What can be done for non-itchy painful rash in penis?

Question

Hello doctor,

I am a 47-year-old, unmarried, not sexually active, uncircumcised male with a history of ulcerative colitis, which was managed with a total colectomy and pouch replacement 12 years ago. For the past five years, I have had occasional slight pain or irritation at the base of the glans of my penis. Mild redness sometimes appears below the glans, but it was not concerning until about six months ago.

At that point, the glans of my penis became inflamed, particularly the bottom half and the tip. There's been no itching, bumps, or scaling, just persistent redness and soreness. It doesn’t hurt when untouched, but friction from underwear or activities like masturbation causes significant pain. Urination remains pain-free.

I first consulted my family doctor, who suspected a yeast infection, and prescribed an antifungal cream with 1% hydrocortisone (Clotrimaderm). When this didn’t help, he suggested an over-the-counter antifungal cream without hydrocortisone. Unfortunately, that also had no effect. While the 1 % hydrocortisone mildly reduced the pain, it did not resolve the issue.

My doctor then considered a bacterial cause and prescribed Polysporin ointment, which I accidentally purchased with lidocaine. Though lidocaine relieved some pain, the underlying issue persisted. After two weeks, my doctor referred me to a urologist, who recommended I see a dermatologist or consider circumcision. My doctor doubted circumcision would help, so he referred me to a dermatologist instead.

The dermatologist examined the rash and confirmed it was non-contagious and non-cancerous. He prescribed four creams to try sequentially for a week each: Ketoderm 2%, Fucidin 2%, Noritate 1%, and Hydroval. None of these solved the issue, though hydrocortisone provided slight pain relief. The dermatologist also conducted a swab test, which came back negative, and assured me it was not an STI.

At this point, I feel at a loss, as my doctor, urologist, and dermatologist have not been able to pinpoint the cause or provide a solution. Do you have any insights or suggestions regarding the potential cause and treatment for my symptoms?

Please help.

Answer 1

Hi,

Welcome to icliniq.com.

I went through your query.

Depending on the symptoms you have mentioned, and all the treatment you have taken with no much help, I can list few possibilities though it is difficult to comment without seeing the picture.

Plasma cell balanitis.
Erythroplasia of Queyrat.
Contact dermatitis (because there was some help with Hydrocortisone).

Since it is bothering you for few months, I strongly feel this condition would need shave biopsy of skin to know the exact nature of the problem so that treatment can be targeted for the cause instead of treating it with antibacterial or antifungal or topical steroids. Hope your blood glucose is within normal limits, if not it strongly favors candidal balanitis which may not respond to only topical anti-fungal but needs oral antifungal medicine.

Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

A biopsy means taking a piece of skin for examination under the microscope after that piece of skin has been mounted on a glass slide and stained with appropriate staining agents. The microscopic details provide more information regarding the pathology that is going on in the tissue. It would say if the condition is a fungal infection or bacterial or inflammatory condition like plasma cell balanitis. There are many types of skin biopsy like:

Punch biopsy: deeper tissue is taken using the varied size (1 mm, 2 mm, and 4 mm) of disposable punch instruments that look like a pen.
Wedge biopsy: a piece of skin tissue is cut with a scalpel blade.
Shave biopsy: a thin layer of skin is shaved using a razor blade or dermablade.

Yes, it is not pleasant, yet it is made comfortable by giving a local numbing injection (local anesthesia-Lignocaine) so that the pain is not felt. After the skin is shaved off, the area is cauterized to prevent bleeding, later that area heals with little scar tissue. After the procedure, the area has to be treated with healing ointment to aid proper healing. Usually, for genital lesions, the biopsy is kept as last option after all topical and oral medications have been tried with no results.

Thank you.

Answer 3

Hi,

Welcome back to icliniq.com.

I saw your picture (attachment removed to protect patient identity). Considering your history and the clinical features as per the picture, I feel it is plasma cell balanitis. This needs a biopsy to rule out erythroplasia of Queyrat which is a premalignant condition. Clinically both the condition appears almost similar. Plasma cell balanitis will have a red glistening shiny surface (as in your case as per the picture) whereas erythroplasia will have well-defined margins with a velvety appearance.

Thank you.

Answer 4

Hi,

Welcome back to icliniq.com.

Treatment options for PCB are,

1. Topical mild steroid creams like Hydrocortisone 2.5% and Mometasone 0.1%.

2. Topical Tacrolimus 0.1 %.

3. Circumcision, this is considered as curative treatment option. This condition is mostly idiopathic, definite cause is unknown, probable causes attributed are friction and irritation from urine. It is a chronic condition, topical medicine are helpful but there are chances of recurrence. One more thing here to be considered is, when topical steroids are used for longer duration, it can flare up fungal infections. Hence, combination of steroid and antifungal had to be used. Circumcision, removal of prepuce, is considered curative because it is the prepuce that is causing friction and prepuce can hold urine for short period of time when it comes it contact with, causing irritation.

You have mentioned that you have more pain, and never it was itchy. Do you have pain while retracting the prepuce? Do you find it difficult to retract like does it feel tight? Do you experience difficulty while having sexual intercourse or mastrubating? Since you have mentioned that the surface is not shiny, I am thinking of another possibility it is called lichen sclerosus. This condition is painful, skin gets atrophied meaning skin thins out.

Kindly update us with the answers.

Thank you.

Answer 5

Hi,

Welcome back to icliniq.com.

Sorry, I should have been more specific. I meant pain or discomfort. Since these conditions look similar clinically, there are very few differentiating points for instance hypopigmented thin skin, glistening surface, and velvety texture. Dermoscopy is another tool which helps to see finer datails, however biopsy would be very helpful in making exact diagnosis.

Answer 6

Hi,

Welcome back to icliniq.com.

We Dermatologists can make diagnosis depending the positive clinical findings that include history from the patient and morphology of the lesion.

There are many conditions in Dermatology that look similar, in such case we would list the possible diagnosis in the descending order. When I go back and see that picture you have attached, I can think of PCB, and erythroplasia of queyrat. I mentioned PCB first beacuse of shiny red surface and chronic history. But then you clarified that it is shiny because of the medicine you have applied, this makes me think other possible chronic conditions like lichen sclerosus. If I would have seen you in person, I would have been able to see the exact morphology of the lesion. Of course the picture you have sent is very clear and informative. Dermatologists use dermoscope in their routine practice. Dermoscopy helps to see certain minute features which are otherwise not seen with naked eyes like the pattern of pigment, tiny blood vessels, etc. Biopsy is usually done by Dermatologist. Biopsy gives the exact pathology of the lesion.

Answer 7

Hi,

Welcome back to icliniq.com.

Balanitis is inflammation of glans penis. Inflammation could be from various causes like infection- bacterial, fungal, viral, trauma, contact allergy to detergent, cloth, drug induced, premalignant condition or 0ther dermatogical condition like psoriasis, lichen planus, lichen sclerosus Identifying the most likely cause of balanitis is very important so that treatment can be directed to the cause. In my practice, I generally treat fungal infection first as this is the most common cause of balanitis, if it is not responding then I will consider combination of antibacterial with steroid. If still there is no response, then I suggest to undergo biopsy in that way the exact cause will be known. Those are the brand name of the creams, and I looked up the content Ketoderm is antifungal, Fuciden and Noritate are anti bacterials, Hydroval is hydrocortisone, steroid, Loprox is Ciclopirox, higher antifungal, Bactroban- Mupirocin higher antibiotic, and I could not find Ozanisk. Tacrolimus is an immunomodulator, this is helpful for inflamatory conditions like plasma cell balanitis and lichen sclerosus along with steroid.

Thank you.

Answer 8

Hi,

Welcome back to icliniq.com.

You can use Loprox (antifungal) and Bactroban (antibacterial) and there is no harm. These creams will help to treat the secondary infection if there is any.

Hope this helps.

Thank you.