2026 BASHH国家指南：包皮龟头炎及相关的阴茎皮肤状况的管理

Abstract

Background: Balanoposthitis is a common presentation within sexual health services and encompasses a broad spectrum of infective, inflammatory, premalignant, and systemic conditions affecting the glans penis and foreskin. Accurate diagnosis is essential to ensure appropriate management, avoid unnecessary antimicrobial use, identify sexually transmitted infections (STIs), and recognise conditions requiring specialist referral. The 2025 guideline update was developed to strengthen recommendations on the diagnosis and management of infective balanoposthitis while improving recognition of important non-infective dermatoses and systemic disease presentations.

Methods: The guideline update was informed by a review of the current evidence base, emerging clinical data, and expert multidisciplinary consensus. Existing recommendations were reviewed and revised to reflect advances in diagnostic approaches, antimicrobial stewardship, and the management of inflammatory and premalignant penile dermatoses. Particular emphasis was placed on improving diagnostic accuracy, identifying clinical features suggestive of STIs or systemic disease, and clarifying indications for biopsy and specialist referral.

Discussion: The updated guideline highlights the importance of a structured clinical assessment supported by targeted investigations where appropriate. Infective causes remain an important consideration, including candidal balanoposthist, bacterial infection, and STIs; however, the guideline also emphasises the need to recognise common inflammatory dermatoses such as lichen sclerosus, psoriasis, eczema, and Zoon balanitis, as well as premalignant and malignant conditions. The recommendations promote evidence-based treatment strategies, reduce unnecessary empirical antimicrobial prescribing, and encourage earlier identification of patients requiring dermatology, urology, or penile cancer specialist input.

Conclusion: This 2025 guideline update aims to support clinicians in the earlier recognition and accurate diagnosis of balanoposthitis and related penile dermatoses. By promoting evidence-based management, antimicrobial stewardship, and timely referral for specialist care where indicated, the guideline seeks to improve patient outcomes and standardise care across sexual health and related clinical services.

Keywords

penile skin, genital dermatoses, men

# Corresponding author:

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# What is new in the 2025 guideline

Guideline reviewed to cover the diagnosis and management of infective causes of balanoposthitis and the recognition of other presentations, with initial treatment advice and reference to other relevant guidelines for management.

# Introduction and methodology

Objectives: The main objective is to aid recognition of the signs and symptoms and complications of penile skin con-ditions which may present in Sexual Health clinic attendees. This guideline concentrates on a selected group of conditions, which may present to sexual health services, either alone or in conjunction with other specialists. It is not intended as a comprehensive review of the treatment of all balanitis. The guideline is aimed primarily at people aged 16 years or older presenting to health care professionals working in sexual health services. The recommendations are primarily aimed at services offering level 3 care in sexually transmitted infections (STIs) management within the United Kingdom. However, the principles will apply to those presenting to level 1 and 2 services, and appropriate local referral pathways will need to be developed. This guideline offers re-com-mendations on the diagnostic tests and treatment regimens needed for the effective management of infective balano-posthistis and includes the following conditions:

o Candidal balanoposthitis

o Anaerobic infection

o Aerobic infection

o Balanoposthitis relating to STIs

It also provides guidance on the recognition of the following causes of balanoposthitis and gives general management advice only but provides references to the appropriate guidelines for specialist referral and care:

o Lichen sclerosus

o Lichen planus

o Zoon’s (plasma cell) balanitis

o Psoriasis and circinate balanitis

o Fixed drug eruptions

o Penile intraepithelial neoplasia (PeIN).

o Eczema

- Seborrheic

- Irritant/Allergic

o Balanitis associated with systemic disease

- Sarcoid

● Tuberculosis (TB).

- Crohn's disease

- Bechet's syndrome

Search strategy

This guideline was produced according to specifications set out in the CEG 21 document 'Framework for guideline development and assessment' (2015, 22 updated 2020).

Table I. Range of factors causing balanitis.$^{2,3}$

|Infectious|Dermatoses|Miscellaneous| |---|---|---| |Candida spp.|Lichen sclerosus|Trauma| |Staphylococcus aureus|Lichen planus|Poor hygiene| |Streptococci (Group A and B)|Psoriasis|Penile intraepithelial neoplasia (PelN)| |Anaerobes|Circinate balanitis|Systemic disease| |Gardnerella vaginalis|Zoon's balanitis|Behçet's| |Bacterial STIs|Eczema|Crohn's| |Chlamydia trachomatis|Irritant|Sarcoid| |Lymphogranuloma venereum|Seborrhoeic|Tuberculosis| |Neisseria gonorrhoeae|Contact allergy|| |Mycoplasma genitalium||| |Syphilis||| |Chancroid||| |Granuloma inguinale||| |Viral STIs|Fixed drug eruption|| |Herpes simplex||| |Human papillomavirus||| |Protozoal STIs|Stevens-Johnson syndrome|| |Trichomonas vaginalis||| |Entamoeba histolytica||| |Parasitic|Immuno-bullous disorders|| |Scabies|||

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accessed at https://www.bashh.org/userfiles/pages/files/resources/2020_guidelines_framework.pdf. It has been updated by reviewing the previous balanoposthitis guideline (2008) and medical literature since its publication using abstracts and articles in the English language up to August 2020. The following sources were reviewed: Medline/Pubmed and Embase, the Cochrane Library (including the Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews and Cochrane Central Register of Controlled Trials), British Association for Sexual Health and HIV (BASHH) and British Association of Dermatologists (BAD) guidelines (including the previous European guideline for the management of balanitis 2014 and the UK National guideline for the management of balanitis 2008), and the National Institute for Health and Care Excellence (NICE) guidelines. Other relevant guidelines were identified on Google or produced by the US Centres for Disease Control. The evidence reviewed included randomised controlled trials, cohort studies and in the absence of these, case series, case reports and consensus of the writing group. Where there was a paucity of randomised control trials and high-quality evidence for the management of genital manifestations of skin conditions, evidence from other sites was also reviewed by the writing group.

Search terms: Balanitis, Balanoposthitis, Penile dermatoses, and specific terms in respect of each condition.

Sources: OVID, Medline, PubMed, National Institute for Health, and Care Excellence (NICE), Cochrane Library, Guidelines produced by: IUSTI, BASHH, CDC.

Equality impact assessment: An assessment of the guideline and its recommendations was undertaken to ensure the principles of equality and diversity were adhered to.

Stakeholder involvement, piloting, and feedback

The document was reviewed by the Clinical Effectiveness Group of BASHH, and their comments incorporated. The draft guideline was placed on the BASHH website, and any comments received during the consultation period were reviewed by the authors and acted on appropriately. The document was also piloted by target users and the public panel of BASHH, and their feedback considered by the authors.

The guideline was circulated to Fabia Brackenburg (Vulval Health Awareness Campaign and Worldwide Lichen Sclerosus Support) and lay representative on the BASHH Dermatology special interest group, and her comments incorporated.

After publication on the BASHH website the CEG will keep it under review. The guideline will be formally reviewed and updated every 5 years.

Aetiologies. Balanitis is the term for inflammation of the glans penis, and posthititis describes inflammation of the prepuce. In practice both areas are often affected and the term balanoposthititis is then used. It is a common condition affecting up to 20% of uncircumcised men$^{1}$ but is

uncommon after circumcision. In many cases preputial dysfunction is a causal or contributing factor. It is a collection of disparate conditions with similar clinical presentation and varying aetologies affecting a particular anatomical site (see Table 1).

Other, rarer dermatoses are not included in this chart.

Infections may be secondary to primary inflammatory dermatoses.

General Management$^{2,3}$

Clinical features. The clinical features of balanoposthitis can be divided into local and systemic and primarily include a rash affecting the glans penis and preupce, which can cause itch. There may be associated changes in colour or texture and sometimes oedema of the skin. If fissuring or ulceration is present, this can be associated with discomfort and dyspareunia. There may also be difficulty retracting the foreskin and a sub-preputial discharge (which can be malodorous). The typical appearances of different conditions are covered in more detail in the individual management sections. Systemic symptoms include rash elsewhere on the body (including mucosal surfaces), joint pains and swelling, lymphadenopathy, and general malaise.

Diagnosis. Balanoposthitis is only a descriptive term, and a more specific diagnosis can often be made from the clinical appearances. However, the appearances should not be considered pathognonomic, particularly as complication by superinfection is common. Biopsy may be required for diagnostic uncertainty or to exclude Penile intraepithelial neoplasia (PeIN).$^{4}$

The following investigations aid diagnosis in cases of uncertainty, and onward referral may be required.

Sub-preputial swab for Candida spp. and bacterial culture - to exclude an infective cause or superinfection of a skin lesion or dermatosis.

Urinalysis for glucose - appropriate in most cases but especially if candidal infection is suspected.

Herpes simplex virus nucleic acid amplification test (NAAT) - if ulceration present.

Treponemal pallidum NAAT and/or dark ground examination for spirochaetes if an ulcer is present, with syphilis serology followed up to 3 months.

Microscopy or NAAT for Trichomonas vaginalis -particularly if a female partner has an undiagnosed vaginal discharge.

Screening for other sexually transmitted infections (STIs) - particularly screening for Chlamydia trachomatis infection/Non-specific urethritis if a circinate-type balanitis is present.

Dermatology opinion for dermatoses and suspected allergy.

Urological referral for circumcision or assessment of PeIN or possible malignancy.

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Biopsy - if the diagnosis is uncertain and the condition persists.$^{4}$

General management. The aims of diagnosis and treatment are to identify and manage patient symptoms, to diagnose and treat any related sexually transmitted disease, to minimise sexual dysfunction, to minimise urinary dysfunction, to treat pre-malignant disease and exclude penile cancer. The identification of any underlying diagnosis is also important in providing the patient with detailed information about the natural history and long-term health implications or their condition (such as risk of malignancy) and any risk to their partner if an STI is identified.

As predisposing factors for balanoposthitis include both poor hygiene and overwashing,$^{5}$ advice should be given on good genital skin care, personal hygiene, and avoidance of soaps. The use of emollients as soap substitutes should be encouraged. Patients should be warned of effects on condoms if creams are applied. Management of other predisposing factors such as a non-retractile foreskin and systemic conditions such as diabetes should be optimised and the role of circumcision$^{6}$ should be discussed.

Infective causes

Balanoposthitis may be caused by infectious agents, $7.8$ both sexually and non-sexually transmitted (although some of the latter may be sexually transmissible) as shown in Table 1. If an STI is suspected as a cause, a full screen for common STIs should be done. There is also an association between carriage of organisms and increased risk of Human Immunodeficiency virus (HIV) infection. However, the presence of an infective agent on swabbing does not confirm causality as superinfection of other skin conditions is common. Follow up is not generally needed.

Candidal balanoposthitis

Clinical features. Patients generally present with an ery-thematous rash which may be associated with itch and/or soreness. The typical appearance is of blotchy erythema with small papules, which can be eroded, or of dull red areas with a glazed appearance. In severe cases the whole of the glans and prepuce may be involved. It is commoner with increasing age$^{10}$ and can be the presenting sign of diabetes mellitus.

Diagnosis. The presence of Candida spp. can be confirmed by sub-preputial culture, but other dermatoses should be excluded as the presence of Candida spp. is most commonly an opportunistic infection. Similar appearances can be seen with irritant and non-specific balanoposthitis.

Urinalysis for glucose should be considered, as should investigation for causes of immunosuppression, if the balanitis is severe or persistent.

Management. Although there has been an increase in reports of drug resistance in serious candidal infection, there is no new evidence pertaining to treatment of candidal balanitis. Hygiene measures should be recommended as above. As there is a high rate of candidal infection in sexual partners, treatment of symptomatic partners can be considered (2, D).

Recommended regimens$^{11}$

Clotrimazole cream 1%$^{12}$ (I, A)

Miconazole cream 2%13(2,B)

Apply twice daily for 7-14 days.

Alternative regimens

Fluconazole 150 mg stat orally$^{12}$ (I, A)- if symptoms severe

Nystatin cream$^{13}$ 100,000 units/gm - if resistance suspected, or allergy to imidazoles (2, B)

Topical imidazole with 1% hydrocortisone - if marked inflammation is present$^{11}$ (2, D)

Anaerobic infection14

Clinical features. Characteristic features include the presence of foul-smelling odour and sub-preputial discharge, which may be associated with superficial erosions, oedema, and tender lymphadenopathy in severe cases. There is an association with phimosis.

Diagnosis. The diagnosis may be made clinically, but gram stain may show fusiform bacteria or a mixed bacterial picture. Culture may not be helpful, although Gardnerella vaginalis (a facultative anaerobe) may be isolated. Subpreputial NAAT should be taken to exclude other causes such as Trichomonas vaginalis or Herpes simplex virus (if ulcerated).

Management. If phimosis is present, circumcision may be required to prevent recurrence, and advice should be given about genital hygiene.

Recommended regimen

Metronidazole 400–500 mg twice daily × 1 week (1, D). The optimum dosage schedule for treatment is unknown.

Milder cases may respond to topical metronidazole.

Alternative regimen

Co-amoxiclav 375 mg three times daily $\times 1$ week.Clindamycin cream applied twice daily until resolved.

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These treatments have not been assessed in clinical trials (2, D).

Aerobic infection

Clinical features. The presence of erythema +/- oedema and purulent discharge may suggest an infective aetiology.

Diagnosis. This is dependent on the isolation of a potential causative organism on sub-preputial culture. Streptococcus spp. and Staphylococcus aureus have been reported as causing balanitis$^{7,8,15}$ although other organisms may also be involved. Superinfection of an underlying dermatosis rather than a primary infective balanitis should also be considered.

Management. Hygiene measures and topical treatment may be sufficient for milder cases, but more severe cases (i.e., if oedematous or if Group A Streptococci isolated) warrant systemic treatment and would depend on the sensitivities of the isolate.

Recommended regimens (2, D)

Mupirocin ointment 2–3 times per day for 7–10 days$^{16}$ Trimovate cream once or twice daily for 7–10 days. Severe cases may require systemic antibiotics while awaiting culture results.$^{16,17}$

Consider prescribing oral phenoxymethylpenicillin 500 mg four times a day for 10 days while awaiting swab results.

Oral clarithromycin 250 mg twice daily for 7 days

Balanoposthitis relating to STIs

Balanoposthitis can be a feature of many STIs (see Table 1). The following section describes the presentation of balanoposthitis relating to specific STIs. For further diagnostic and management information please refer to BASHH guidelines for each condition.

Chlamydia (D-K serovars)

Clinical features. Chlamydial infection is associated with circinate balanitis, which is a feature in 40% of cases of reactive arthritis. $^{18}$ It presents as erythematous annular shallow erosions with raised borders and surface covered with yellowish white scaly areas. There may also be a serpiginous annular lesion that often has a greyish white granular appearance that may form geographical patterns. $^{17,18}$

Diagnosis. The diagnosis of chlamydial circinate balanitis is based on the clinical appearance with an associated positive NAAT for chlamydia. Histology should not be undertaken routinely but shows spongiform pustules seen in the upper

epidermis and resembles that of pustular psoriasis. The diagnosis may be supported by HLA B27 positivity.

Management. Chlamydial infection should be managed as per BASHH guidelines.$^{19}$ Skin lesions should be managed as for Psoriasis (see subsequent section).

Lymphogranuloma venereum (LGV)

Clinical features. The genital form of LGV causes transient superficial herpetiform ulcers on coronal sulcus, prepuce, glans & scrotum in men. Penile oedema may result in varying degrees of $phimosis^{20}$ although balanitis is a recognised but uncommon type of primary lesion in $LGV.^{21}$

Diagnosis and management$^{22,23}$. Refer to guidelines.$^{22,23}$

Gonorrhoea

Clinical features. Gonococcal balanoposthitis can rarely be the primary manifestation and is characterized by tender ulcers, pustules, or furuncles on the prepuce or shaft of the penis.$^{24}$ Abscesses of the prepuce and ulceration of glans penis have also been reported, but are rare.$^{25,26}$ It can also cause preputial oedema and erythema in men with ure-thritis.$^{27}$ Recurrent gonococcal balanoposthitis may result in secondary hypopigmentation of the glans.$^{28}$

Diagnosis and management. Refer to BASHH guidelines.$^{29}$

Mycoplasma

Clinical features. There is a significant correlation of Mycoplasma genitalium with development of balanitis/posthistis, usually in association with urethritis.$^{30}$ Mycoplasma genitalium can present as a non-specific balanitis and/or posthistis, and erythematous or circinate lesions with a tendency for haemorrhage may be seen.$^{31}$ Balanitis may also occur in the absence of urethral discharge.$^{30}$

Diagnosis and management. Refer to BASHH guidelines.$^{32}$

Syphilis

Clinical features. Syphilitic balanitis of Follman is an uncommon presentation of primary syphilis and is described as erosive balanitis with a bright red glans and foreskin, with multiple oozing superficial erosions and associated with palpable non-tender lymph nodes.$^{33}$

Features may be variable and can also include oedema and dark red erythema over the glans penis,$^{34,35}$ diffuse induration of the glans penis.$^{34-37}$ Erosions, crusted or scaly lesions and coalescent white/pink papules and circinate lesions have also been described.$^{35,36,38-40}$

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Syphilitic balanoposthitis has been reported at all stages of infectious syphilis and may not always present with a concomitant chancre.$^{33,35-37,41,42}$

Diagnosis and management. Balanitis can be the sole clinical feature of primary syphilis. Syphilis should be suspected in cases of balanoposthistis, particularly when there is indu-ration of the glans penis and lymphadenopathy. Dark field microscopy or NAAT should be undertaken where possible and syphilis serology should be performed. Diagnosis of syphilitic balanoposthistis requires the exclusion of other infections.

For further details of diagnosis and management refer to BASHH guidelines.43

Chancroid

Clinical features. Lesions begin as tender erythematous papules on prepuce and frenulum in men which then ulcerate. Balanoposthitis develops from the irritant effects of by purulent discharge from untreated lesions in uncircumcised $men.^{44}$

Diagnosis and management. Refer to BASHH guidelines.$^{45}$

Granuloma inguinale

Clinical features. Balanoposthitis may be caused by the purulent exudate from fleshy granulomatous ulcers affecting the foreskin or glans. The lesions themselves are

painless, non-indurated and covered with friable granula-tion tissue.

Diagnosis and management. Refer to BASHH guidelines.$^{46}$

Genital Herpes simplex virus infection

Clinical features. Typical lesions of herpes may rarely develop into a necrotising balanitis.$^{47,48}$ This is characterised by eschars, pustules and purulent discharge on the glans and erythema and oedema of the glans, prepuce, and shaft. Immunosuppressed patients may develop chronic ulceration, crusted and verrucous lesions.

Diagnosis and management. Refer to BASHH guidelines.$^{49}$

Human papillomavirus (HPV) infection

Clinical features. Balanoposthitis has been associated with subclinical HPV infection of the glans and prepuce. This is commoner in uncircumcised men with a history of prior treatment for warts, and can present with redness, itching, burning, tenderness, and dyspareunia. It may cause macular lesions, fissuring and rarely, penile oedema and adenopathy.$^{50,51}$

Diagnosis. HPV should be considered in the pathogenesis of chronic and/or recurrent balanoposthitis. Usually a clinical diagnosis is made from recognition of characteristic lesions although dermatoscopy/penoscopy may be helpful (if

Dermatological Presentations


Figure I. Dermatological presentations.

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available). Rarely, biopsy may be required to confirm the diagnosis in atypical lesions. HPV detection or typing does not influence management and is not recommended.$^{52}$

Management. Refer to BASHH guidelines.$^{53}$

Human Immunodeficiency Virus (HIV) infection

HIV may be associated with balanoposthitis, particularly circinate balanitis, which may be in a more severe form. Other forms of balanitis have also presented in HIV infection but no specific HIV related balanoposthitis is reported. There is also an association between carriage of organisms and increased risk of Human Immunodeficiency virus (HIV) infection.$^{9}$

Trichomoniasis

Clinical features. Balanoposthitis may occur in approximately one third of male carriers of Trichomonas vaginalis (TV), and a long prepuce has been found to be a predisposing factor.$^{54}$ It typically causes an erosive balanitis, but ulcerative forms can also occur. Patients may also have an associated urethritis, and inguinal adenopathy.$^{54,55}$

Diagnosis. Diagnosis can be confirmed by identification of TV from the sub-preputial space in a wet preparation or by NAAT.

Management. Refer to BASHH guidelines.$^{56}$

Scabies

Clinical features. Scabetic balanitis can present with erythematous, excoriated papules and nodules with pustules secondary to bacterial infection.$^{57}$ Bullous lesions have also been described.$^{58,59}$

Diagnosis and management. Diagnosis is dependent on identification of pathognomonic lesions in association with balanitis.

Refer to BASHH guidelines.$^{60}$

Dermatological presentations (see Figure I)

Pallor

Lichen sclerosus typically reveals pale or white patches on the glans, often with involvement of the prepuce. Architectural changes such as blunting of the coronal sulcus, phimosis or ‘wasting’ of the prepuce, and meatal narrowing.

Differential diagnosis of pallor: vitiligo – this present without any inflammation or structural change.

Initial management: Ultra-potent topical steroids (e.g., clobetasol propionate 0.05% ointment) applied once daily for up to 3 months (reducing course) until remission, then gradually reduce to a maintenance dose.$^{61-63}$

Complications: superinfection, penile cancer.

Further management and guidelines: Ref. 61–76.

Well demarcated erythema

Lichen planus$^{6,77-88}$

Characteristic clinical appearance on keratinised skin is of polygonal violaceous papules, which may be itchy and associated with white reticulate surface (Wickham's striae), with linear lesions exhibiting Koebner's phenomenon. Annular white patches and erosive lesions can occur on mucosal surfaces.

Initial management

Moderate to ultrapotent topical steroids depending on $severity^{83,84}$ (1, B).

E.g., Clobetasol propionate ointment or cream applied daily for 4 weeks then reducing in frequency over the next 8 weeks depending on response.

Complications: phimosis, dysplasia/squamous ca.

Further management and guidance: Ref. 6,77–88.

Zoon's balanitis$^{89-99}$

Appearance includes well circumscribed orange-red glazed areas with multiple pinpoint redder spots - “cayenne pepper spots” on the glans and contiguous inner aspect of the prepuce in a symmetrical pattern.

Initial $management^{92,93}$: consider topical steroid preparations with or without added antibacterial agents e.g. Clobetasol proprionate or Trimovate cream, applied once or twice daily (1, D) and refer for $circumcision.^{92}$

Complications: missing diagnosis of PeIN/SCC.

Further management and guidance: Ref. 89–99.

Psoriasis and circinate balanitis$^{100-105}$

The lesions are characteristically well demarcated, and in the circumcised male, psoriasis on the glans is similar in appearance to the condition elsewhere, presenting with red scaly plaques. However, in uncircumcised men, scaling is lost, and the patches appear red and glazed. The clinical features of circinate balanitis are described under chlamydial infection.

Initial management: Moderate potency topical $steroids^{102,103}$ (+/- antibiotic and antifungal) (1, C).

Further management and guidance: ref 102-107.

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Fixed drug eruptions106-108

The lesions are usually well demarcated and erythematous but can be bullous with subsequent ulceration. As the inflammation settles there may be post-inflammatory hyperpigmentation.

Initial management: Lesions will settle without treatment when the precipitant is discontinued, but mild to moderate strength topical steroids may be required for symptomatic $relief^{109}(1,$ C).

Penile intraepithelial neoplasia$^{109-135}$

These are an important differential diagnosis and should be considered for any non-resolving lesion. They are now classified as differentiated and undifferentiated PeIN – the latter more commonly affecting the glans and having a greater risk of malignant transformation.

Lesions vary in clinical appearance.

small warty/papillomatous papules, usually appearing on the lower shaft or base of the glans penis and surrounding pubic region. Lesions are usually multiple. (Previously known as Bowenoid papulosis) warty, scaly, and eczematous or psoriatic appearance erythematous patch. (Previously known as Bowen's disease)

A 'glazed' or 'velvety' red patch. (Previously known as Erythroplasia of Queyrat). Risk of progression to invasive cancer appears relatively high if untreated; almost a third of patients.$^{127}$

Management: Patients should be referred to Uro-Oncology multidisciplinary pathways (1, A).

Further management and guidance: Ref. 109–135.

Poorly demarcated erythema

Eczema

Seborrhoeic dermatitis$^{136-138}$. Seborrhoeic dermatitis can cause non-specific redness and itch, without the scale seen at non genital sites. Seborrhoeic dermatitis classically affects other sites such as nasolabial folds, scalp, ears, and eyebrows.

Initial management: Antifungal cream with a mild to moderate steroid (1, D).

Further management and guidance: There is a paucity of evidence specifically for balanitis, and low-quality evidence for other $sites^{138-140}$.

Irritant/allergic $eczema^{139-142}$. Irritant balanoposthitis is commonly associated with frequent washing of the genital area with soap and is associated with fragrances and preservatives. There may be a history of atopy. Patients usually

present with itch and redness, and the appearances can vary in severity from mild erythema to widespread oedema of the penis.

Initial management: Patients should be advised to avoid soaps and other precipitants, and to use emollients as soap substitutes and as required. Recurrent problems are common, and the patients need to be informed of this.

Recommended regimen

Hydrocortisone 1% applied once or twice daily until resolution of symptoms. (1C)

In more florid cases more potent topical steroids may be required and may need to be combined with antifungals and/or antibiotics

Calcineurin inhibitors may be useful (II, b),$^{113}$ but onward referral is recommended

Further management: Refs. 136–142.

Balanitis associated with systemic disease$^{143-164}$

Whilst the majority of genital skin presentations are likely to be sexually transmitted or specific dermatoses, it is important to consider other systemic causes in the differential diagnoses, especially in lesions refractory to treatment or those at low risk of STIs.

Below is a list of alternative causes of genital lesions that should be considered so that they can be appropriately identified and referred on to the appropriate specialty (1, D).

Sarcoid

Sarcoid has been reported to cause ulcerative lesions of the penis,$^{143}$ as well as pink/purple annular eczema-like plaques and papules associated with pruritus and oedema.$^{144-146}$

Tuberculosis (TB)

TB tends to present as small, shallow genital ulceration with either singular or multiple lesions, sometimes with sinus tract formation. Very rarely, it can result in elephantiasis of the $genitals.^{147-149}$

Crohn’s disease

Crohn's of the genital region can present as genital ulceration, balanitis and phimosis or genital oedema.$^{150-152}$

Behçet’s syndrome

BS-related genital aphthous ulcers typically start as a tender nodule, becoming a round, deep and painful ulcer (0.5 cm to

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over 3 cm), interfering with sitting, walking, and causing sexual dysfunction. $^{153-164}$

Consideration of resource implications

It is acknowledged that some tests and treatments may not be available in all settings. Where biopsy is not available these patients should be referred to Dermatology. We recommend if malignancy is considered to refer on 2WW cancer pathway.

Some treatment preparations, e.g., Topical vit D preparations, may not be available on local formularies. It is advised that such preparations are discussed with MDT before prescribing.

Qualifying statement

The recommendations in this guideline may not be appropriate for use in all clinical situations. Decisions to follow these recommendations must be based on the professional judgement of the clinician and consideration of individual patient circumstances and available resources. It is acknowledged that not all departments will have specific genital dermatology provision.

All possible care has been taken to ensure the publication of the correct dosage of medication and route of administration. However, it remains the responsibility of the prescribing physician to ensure the accuracy and appropriateness of the medication they prescribe.

Auditable outcome measures

Patients should be given a full explanation of their condition with written or web-based information. Target 97%

An assessment should be made of the impact of the condition on the person's quality of life and/or sexual health should be assessed and documented. Target 97%

ORCID iDs

Georgina Morris iD https://orcid.org/0000-0001-5986-0695 Jason Eng Kiat Lim iD https://orcid.org/0000-0002-1862-452X Deepa Grover iD https://orcid.org/0000-0002-0232-1583

Ethical considerations

This guideline is based on a review of published literature and expert consensus and does not involve primary research on human participants.

Author contributions

Conceptualisation: Sarah K. Edwards, Deepa Grover Methodology: Sarah K. Edwards, Deepa Grover Investigation (literature review): All authors

Writing – original draft: Sarah K. Edwards, Pareswaran Shashidharan

Writing – review & editing: Sarah Edwards, Deepa Grover

Editor: Deepa Grover

All authors have read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work received no external funding. The guideline was commissioned and supported by the British Association for Sexual Health and HIV (BASHH) Clinical Effectiveness Group.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All members of the guideline writing committee completed the BASHH conflict of interest declaration form at the time the guideline's final draft was submitted to the CEG.

Editorial independence

This guideline was commissioned, edited, and endorsed by the BASHH CEG without funding being sought or obtained.

Guarantor

SKE.

References

1. Morris BJ and Krieger JN. Penile inflammatory skin disorders, and the preventive role of circumcision. Int J Prev Med 2017; 8: 32. https://doi.org/10.4103/ijpvm.IJPVM_377_16

2. Edwards S and Bunker C. Chapter 7: other conditions affecting the male genitalia. In: Rogstad K (ed). ABC of Sexually Transmitted Infections. 6th ed. Wiley-Blackwell, 2011, pp. 35–41.

3. Bunker CB. Male genital skin disease. W B Saunders Co Ltd, 2004. E-book.

4. Rao A and Bunker CB. Male genital skin biopsy. Int J STD AIDS 2011; 22(7): 418-419. https://doi.org/10.1258/ijsa.2011.011072

5. Birley HDL, Walker MM, Luzzi GA, et al. Clinical features and management of recurrent balanitis: association with atopy and genital washing. Genitourin Med 1993; 69: 400–403. https://doi.org/10.1136/sti.69.5.400

6. Mallon E, Hawkins D, Dinneen M, et al. Circumcision, and genital dermatoses. Arch Dermatol 2000; 136(3): 350–354. https://doi.org/10.1001/archderm.136.3.350

7. Alsterholm M, Flytström I, Leifsdottir R, et al. Frequency of bacteria, Candida and malassezia species in balanoposthitis. Acta Derm Venereol 2008; 88(4): 331–336. https://doi.org/10.2340/00015555-0478

8. Lisboa C, Ferreira A, Resende C, et al. Infectious balano-posthitis: management, clinical and laboratory features. Int

10

International Journal of STD & AIDS O(0)

J Dermatol 2009; 48(2): 121–124. https://doi.org/10.1111/j.1365-4632.2009.03966.x

9. Onywera H, Williamson AL, Cozzuto L, et al. The penile microbiota of Black South African men: relationship with human papillomavirus and HIV infection. BMC Microbiol 2020; 20(1): 78. https://doi.org/10.1186/s12866-020-01759-x

10. Lisboa C, Santos A, Dias C, et al. Candidal balanitis: risk factors. J Eur Acad Dermatol Venereol 2010; 24(7): 820–826. https://doi.org/10.1111/j.1468-3083.2009. 03533.x

11. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries. Candida – Skin. https://cks.nice.org.uk/candida-skin (2025, accessed 20 08 2025).

12. Stary A, Soeltz-Szoets J, Ziegler C, et al. Comparison of the efficacy and safety of oral fluconazole and topical clotrimazole in patients with Candida balanitis. Genitourin Med 1996; 72(2): 98–102. https://doi.org/10.1136/sti.72.2.98

13. Forster GE and Harris JRW. Double blind therapeutic trial in balanitis – miconazole and nystatin. Eur J Sex Transm Dis 1986; 3: 81–83.

14. Ewart CG, Willis AT, Phillips KD, et al. Anaerobic bal-anoposthitis. Br Med J 1982; 284: 859–860.

15. Minami M, Wakimoto Y, Matsumoto M, et al. Characterization of Streptococcus pyogenes isolated from balano-posthitis patients presumably transmitted by penile-oral sexual intercourse. Curr Microbiol 2010; 61(2): 101–105. https://doi.org/10.1007/s00284-010-9581-x

16. National Institute for Health and Care Excellence (NICE).Clinical knowledge summaries CKS. Balanitis, 2024.https://cks.nice.org.uk/balanitis(accessed 20 08 2025).

17. Edwards SK, Bunker CB, van der Snoek EM, et al. 2022 European guideline for the management of balanoposthitis. J Eur Acad Dermatol Venereol 2023; 37(6): 1104–1117. https://doi.org/10.1111/jdv.18954

18. Wray AA, Velasquez J, Leslie SW, et al. Balanitis. In: StatPearls. StatPearls Publishing, 2020. Updated 31st August 2024. https://www.ncbi.nlm.nih.gov/books/ NBK537143/

19. Nwokolo NC, Dragovic B, Patel S, et al. 2015 UK national guideline for the management of infection with Chlamydia trachomatis. Int J STD AIDS 2016; 27(4): 251–267. Updated 26th Sept 2018. https://doi.org/10.1177/0956462415615443. https://www.bashh.org/guidelines/

20. Kiley JL. Lymphogranuloma Venereum (LGV) Clinical Presentation: History, Physical, Causes. Medscape, 2025. Updated January 3, 2025. Available at: Medscape LGV Clinical Presentation. (Accessed 20 August 2025).

21. Coutts WE. Lymphogranuloma venereum; a general review. Bull World Health Organ 1950; 2(4): 545–562.

22. de Vries HJC, de Barbeyrac B, de Vrieze NHN, et al. 2019 European guideline on the management of lymphogranuloma venereum. J Eur Acad Dermatol Venereol 2019; 33(10): 1821–1828. https://doi.org/10.1111/jdv.15729

23. White J, O'Farrell N and Daniels D. British association for sexual health, and HIV. 2013 UK national guideline for the management of lymphogranuloma venereum: Clinical Effectiveness Group of the British Association for Sexual Health and HIV (CEG/BASHH) guideline development group. Int J STD AIDS 2013; 24(8): 593–601.

24. Haim S and Merzbach D. Gonococcal penile ulcer. Br. J Vener Dis 1970; 46(4): 336–337. https://doi.org/10.1136/sti.46.4.336

25. Rosen T. Unusual presentations of gonorrhea. J Am Acad. Dermatol 1982; 6: 369–372. https://doi.org/10.1016/s0190-9622(82)70031-3

26. Neubert U, Korting HC, Luderschmidt C, et al. Preputial abscesses caused by beta-lactamase-producing gonococci. Cutis 1985; 36(2): 161–163.

27. Fiumara NJ and Kahn S. Contact dermatitis from a gonococcal discharge: a case report. Sex Transm Dis 1982; 9(1): 41–42. https://doi.org/10.1097/00007435-198201000-00008

28. Abdul Gaffoor PM. Hypopigmentation of the glans penis. Cutis 1983; 31(2): 214.

29. Fifer H, Ismail MA, Soni S, et al. British association of sexual health, and HIV UK national guideline for the management of infection with Neisseria gonorrhoeae, 2025. Int J STD AIDS 2025: 9564624251345195. https://www.bashh.org/guidelines/

30. Horner PJ and Taylor-Robinson D. Association of Mycoplasma genitalium with balanoposthitis in men with non-gonococcal urethritis. Sex Transm Infect 2011; 87(1): 38–40. https://doi.org/10.1136/sti.2010.044487

31. Siboulet A, Catalint F and Deubel M. Balanitis et mycoplasma. Bull Soc Fr Dermatol Syphiligr 1975; 82: 419–422.

32. Soni S, Horner P, Rayment M, et al. British association for sexual health and HIV national guideline for the management of infection with Mycoplasma genitalium (2018). Int J STD AIDS 2019; 30(10): 938-950. https://doi.org/10.1177/0956462419825948. https://www.bashh.org/guidelines/

33. Follmann E. Le problème de la balanite syphilitique. Ann Dermatol Syphiligr 1948; 8: 470–483.

34. Degos R. Present-days aspects of primo-secondary syphilis. Rev Med (Paris) 1970; 23: 1333–1341.

35. Oanţă A and Irimie M. Syphilitic balanitis of Follmann. Int J Dermatol 2014; 53(7): 830–831. https://doi.org/10.1111/ijd.12068

36. Abdennader S, Janier M and Morel P. Syphilitic balanitis of Follmann: three case reports. Acta Derm Venereol 2011; 91(2): 191–192. https://doi.org/10.2340/00015555-0983

37. Rovira-López R, García-Martínez P, Martín-Ezquerra G, et al. Balanoposthitis and penile edema: atypical manifestations of primary syphilis. Sex Transm Dis 2015; 42(9): 524–525. https://doi.org/10.1097/OLQ.0000000000000322

38. Mainetti C, Scolari F and Lautenschlager S. The clinical spectrum of syphilitic balanitis of Follmann: report of five cases and a review of the literature. J Eur Acad Dermatol Venereol 2016; 30(10): 1810–1813. https://doi.org/10.1111/jdv.13802

Edwards et al.

||

39. Babu CS, Vitharana S and Higgins SP. Primary syphilis presenting as balanitis. Int J STD AIDS 2007; 18(7): 497–498. https://doi.org/10.1258/095646207781147346

40. Lejman K and Starzycki Z. Syphilitic balanitis of Follmann developing after the appearance of the primary chancre. A case report. Br J Vener Dis 1975; 51(2): 138–140. https://doi.org/10.1136/sti.51.2.138

41. Waugh MA. Balanitis. Dermatol Clin 1998; 16(4): 757–762. https://doi.org/10.1016/s0733-8635(05)70042-5

42. Korta DZ, Lewin JM, Patel RR, et al. Acute syphilitic balanitis and gross penile edema in an HIV-Infected man. Global J Dermatol Venereol 2013; 1: 18–20.

43. Kingston M, Apea V, Evans C, et al. BASHH UK guidelines for the management of syphilis 2024. Int J STD AIDS 2024; 35(14): 1142-1160. https://doi.org/10.1177/09564624241280406. https://www.bashh.org/guidelines/

44. Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect 2003; 79: 68–71. https://doi.org/10.1136/sti.79.1.68

45. O'Farrell N and Lazaro N. UK national guideline for the management of Chancroid 2014. Int J STD AIDS 2014; 25(14): 975-983. https://doi.org/10.1177/0956462414542988. https://www.bashh.org/guidelines/

46. O'Farrell N, Hoosen A and Kingston M. 2018 UK national guideline for the management of donovanosis. Int J STD AIDS 2018; 29(10): 946–948. https://www.bashh.org/guidelines/

47. Powers RD, Rein MF and Hayden FG. Necrotizing bal-anitis due to herpes simplex type 1. JAMA 1982; 248(2): 215–216.

48. Peutherrer JF, Smith IW and Robertson DHH. Necrotising balanitis due to a generalized primary infection with herpes simplex virus type 2. Br J Vener Dis 1979; 55(1): 48–51.

49. Patel R, Green J, Moran B, et al. British association of sexual health, and HIV UK national guideline for the management of anogenital herpes, 2024. Int J STD AIDS 2025; 36(2): 90-105. https://doi.org/10.1177/09564624241282396. https://www.bashh.org/guidelines/

50. Wikström A, von Krogh G, Hedblad MA, et al. Papillomavirus-associated balanoposthitis. Genitourin Med 1994; 70(3): 175–181. https://doi.org/10.1136/sti.70.3.175

51. Löwhagen GB, Bolmstedt A, Ryd W, et al. The prevalence of "high-risk" HPV types in penile condyloma-like lesions: correlation between HPV type and morphology. Sex Transm Infect 1993; 69: 87–90. https://doi.org/10.1136/sti.69.2.87

52. Gilson R, Nugent D, Werner RN, et al. 2019 IUSTI-Europe guideline for the management of anogenital warts. J Eur Acad Dermatol Venereol 2020; 34(8): 1644–1653. https://doi.org/10.1111/jdv.16522

53. Nugent D, Apoola A, Coleman H, et al. British association for sexual health and HIV national guideline for the management of anogenital warts in adults (2024). Int J STD AIDS 2024; 35(7): 498-509. https://doi.org/10.1177/09564624241233338. https://www.bashh.org/guidelines/

54. Michalowski R. Balano-posthites à Trichomonas. A propos de 16 observations [Trichomonal balano-posthitis. Report of 16 cases (author's transl)]. Ann Dermatol Venereol 1981; 108(10): 731–738.

55. English JC 3rd, Laws RA, Keough GC, et al. Dermatoses of the glans penis and prepuce. J Am Acad Dermatol 1997; 37(1): 1-24, quiz 25-6. https://doi.org/10.1016/s0190-9622(97)70207-x

56. Sherrard J, Pitt R, Hobbs KR, et al. British Association for Sexual Health, and HIV (BASHH) United Kingdom national guideline on the management of Trichomonas vaginalis 2021. Int J STD AIDS 2022; 33(8): 740–750. https://doi.org/10.1177/09564624221103035. https://www.bashh.org/guidelines/

57. Elgart ML. Scabies. Dermatol Clin 1990; 8(2): 253–263.

58. Viraben R and Dupre A. Scabies mimicking bullous pemphigoid. J Am Acad Dermatol 1989; 20(1): 134–136. https://doi.org/10.1016/s0190-9622(89)80013-1

59. Chapel TA, Krugel L, Chapel J, et al. Scabies presenting as urticaria. JAMA 1981; 246(13): 1440–1441.

60. Morris G, Haddow L, Sashidharan PN, et al. British association for sexual health, and HIV national guideline on the management of scabies in adults 2025. Int J STD AIDS 2025; 36: 516-532. https://doi.org/10.1177/09564624251321264. https://www.bashh.org/guidelines/

61. Kravvas G, Shim TN, Doiron PR, et al. The diagnosis and management of male genital lichen sclerosus: a retrospective review of 301 patients. J Eur Acad Dermatol Venereol 2018; 32(1): 91–95. https://doi.org/10.1111/jdv.14488

62. Lewis FM, Tatnall FM, Velangi SS, et al. British association of dermatologists guidelines for the management of lichen sclerosus, 2018. Br J Dermatol 2018; 178(4): 839–853. https://doi.org/10.1111/bjd.16241

63. Piris A, Sanchez DF, Fernandez-Nestosa MJ, et al. Topographical evaluation of penile Lichen sclerosus reveals a lymphocytic depleted variant, preferentially associated with neoplasia: a report of 200 cases. Int J Surg Pathol 2020; 28(5): 468-476. https://doi.org/10.1177/1066896920901333

64. Bunker CB and Shim TN. Male genital lichen sclerosus. Indian J Dermatol 2015; 60(2): 111–117. https://doi.org/10.4103/0019-5154.152501

65. Bunker CB, Patel N and Shim TN. Urinary voiding symptomatology (micro-incontinence) in male genital li- chen sclerosus. Acta Derm Venereol 2013; 93(2): 246-248. https://doi.org/10.2340/00015555-1481

66. Hofer MD, Meeks JJ, Mehdiratta N, et al. Lichen sclerosus in men is associated with elevated body mass index, diabetes mellitus, coronary artery disease and smoking. World J Urol 2014; 32(1): 105–108. https://doi.org/10.1007/s00345-013-1090-7

67. Kirtschig G, Becker K, Günthert A, et al. Evidence-based (S3) guideline on (anogenital) Lichen sclerosus. J Eur Acad Dermatol Venereol 2015; 29(10): el-e43. https://doi.org/10.1111/jdv.13136

12

International Journal of STD & AIDS O(0)

68. Edmonds EV, Hunt S, Hawkins D, et al. Clinical parameters in male genital lichen sclerosus: a case series of 329 patients. J Eur Acad Dermatol Venereol 2012; 26(6): 730–737. https://doi.org/10.1111/j.1468-3083.2011.04155.x

69. Kantere D, Löwhagen GB, Alvengren G, et al. The clinical spectrum of lichen sclerosus in male patients - a retrospective study. Acta Derm Venereol 2014; 94(5): 542–546. https://doi.org/10.2340/00015555-1797

70. Powell J, Robson A, Cranston D, et al. High incidence of lichen sclerosus in patients with squamous cell carcinoma of the penis. Br J Dermatol 2001; 145(1): 85–89. https://doi.org/10.1046/j.1365-2133.2001.04287.x

71. Pietrzak P, Hadway P, Corbishley CM, et al. Is the association between balanitis xerotica obliterans and penile carcinoma underestimated? BJU Int 2006; 98(1): 74–76. https://doi.org/10.1111/j.1464-410X.2006.06213.x

72. Philippou P, Shabbir M, Ralph DJ, et al. Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis. BJU Int 2013; 111(6): 970–976. https://doi.org/10.1111/j.1464-410X.2012.11773.x

73. Chi CC, Kirtschig G, Baldo M, et al. Topical interventions for genital lichen sclerosus. Cochrane Database Syst Rev 2011; 12: CD008240. https://doi.org/10.1002/14651858. CD008240.pub2

74. Dahlman-Ghozlan K, Hedblad MA and von Krogh G. Penile lichen sclerosus et atrophicus treated with clobetasol diproprionate 0.05% cream: a retrospective clinical and histopathological study. J Am Acad Dermatol 1999; 40(3): 451-457. https://doi.org/10.1016/s0190-9622(99) 70496-2

75. Goldstein AT, Creasey A, Pfau R, et al. A double-blind, randomized controlled trial of clotebasol versus pimecrolimus in patients with vulgar lichen sclerosus. J Am Acad Dermatol 2011; 64(6): e99-e104. https://doi.org/10.1016/j.jaad.2010.06.011

76. Kulkarni S, Barbagli G, Kirpekar D, et al. Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol 2009; 55(4): 945–954. https://doi.org/10.1016/j.eururo.2008.07.046

77. Petruzzi M, De Benedittis M, Pastore L, et al. Peno-gingival lichen planus. J Periodontol 2005; 76(12): 2293–2298. https://doi.org/10.1902/jop.2005.76.12.2293

78. Halevy S and Shai A. Lichenoid drug eruptions. J Am Acad. Dermatol 1993; 29: 249–255. https://doi.org/10.1016/0190-9622(93)70176-t

79. Garcovich S, De Simone C, Genovese G, et al. Paradoxical skin reactions to biologics in patients with rheumatologic disorders. Front Pharmacol 2019; 10: 282. https://doi.org/10.3389/fphar.2019.00282

80. Itin PH, Hirsbrunner P and Büchner S. Lichen planus: an unusual cause of phimosis. Acta Derm Venereol 1992; 72(1): 41–42.

81. Kristiansen S, Svensson Å, Drevin L, et al. Risk factors for penile intraepithelial Neoplasia: a population-based register

study in Sweden, 2000–2012. Acta Derm Venereol 2019; 99(3): 315–320. https://doi.org/10.2340/00015555-3083

82. de Oliveira Leal ML, Alencar LRPJ, Santana SC, et al. Penile squamous cell carcinoma and lichen planus. Surg Exp Pathol 2020; 3: 1–3. https://doi.org/10.1186/s42047-019-0053-8

83. Irvine C, Irvine F and Champion RH. Long-term follow-up of lichen planus. Acta Derm Venereol 1991; 71(3): 242–244.

84. Cheng S, Kirtschig G, Cooper S, et al. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev 2012; 2: CD008092. https://doi.org/10.1002/14651858.CD008092.pub2

85. Husein-ElAhmed H, Gieler U and Steinhoff M. Lichen planus: a comprehensive evidence-based analysis of med- ical treatment. J Eur Acad Dermatol Venereol 2019; 33(10): 1847-1862. https://doi.org/10.1111/jdv.15771

86. Volz T, Caroli U, Lüdtke H, et al. Pimecrolimus cream 1% in erosive oral lichen planus-a prospective randomized double-blind vehicle-controlled study. Br J Dermatol 2008; 159(4): 936–941. https://doi.org/10.1111/j.1365-2133. 2008.08726.x

87. Poon F, De Cruz R and Hall A. Acitretin in erosive penile lichen planus. Australas J Dermatol 2017; 58(3): e87-e90. https://doi.org/10.1111/ajd.12506

88. Porter WM, Dinneen M, Hawkins DA, et al. Erosive penile lichen planus responding to circumcision. J Eur Acad Dermatol Venereol 2001; 15(3): 266–268.

89. Zoon JJ. Balanoposthite chronique circonscrite bénigne à plasmocytes [Chronic benign circumscript plasmocytic balanoposthitis]. Dermatologica (Basel) 1952; 105(1): 1–7.

90. Bunker CB. Zoon balanitis – does it exist? J Eur Acad Dermatol Venereol 2020; 34(3): e116–e117. https://doi.org/ 10.1111/jdv.16037

91. Weyers W, Ende Y, Schalla W, et al. Balanitis of Zoon: a clinicopathologic study of 45 cases. Am J Dermatopathol 2002; 24(6): 459–467. https://doi.org/10.1097/00000372-200212000-00001

92. Kumar B, Sharma R, Rajagopalan M, et al. Plasma cell balanitis: clinical and histological features - response to circumcision. Genitourin Med 1995; 71(1): 32–34. https://doi.org/10.1136/sti.71.1.32

93. Tang A, David N and Horton LW. Plasma cell balanitis of Zoon: response to Trimovate cream. Int J STD AIDS 2001; 12(2): 75–78. https://doi.org/10.1258/0956462011916811

94. Cohen PR. Topical mupirocin 2% ointment for diagnosis of Zoon's balanitis and monotherapy of balanitis circumscripta plasmacellularis. Int J Dermatol 2019; 58(6): e114–e115. https://doi.org/10.1111/ijd.14368

95. Lee MA and Cohen PR. Zoon Balanitis revisited: report of Balanitis Circumscripta plasmacellularis resolving with topical mupirocin ointment monotherapy. J Drugs Dermatol JDD 2017; 16(3): 285–287.

96. Bari O and Cohen PR. Successful management of Zoon's balanitis with topical mupirocin ointment: a case report and literature review of mupirocin-responsive balanitis circumscripta plasmacellularis. Dermatol Ther 2017;

Edwards et al.

13

7(2): 203-210. https://doi.org/10.1007/s13555-017-0178-1

97. Roe E, Dalmau J, Peramiquel L, et al. Plasma cell bal- anitis of zoon treated with topical tacrolimus 0.1%: rep- port of three cases. J Eur Acad Dermatol Venereol 2007; 21(2): 284–285. https://doi.org/10.1111/j.1468-3083. 2006.01857.x

98. Castellsague J, Kuiper JG, Pottegård A, et al. A cohort study on the risk of lymphoma and skin cancer in users of topical tacrolimus, pimecrolimus, and corticosteroids (joint European longitudinal lymphoma and skin cancer evaluation - JOELLE study). Clin Epidemiol 2018; 10: 299–310. https://doi.org/10.2147/CLEP.S146442

99. Retamar RA, Kien MC and Chouela EN. Zoon's balanitis: presentation of 15 patients, five treated with a carbon dioxide laser. Int J Dermatol 2003; 42(4): 305–307. https://doi.org/10.1046/j.1365–4362.2003.01304.x

100. Menon K, Van Voorhees AS, Bebo BF Jr, et al. Psoriasis in patients with HIV infection: from the medical board of the national psoriasis foundation. J Am Acad Dermatol 2010; 62(2): 291–299. https://doi.org/10.1016/j.jaad.2009.03.047

101. Nast A, Kopp I, Augustin M, et al. German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version). Arch Dermatol Res 2007; 299(3): 111–138. https://doi.org/10.1007/s00403-007-0744-y

102. National Institute for Health and Clinical Excellence (NICE). Psoriasis: assessment and management [CG153]. https://www.nice.org.uk/guidance/cg153/resources/psoriasis-assessment-and-management-pdf-35109629621701 (2012, accessed 20 08 2025).

103. Reynolds KA, Pithadia DJ, Lee EB, et al. Treatments for inverse psoriasis: a systematic review. J Dermatol Treat 2019; 31(8): 786–793. https://doi.org/10.1080/09546634. 2019.1620912

104. Meeuwis KA, de Hullu JA, Massuger LF, et al. Genital psoriasis: a systematic literature review on this hidden skin disease. Acta Derm Venereol 2011; 91(1): 5–11. https://doi.org/10.2340/00015555-0988

105. Dattola A, Silvestri M, Bennardo L, et al. Update of calcineurin inhibitors to treat inverse psoriasis: a systematic review. Dermatol Ther 2018; 31(6): e12728. https://doi.org/10.1111/dth.12728

106. Flowers H, Brodell R, Brents M, et al. Fixed drug eruptions: presentation, diagnosis, and management. South Med J, 2014; 107(11): 724–727. https://doi.org/10.14423/SMJ. 0000000000000195

107. Zaouak A, Chabchoub I, Essid D, et al. Genital involvement in bullous fixed drug eruption. Skinmed 2019; 17(5): 306–309.

108. Maatouk I, Moutran R, Fahed M, et al. A "sexually transmitted" fixed drug reaction. Sex Transm Dis 2014; 41(10): 626-627. https://doi.org/10.1097/OLQ.0000000000000173

109. Miralles-Guri C, Bruni L, Cubilla AL, et al. Human papillomavirus prevalence and type distribution in penile

carcinoma. J Clin Pathol 2009; 62(10): 870–878. https://doi.org/10.1136/jcp.2008.063149

110. Barnholtz-Sloan JS, Maldonado JL, Pow-sang J, et al. Incidence trends in primary malignant penile cancer. Urol Oncol 2007; 25(5): 361–367. https://doi.org/10.1016/j. urolone.2006.08.029

111. Arya M, Li R, Pegler K, et al. Long-term trends in incidence, survival, and mortality of primary penile cancer in England. Cancer Causes Control 2013; 24(12): 2169–2176. https://doi.org/10.1007/s10552-013-0293-y

112. Kirrander P, Sherif A, Friedrich B, et al. Swedish national penile cancer register: incidence, tumour characteristics, management, and survival. BJU Int 2016; 117(2): 287–292. https://doi.org/10.1111/bju.12993

113. Rubin MA, Kleter B, Zhou M, et al. Detection and typing of human papillomavirus DNA in penile carcinoma: evidence for multiple independent pathways of penile carcinogenesis. Am J Pathol 2001; 159(4): 1211–1218. https://doi.org/10.1016/S0002-9440(10)62506-0

114. Olesen TB, Sand FL, Rasmussen CL, et al. Prevalence of human papillomavirus DNA and $p16^{INK4a}$ in penile cancer and penile intraepithelial neoplasia: a systematic review and meta-analysis. Lancet Oncol 2019; 20(1): 145–158. https://doi.org/10.1016/S1470-2045(18) 30682-X

115. Bleeker MC, Heideman DA, Snijders PJ, et al. Penile cancer: epidemiology, pathogenesis, and prevention. World J Urol 2009; 27(2): 141–150. https://doi.org/10.1007/s00345-008-0302-z

116. Paolino G, Panetta C, Cota C, et al. Lichen sclerosus and the risk of malignant progression: a case series of 159 patients. G Ital Dermatol Venereol 2013; 148(6): 673–678.

117. Mentrikoski MJ, Stelow EB, Culp S, et al. Histologic and immunohistochemical assessment of penile carcinomas in a North American population. Am J Surg Pathol 2014; 38(10): 1 3 4 0-1 3 4 8. https://doi.org/10.1097/PAS.0000000000000124

118. Engels EA, Biggar RJ, Hall HI, et al. Cancer risk in people infected with human immunodeficiency virus in the United States. Int J Cancer 2008; 123(1): 187–194. https://doi.org/10.1002/ijc.23487

119. Thuret R, Sun M, Budaus L, et al. A population-based analysis of the effect of marital status on overall and cancer-specific mortality in patients with squamous cell carcinoma of the penis. Cancer Causes Control 2013; 24(1): 71–79. https://doi.org/10.1007/s10552-012-0091-y

120. Ulff-Møller CJ, Simonsen J and Frisch M. Marriage, cohitation, and incidence trends of invasive penile squamous cell carcinoma in Denmark 1978-2010. Int J Cancer 2013; 133(5): 1173–1179. https://doi.org/10.1002/ijc.28107

121. Larke NL, Thomas SL, dos Santos Silva I, et al. Male circumcision and penile cancer: a systematic review and meta-analysis. Cancer Causes Control 2011; 22(8): 1097–1110. https://doi.org/10.1007/s10552-011-9785-9

14

International Journal of STD & AIDS O(0)

122. Wolbarst A. Circumcision and penile cancer. Lancet 1932; 219: 150–153. https://doi.org/10.1016/s0140-6736(01) 24346-3

123. Schoen EJ. The relationship between circumcision and cancer of the penis. CA Cancer J Clin 1991; 41(5): 306–309. https://doi.org/10.3322/canjclin.41.5.306

124. Moch H, Cubilla AL, Humphrey PA, et al. The 2016 WHO classification of tumours of the urinary system and male genital organs- part A: renal, penile, and testicular tumours. Eur Urol 2016; 70(1): 93–105. https://doi.org/10.1016/j.eururo.2016.02.029

125. Hoekstra RJ, Trip EJ, Ten Kate FJ, et al. Penile intra-epithelial neoplasia: nomenclature, incidence and progres-sion to malignancy in the Netherlands. Int J Urol 2019; 26(3): 353–357. https://doi.org/10.1111/iju.13871

126. Guimarães GC, Rocha RM, Zequi SC, et al. Penile cancer: epidemiology and treatment. Curr Oncol Rep 2011; 13(3): 231–239. https://doi.org/10.1007/s11912-011-0163-2

127. Wieland U, Jurk S, Weissenborn S, et al. Erythroplasia of queyrat: coinfection with cutaneous carcinogenic human papillomavirus type 8 and genital papillomaviruses in a carcinoma in situ. J Invest Dermatol 2000; 115(3): 396-401. https://doi.org/10.1046/j.1523-1747.2000.00069.x

128. Hakenberg OW, Compérat EM, Minhas S, et al. EAU guidelines on penile cancer: 2014 update. Eur Urol 2015; 67(1): 142–150. https://doi.org/10.1016/j.eururo.2014.10. 017

129. Kravvas G, Ge L, Ng J, et al. The management of penile intraepithelial neoplasia (PeIN): clinical and histological features and treatment of 345 patients and a review of the literature. J Dermatol Treat 2020; 33(2): 1047–1062. https://doi.org/10.1080/09546634.2020.1800574

130. Alnajjar HM, Lam W, Bolgeri M, et al. Treatment of carcinoma in situ of the glans penis with topical chemotherapy agents. Eur Urol 2012; 62(5): 923–928. https://doi.org/10.1016/j.eururo.2012.02.052

131. Manjunath A, Brenton T, Wylie S, et al. Topical therapy for non-invasive penile cancer (Tis)-updated results and toxicity. Transl Androl Urol 2017; 6(5): 803–808. https://doi.org/10.21037/tau.2017.06.24

132. Chipollini J, Yan S, Ottenhof SR, et al. Surgical management of penile carcinoma in situ: results from an international collaborative study and review of the literature. BJU, Int 2018; 121(3): 393–398. https://doi.org/10.1111/bju.14037

133. Ilkay AK, Chodak GW, Vogelzang NJ, et al. Buschke-Löwenstein tumor: therapeutic options including systemic chemotherapy. Urology 1993; 42(5): 599–602. https://doi.org/10.1016/0090-4295(93)90288-l

134. Kim SJ, Thompson AK, Zubair AS, et al. Surgical treatment and outcomes of patients with extramammary paget disease: a cohort study. Dermatol Surg 2017; 43(5): 708–714. https://doi.org/10.1097/DSS.0000000000001051

135. Snast I, Sharon E, Kaftory R, et al. Nonsurgical treatments for extramammary paget disease: a systematic review and

meta-analysis. Dermatology 2020; 236(6): 493–499. https://doi.org/10.1159/000506832

136. Okokon EO, Verbeek JH, Ruotsalainen JH, et al. Topical antifungals for seborrhoeic dermatitis. Cochrane Database Syst Rev 2015; 5: CD008138. https://doi.org/10.1002/14651858.CD008138.pub3

137. Kastarinen H,Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Cochrane Database Syst Rev 2014; 2014(5): CD009446. https://doi.org/10.1002/14651858.CD009446. pub2

138. Vena GA, Micali G, Santoianni P, et al. Oral terbinafine in the treatment of multi-site seborrhoic dermatitis: a multi-center, double-blind placebo-controlled study. Int J Immunopathol Pharmacol 2005; 18(4): 745–753. https://doi.org/10.1177/039463200501800418

139. Yale K, Awosika O, Rengifo-Pardo M, et al. Genital allergic contact dermatitis. Dermatitis 2018; 29(3): 112–119. https://doi.org/10.1097/DER.00000000000000371

140. Warshaw EM, Kimyon RS, Silverberg JI, et al. Evaluation of patch test findings in patients with anogenital dermatitis. JAMA Dermatol 2019; 156(1): 85–91. https://doi.org/10.1001/jamadermatol.2019.3844

141. Wollenberg A, Barbarot S, Bieber T, et al. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I. J Eur Acad Dermatol Venereol 2018; 32(5): 657–682. https://doi.org/10.1111/jdv.14891

142. Abędż N and Pawliczak R. Efficacy, and safety of topical calcineurin inhibitors for the treatment of atopic dermatitis: meta-analysis of randomized clinical trials. Postepy Dermatol Alergol 2019; 36(6): 752–759. https://doi.org/10.5114/ada.2019.91425

143. Rubinstein I, Baum GL and Hiss Y. Sarcoidosis of the penis: report of a case. J Urol 1986; 135(5): 1016–1017. https://doi.org/10.1016/s0022-5347(17)45964-7

144. McLaughlin SS, Linquist AM and Burnett JW. Cutaneous sarcoidosis of the scrotum: a rare manifestation of systemic disease. Acta Derm Venereol 2002; 82(3): 216–217. https://doi.org/10.1080/00015550260132578

145. Pereira IB and Khan A. Sarcoidosis rare cutaneous manifestations: vulval and perianal involvement. J Obstet Gy- naecol 2017; 37(4): 539–540. https://doi.org/10.1080/ 01443615.2016.1256964

146. May M, Gunia S, Siegsmund M, et al. Testikulärer Keimzelltumor und Sarkoidose: eine diagnostische Herausforderung [Coincidence of testicular germ cell tumor and sarcoidosis: a diagnostic challenge]. Urologe 2006; 45(9): 1176–1180. https://doi.org/10.1007/s00120-006-1052-4

147. Singal A, Pandhi D, Kataria V, et al. Tuberculosis of the glans penis: an important differential diagnosis of genital ulcer disease. Int J STD AIDS 2017; 28(14): 1453–1455. https://doi.org/10.1177/0956462417703027

148. Arakeri SU and Sinkar P. An unusual gross appearance of vulval tuberculosis masquerading as tumor. Case Rep

Edwards et al.

15

Obstet Gynecol 2014; 2014: 815401. https://doi.org/10.1155/2014/815401

149. Sinha RK, Mukherjee S, Kamal MR, et al. Tuberculosis of the glans penis healing with meatal stenosis. BMJ Case Rep 2014; 2014: bcr2013202155, Published 2014 Feb 5. https://doi.org/10.1136/bcr-2013-202155

150. Dederichs F, Iesalnieks I, Sladek M, et al. Genital granulomatosis in Male and female patients with Crohn's disease: clinical presentation and treatment outcomes. J Crohns Colitis 2018; 12(2): 197–203. https://doi.org/10.1093/eccojcc/jjx131

151. Phillips SS, Baird DB, Joshi VV, et al. Crohn's disease of the prepuce in a 12-year-old boy: a case report and review of the literature. Pediatr Pathol Lab Med 1997; 17(3): 497–502.

152. Reinders MGHC and Kukutsch NA. Genital edema in childhood: harbinger of Crohn's disease? J Am Acad Dermatol 2011; 65(2): 449–450. https://doi.org/10.1016/j. jaad.2010.02.037

153. Saadoun D and Wechsler B. Behçet's disease. Orphanet J Rare Dis 2012; 7: 20. https://doi.org/10.1186/1750-1172-7-20

154. Gürler A, Boyvat A and Türsen U. Clinical manifestations of Behçet's disease: an analysis of 2147 patients. Yonsei Med J 1997; 38(6): 423–427. https://doi.org/10.3349/ymj.1997.38.6.423

155. Tursen U, Gurler A and Boyvat A. Evaluation of clinical findings according to sex in 2313 Turkish patients with Behçet's disease. Int J Dermatol 2003; 42(5): 346–351. https://doi.org/10.1046/j.1365-4362.2003.01741.x

156. Ghate JV and Jorizzo JL. Behçet's disease and complex aphthosis. J Am Acad Dermatol 1999; 40(1): 1–18; quiz 19–20. https://doi.org/10.1016/s0190-9622(99)70523-2

157. Bandow GD. Diagnosis and management of vulgar ulcers. Dermatol Clin 2010; 28(4): 753–763. https://doi.org/10.1016/j.det.2010.08.008

158. Alpsoy E, Zouboulis CC and Ehrlich G. Mucocutaneous lesions of Behcet's disease. Yonsei Med J 2007; 48(4): 573–585. https://doi.org/10.3349/ymj.2007.48.4.573

159. Criteria for diagnosis of Behçet's disease. International study group for Behçet's disease. Lancet 1990; 335(8697): 1078–1080.

160. International Team for the Revision of the International Criteria for Behçet's Disease (ITR-ICBD). The International Criteria for Behçet's Disease (ICBD): a collaborative study of 27 countries on the sensitivity and specificity of the new criteria. J Eur Acad Dermatol Venereol 2014; 28(3): 338–347.

161. Kokturk A. Clinical and pathological manifestations with differential diagnosis in Behçet's disease. Pathol Res Int 2012; 2012: 690390. https://doi.org/10.1155/2012/690390

162. Ucar-Comlekoglu D, Fox A and Sen HN. Gender differences in Behçet's disease associated Uveitis. J Ophthalmol 2014; 2014: 820710. https://doi.org/10.1155/2014/820710

163. Behçet's UK. https://behcetsuk.org/national-behcets-centres-of-excellence/ (accessed 20/08/2025).

164. Hatemi G, Christensen R, Bang D, et al. 2018 Update of the EULAR recommendations for the management of Behçet's syndrome. Ann Rheum Dis 2018; 77(6): 808–818. https://doi.org/10.1136/annrheumdis-2018-213225