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Balanitis - Management
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How should I manage a child with balanitis?
- Advise the child or the parents or carers to clean the penis with luke warm water and gently dry it.
- No attempt should be made to retract the foreskin to clean under it, if it is still fixed.
- Soap, bubble bath, or baby wipes should not be used.
- If the child is still in nappies, these need to be changed frequently (see the CKS topic on Nappy rash).
- For suspected non-specific dermatitis, with or without candidal or bacterial colonization:
- Prescribe topical hydrocortisone 1% combined with an imidazole cream (clotrimazole 1%, miconazole 2%, or econazole 1%) once or twice a day until symptoms settle, or for up to 14 days.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- For suspected irritant or allergic contact dermatitis:
- Discontinue any suspected triggers (such as soap or creams).
- Prescribe a mild topical hydrocortisone 1% cream or ointment once a day until symptoms settle, or for up to 14 days.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- For suspected or confirmed candidal balanitis:
- Prescribe an imidazole cream (clotrimazole 1%, econazole 1%, ketoconazole 2%, or miconazole 2%) twice a day until symptoms settle.
- If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to an antifungal.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
- For suspected or confirmed bacterial balanitis:
- Prescribe oral flucloxacillin for 7 days.
- Oral erythromycin or clarithromycin for 7 days are alternatives for boys who are allergic to penicillin (see Prescriptions).
- Adjust treatment if indicated by sub-preputial swab results.
- If inflammation is causing discomfort, consider prescribing hydrocortisone 1% cream or ointment for up to 14 days in addition to an antibiotic.
- If symptoms are not improving by 7 days:
- Advise people to stop treatment with topical hydrocortisone.
- Take a sub-preputial swab to exclude or confirm a fungal or bacterial infection, and treat accordingly.
Basis for recommendation
These recommendations are based on expert advice from review articles [Orden et al, 1996; Schwartz and Rushton, 1996].
Non-specific dermatitis, with or without candidal or bacterial colonization
- A mild topical corticosteroid combined with an imidazole to treat the dermatitis (and any candidal infection) seems a logical approach if the balanitis is mild and clinical suspicion of a bacterial infection is low.
Candidal balanitis
- Topical imidazoles are recommended by experts based on their proven effectiveness in the treatment of candidiasis of the skin, toenails, and perineum in infants [Hay and Moore, 2004].
- CKS recommends continuing treatment until symptoms have settled, based on advice given in the UK national guideline on the management of balanoposthitis from the British Association for Sexual Health and HIV, for people older than 16 years of age [BASHH, 2008]. Although the licences for most antifungal drugs recommend continuing treatment for a short period of time after clinical cure, CKS found no evidence to support this approach in balanitis.
Bacterial balanitis
- An antibiotic with activity against group A beta-haemolytic streptococci and Staphylococcus aureus (bacteria that commonly cause bacterial balanitis) will usually result in rapid resolution of symptoms and eradication of the offending organism. CKS found no specific trial evidence for the use of antibiotics for balanitis.
When should I refer a child with balanitis?
- If balanitis is recurrent or chronic, refer to a paediatrician or a dermatologist.
Basis for recommendation
This recommendation is based on expert advice from review articles [Edwards, 1996; English et al, 1997].
- Most pre-pubertal boys only experience a single episode of balanitis. Therefore, if symptoms are recurrent or significant phimosis is present, a paediatric urologist may consider circumcision [Escala and Rickwood, 1989].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Topical imidazoles
Age from 1 month to 16 years
Clotrimazole 1% cream
Apply to the affected area 2 to 3 times a day until symptoms have settled.
Supply 20 grams.
Econazole 1% cream
Apply to the affected area twice a day, until symptoms have settled.
Supply 30 grams.
Ketoconazole 2% cream
Apply to the affected area twice a day, until symptoms have settled.
Supply 30 grams.
Miconazole 2% cream
Apply to the affected area twice a day, until symptoms have settled.
Supply 30 grams.
Topical corticosteroids
Age from 1 month to 16 years
Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 15 grams.
Hydrocortisone 1% ointment
Hydrocortisone 1% ointment
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 15 grams.
Anticandidal + hydrocortisone preparations
Age from 1 month to 16 years
Clotrimazole 1% + hydrocortisone 1% cream
Clotrimazole 1% / Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Miconazole 2% + hydrocortisone 1% cream
Miconazole 2% / Hydrocortisone 1% cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Nystaform HC cream (contains nystatin and hydrocortisone 0.5%)
Nystaform HC cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Timodine cream (contains nystatin + hydrocortisone 0.5%)
Timodine cream
Apply thinly to the affected area once or twice a day. If there is no improvement after 7 days return to your doctor; if there is an improvement, continue using this cream for up to 14 days.
Supply 30 grams.
Antibiotics for 7 days
Age from 1 month to 11 months
Clarithromycin suspension: child weighs 7.9kg or less
Clarithromycin 125mg/5ml oral suspension
*WEIGHT REQUIRED* Take 7.5mg per kg bodyweight TWICE a day for 7 days.
Supply 70 ml.
Age from 1 month to 1 year 11 months
Flucloxacillin oral solution: 62.5mg four times a day
Flucloxacillin 125mg/5ml oral solution
Take 2.5ml four times a day for 7 days.
Supply 100 ml.
Erythromycin s/f suspension: 125mg four times a day
Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 7 days.
Supply 140 ml.
Age from 1 year to 2 years 11 months
Clarithromycin suspension: child weighs 8kg to 11.9kg
Clarithromycin 125mg/5ml oral suspension
Take 2.5ml twice a day for 7 days.
Supply 70 ml.
Age from 2 years to 9 years 11 months
Flucloxacillin oral solution: 125mg four times a day
Flucloxacillin 125mg/5ml oral solution
Take one 5ml spoonful four times a day for 7 days.
Supply 200 ml.
Age from 2 years to 11 years 11 months
Erythromycin s/f suspension: 250mg four times a day
Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free
Take one 5ml spoonful four times a day for 7 days.
Supply 140 ml.
Age from 3 years to 6 years 11 months
Clarithromycin suspension: child weighs 12kg to 19.9kg
Clarithromycin 125mg/5ml oral suspension
Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Age from 7 years to 9 years 11 months
Clarithromycin suspension: child weighs 20kg to 29.9kg
Clarithromycin 125mg/5ml oral suspension
Take 7.5ml twice a day for 7 days.
Supply 140 ml.
Age from 10 years to 11 years 11 months
Flucloxacillin oral solution: 250mg four times a day
Flucloxacillin 250mg/5ml oral solution
Take one 5ml spoonful four times a day for 7 days.
Supply 200 ml.
Clarithromycin suspension: child weighs 30kg or more
Clarithromycin 250mg/5ml oral suspension
Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Age from 12 years onwards
Flucloxacillin capsules: 250mg four times a day
Flucloxacillin 250mg capsules
Take one capsule four times a day for 7 days.
Supply 28 capsules.
Erythromycin e/c tablets: 250mg four times a day
Erythromycin 250mg gastro-resistant tablets
Take one tablet four times a day for 7 days.
Supply 28 tablets.
Clarithromycin tablets: 250mg twice daily for 7 days
Clarithromycin 250mg tablets
Take one tablet twice a day for 7 days.
Supply 14 tablets.
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