1st line – 

identify underlying disease + topical antifungal + supportive measures

Identify and treat underlying disease and address predisposing factors.[1]​ Consider that it may be a secondary opportunistic complication of an underlying dermatosis, especially lichen sclerosus.

The antifungal agent is applied until resolution of active skin disease.

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Advise the patient to keep the area as cool and dry as possible and advise wearing undergarments that allow air to circulate (e.g., boxer-type undershorts, white cotton underwear).

Partners may need treatment as well.

Primary options

ketoconazole topical: (2%) apply to the affected area(s) once daily

Plus – topical corticosteroid

Back
ACUTE
|
candidiasis
|
severe erythema/inflammation
Plus – 

topical corticosteroid

Treatment recommended for ALL patients in selected patient group

Topical azole antifungal agents are often very usefully combined with hydrocortisone in cases with severe erythema/inflammation.[1]

Use of topical corticosteroids should not be continued for >2-3 weeks.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

Plus – oral antifungal

Back
ACUTE
|
candidiasis
|
resistant to topical therapies or severe/widespread involvement
Plus – 

oral antifungal

Treatment recommended for ALL patients in selected patient group

Under certain severe circumstances an oral azole antifungal (e.g., fluconazole) may be indicated if the patient has not responded to topical therapies or if there is severe/widespread involvement, as may be seen in immunocompromised patients.

Primary options

fluconazole: 50-100 mg orally once daily for 14 days

nonspecific balanoposthitis

1st line – lower-potency topical corticosteroid

Back
ACUTE
|
nonspecific balanoposthitis
1st line – 

lower-potency topical corticosteroid

Treatment can be very difficult, as nonspecific balanoposthitis often does not respond to general skin care measures, topical corticosteroids, or topical and systemic antibiotics. Consider subtle underlying lichen sclerosus.

Use hydrocortisone, a low-potency topical corticosteroid, for mild disease and triamcinolone, a medium-potency topical corticosteroid, for moderate disease. Limit use to 2-3 weeks.

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Plus – supportive measures

Back
ACUTE
|
nonspecific balanoposthitis
Plus – 

supportive measures

Treatment recommended for ALL patients in selected patient group

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]​

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Consider – targeted antibiotic or antifungal to treat identified pathogens

Back
ACUTE
|
nonspecific balanoposthitis
Consider – 

targeted antibiotic or antifungal to treat identified pathogens

Treatment recommended for SOME patients in selected patient group

Add antibiotics or antifungals as indicated by specific findings of diagnostic testing.

2nd line – high-potency topical corticosteroid

Back
ACUTE
|
nonspecific balanoposthitis
2nd line – 

high-potency topical corticosteroid

Use when the condition does not respond to treatment with lower-potency topical corticosteroids, antibiotics/ antifungals, and supportive measures.

Intermittent application of clobetasol may provide benefit. Continue until resolution of active skin disease.

Primary options

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

3rd line – surgery-circumcision

Back
ACUTE
|
nonspecific balanoposthitis
3rd line – 

surgery-circumcision

Circumcision is curative in most instances where patients have not responded to consecutive treatment trials of topical agents and other therapies (e.g., antibiotics).[33]​​

Zoon balanitis

1st line – moderate or high-potency topical corticosteroid

Back
ACUTE
|
Zoon balanitis
1st line – 

moderate or high-potency topical corticosteroid

Intermittent application of betamethasone (a moderate potency topical corticosteroid) or clobetasol (a high-potency topical corticosteroid) may provide benefit.[1]​ Continue until resolution of active skin disease (for no more than a few days at a time). Consider that it may represent underlying lichen sclerosus.

Primary options

betamethasone valerate topical: (0.1%) apply sparingly to the affected area(s) once or twice daily

OR

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily

Plus – supportive measures

Back
ACUTE
|
Zoon balanitis
Plus – 

supportive measures

Treatment recommended for ALL patients in selected patient group

Advise patients to pay attention to personal hygiene. With regard to the genital area, they should: avoid irritants (e.g., antibacterial soaps) and overwashing; avoid common allergens (e.g., perfumes, fragrant soaps, detergents, and fabric softeners).[1]

Use soap substitutes (e.g., aqueous cream, emulsifying ointment) once or twice daily and emollients (e.g., petroleum jelly, aqueous creams, lotions) when needed.[1]​

Use of a lubricant during sexual intercourse can improve symptoms of dyspareunia.

Affected patients should wear white cotton underwear.

Consider – targeted antibiotic or antifungal to treat identified pathogens

Back
ACUTE
|
Zoon balanitis
Consider – 

targeted antibiotic or antifungal to treat identified pathogens

Treatment recommended for SOME patients in selected patient group

Add antibiotics or antifungals as indicated by specific findings of diagnostic testing.

2nd line – surgery-circumcision

Back
ACUTE
|
Zoon balanitis
2nd line – 

surgery-circumcision

Circumcision is curative in most instances where patients have not responded to consecutive treatment trials of topical agents and other therapies (e.g., antibiotics).[33]​​

carcinoma in situ/penile intraepithelial neoplasia (PeIN)

1st line – circumcision (if not already circumcised)

Back
ACUTE
|
carcinoma in situ/penile intraepithelial neoplasia (PeIN)
1st line – 

circumcision (if not already circumcised)

Circumcision is the mainstay of treatment for penile carcinoma in situ/PeiN and should be offered if the patient is not already circumcised.

Consider – topical agent

Back
ACUTE
|
carcinoma in situ/penile intraepithelial neoplasia (PeIN)
Consider – 

topical agent

Treatment recommended for SOME patients in selected patient group

Topical agents such as fluorouracil, salicylic acid, podophyllin, and imiquimod can be used singly or in combination, and cyclically. The use of these topical agents in penile carcinoma in situ/PeiN is off-label and will reflect the individual clinical circumstances and the experience and competence of the treating physician; it is an expert area.

Topical treatments alone (in the absence of circumcision) are effective in only about 15% of cases.[25]

Consult specialist for guidance on doses.

Primary options

fluorouracil topical

OR

salicylic acid topical

OR

podophyllin topical

OR

imiquimod topical

Consider – cryotherapy, hyfrecation, laser therapy, or photodynamic therapy

Back
ACUTE
|
carcinoma in situ/penile intraepithelial neoplasia (PeIN)
Consider – 

cryotherapy, hyfrecation, laser therapy, or photodynamic therapy

Treatment recommended for SOME patients in selected patient group

Cryotherapy, hyfrecation, laser therapy, and photodynamic therapy are all options for treatment.

Consider – surgery

Back
ACUTE
|
carcinoma in situ/penile intraepithelial neoplasia (PeIN)
Consider – 

surgery

Treatment recommended for SOME patients in selected patient group

Surgical options include curettage and cautery, excision, Mohs micrographic surgery, and glans resurfacing.

Consider – postexposure HPV vaccination

Back
ACUTE
|
carcinoma in situ/penile intraepithelial neoplasia (PeIN)
Consider – 

postexposure HPV vaccination

Treatment recommended for SOME patients in selected patient group

In the presence of human papillomavirus (HPV)-driven undifferentiated penile intraepithelial neoplasia, there is a compelling rationale for postexposure HPV vaccination.[35][36]

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer