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CASE REPORT
Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 184-186

Topical steroid – An effective treatment for physiologic phimosis in children


Consultant Dermatologist, Nagpur, Maharashtra, India

Date of Submission02-Jan-2020
Date of Decision20-Jan-2020
Date of Acceptance29-Mar-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Vikrant A Saoji
First Floor, Midas Heights, Central Bazar Road, Ramdaspeth, Nagpur - 440 010, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_3_20

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  Abstract 


Asymptomatic phimosis is normal in young children which self-corrects itself but leads to parental anxiety. Topical steroids lead to correction of this physiologic phimosis avoiding the need of circumcision. Six male children aged between 3 and 14 years presented with asymptomatic tight phimosis present since birth. All the children were advised application of small amount of clobetasol propionate cream at night along with manual retraction during bath. At the end of 2 months, all the children had fully retractable prepuce. By the first visit (2 weeks), all the patients showed at least partial retractability of the prepuce. Till the follow-up period of 6 months, there was no recurrence in any patient. No side effects were observed.

Keywords: Physiologic phymosis, tight phimosis, topical steroid


How to cite this article:
Saoji VA. Topical steroid – An effective treatment for physiologic phimosis in children. Indian J Paediatr Dermatol 2020;21:184-6

How to cite this URL:
Saoji VA. Topical steroid – An effective treatment for physiologic phimosis in children. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Aug 5];21:184-6. Available from: http://www.ijpd.in/text.asp?2020/21/3/184/288499




  Introduction Top


The prepuce or foreskin is a small fold of the skin which covers the glans penis. It protect the glans from abrasions and trauma throughout life.[1]

Inability to retract the prepuce is called as phimosis. Narrowed prepucial opening in phymosis can obstruct the urinary flow and can make sexual intercourse painful. Phimosis can predispose to the development of balanitis, an inflammation of the glans. Phimosis is normally seen in younger children due to adhesions between the prepuce and glans penis.[2] This physiologic phimosis is asymptomatic and corrects itself with time, but the anxious parents seek medical advice, and many times, circumcision is performed unnecessarily. Topical steroid application is known to improve this physiologic phimosis in young children avoiding the surgical intervention.

Six cases of physiologic phimosis in young children successfully treated with topical steroid are presented.


  Case Report Top


Details of the patients are shown in [Table 1]. All patients were children with age ranging from 3 years to 14 years and presented with tight phimosis. All patients were asymptomatic. First patient, a 3-year-old child, was treated with topical mometasone furoate cream application at night; within 2 weeks, parents noticed a good retraction of the prepuce and hence discontinued the treatment, but the child presented with recurrence after 2 months which was treated with topical clobetasol propionate cream which resulted in the resolution of phimosis without recurrence. Hence, topical clobetasol propionate cream was used in all the patients. All the patients were treated with application of small quantity of clobetasol propionate 0.05% cream near the tip of the prepuce once a day at night for 2 months along with manual retraction during bath. By the first visit (2 weeks), all the patients showed at least partial retractability of the prepuce. Full retraction of the prepuce was seen in all our patients by the end of 2 months [Figure 1] and [Figure 2]. During follow-up period of 6 months, none of the patient developed recurrence of phimosis. None of the patient reported any side effect of potent topical steroid.
Table 1: Details of the patients

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Figure 1: Patient number 4 after 2 months of topical steroid

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Figure 2: Patient number 2 after 2 months of topical steroid

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  Discussion Top


The prepuce is a loose skin fold which moves freely over the glans. Inability to retract this freely movable prepuce is called phimosis. Around 96% of males at birth are noticed to have a nonretractile foreskin.[2] Phimosis is normal at birth and often self-corrects without needing treatment during the first 3–4 years of life, and only small percentage of children continue to have phimosis beyond 3–5 years of age.[3] In a study from Taiwan involving 2149 school-going boys, the incidence of phimosis was 17.1% in first-grade boys, 9.7% in fourth-grade boys, and 1.2% in seventh-grade boys.[4] This asymptomatic phimosis in young children is considered as physiologic phimosis. Adhesions between the mucosa of the prepuce and glans could be a cause of this physiologic phimosis.[2] Narrow prepucial opening can also lead to an inability to retract the prepuce as seen in all our patients. All our patients presented with tight phimosis with very small prepucial opening since birth and were asymptomatic; hence, we diagnosed it as physiologic phimosis. It is termed pathologic when nonretractability is associated with local or urinary complaints attributed to the phimotic prepuce.[2] Pathological phimosis results from scarring or fibrosis.[2] Pathological phimosis is very uncommon in children. In physiological phimosis, the preputial skin appears normal as seen in all our patients. Meuli et al. have graded severity of phimosis into following four grades, namely Grade I – fully retractable prepuce with stenotic ring in the shaft, Grade II – partial retractability with a partial exposure of the glans, Grade III – partial retractability with an exposure of the meatus only, and Grade IV – no retractability.[5] All our patients had Grade IV phimosis.

The natural history of physiological phimosis tends toward the spontaneous resolution, and only a small number of boys will continue into adulthood with phimosis. Whereas physiological phimosis only needs a conservative approach, surgical management seems justified in pathological phimosis.[2]

Normal washing with lukewarm water and gentle retractions during bathing and urination makes the foreskin retractile over time[6] and should be advised in all young children. Parents should be educated to avoid forcible retraction of the prepuce; the tearing that may result could lead to fibrosis and subsequent true phimosis.[6]

Topical steroids have been tried in cases of phimosis since more than 2 decades. Overall, studies using topical creams for phimosis have yielded dramatic results. Most of the studies are done by urologist and not many studies are reported in dermatology literature.

Golubovic et al. compared topical steroids with Vaseline® and found that 19/20 males benefited with steroids, whereas only 4/20 in vaseline group improved.[7] In a prospective study where 42 children with phimosis were treated with only improved hygiene (foreskin cleaning and parental retraction of prepuce) and 276 children were treated with topical steroid in addition to improved hygiene, 95% of children who used topical steroid improved compared with only 45% improved with only hygiene improvement highlighting the role of topical steroid.[8] Corticosteroids are applied to the stenotic distal portion of the prepuce, with gentle manual retraction of the foreskin. Most studies (Cochrane review) use corticoids for 4–8 weeks and encourage patients to continue retracting their foreskin and to maintain an adequate hygiene after completing the treatment.[9] Cochrane review shows different corticosteroids such as mometasone, betamethasone, beclomethasone, triamcinolone, and clobetasol which have been used with good results.[9]

Mometasone furoate 0.1% application twice a day for 4 weeks gave an overall efficacy of 65.8%.[10] Triamcinolone 0.1% application twice a day for 2 months resulted in improvement in 76% of patients.[11] Mometasone proved beneficial in our first patient, but its premature discontinuation (15 days) has resulted in recurrence indicating a need for longer treatment. Eight weeks treatment in all our patients resulted in long-term/permanent improvement.

Most probably, topical steroid works in phimosis by causing thinning of the skin increasing its stretchability. More potent steroid will cause more atrophy (thinning) and will be more effective for the treatment of phimosis; hence, we use the potent topical steroid clobetasol propionate in all our patients and it proved useful. However, according to the Cochrane database, the subgroups of studies using corticosteroids of high potency – such as clobetasol and betamethasone – did not show statistically significant differences in the magnitude of effect compared with those studies using corticosteroids of low–medium potency.[9] Since only very small quantity is required for the application at the tip of the penis, the potent steroid like clobetasol is unlikely to have any significant systemic effect. Golubovic et al. found that morning cortisol levels were not significantly altered in patients who received betamethasone ointment indicating safety of topical steroid.[7]

All our patients who presented with tight phimosis showed a complete resolution with just 2 months of topical steroid. In three of these patients, circumcision was advised by the pediatrician. Topical steroid use avoided unnecessary circumcision. Neonatal circumcision, before the prepuce has naturally separated, involves tearing the common prepuce/glans penis mucosa apart, with the concomitant risk of glanular excoriation and injury.[12]

A large number of boys are still being circumcised for phimosis. Education of physicians and parents about the natural history of physiological phimosis can reduce unnecessary interventions in boys with this condition. Conservative management with topical steroid is found to be very useful in the treatment of this physiologic phimosis relieving the parental anxiety. The aim or presenting these cases is to make the dermatologists aware of topical steroid use for the treatment of phymosis in children.

Declaration of patient consent

Author certify that they have obtained all appropriate patient consent forms. In the form the patients/parents have given their images and other clinical informations to be reported in the journal. The patients & parents understand that their/their children's names and initials will not be published and due efforts will be made to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dobanovacki D, Lucić Prostran B, Sarac D, Antić J, Petković M, Lakić T. Prepuce in boys and adolescents: What when, and how?Med Pregl 2012;65:295-300.  Back to cited text no. 1
    
2.
Shahid SK. Phimosis in children. ISRN Urol 2012;2012:707329.  Back to cited text no. 2
    
3.
Gairdner D. The fate of the foreskin. Br Med J 1949;2:1433.  Back to cited text no. 3
    
4.
Hsieh TF, Chang CH, Chang SS. Foreskin development before adolescence in 2149 schoolboys. Int J Urol 2006;13:968.  Back to cited text no. 4
    
5.
Meuli M, Briner J, Hanimann B, Sacher P. Lichen sclerosus et atrophicus causing phimosis in boys: A prospective study with 5-year follow up after complete circumcision. J Urol 1994;152:987-9.  Back to cited text no. 5
    
6.
Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemporary Pediatr2002;11:61.  Back to cited text no. 6
    
7.
Golubovic Z, Milanovic D, Vukadinovic V, Rakic I, Perovic S. The conservative treatment of phimosis in boys. Br J Urol 1996;78:786-8.  Back to cited text no. 7
    
8.
Chu CC, Chen KC, Diau GY. Topical steroid treatment of phimosis in boys. J Urol 1999;162:861-3.  Back to cited text no. 8
    
9.
Moreno G, Corbalán J, Peñaloza B, Pantoja T. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev 2014;9:CD008973.  Back to cited text no. 9
    
10.
Esposito C, Centonze A, Alicchio F, Savanelli A, Settimi A. Topical steroid application versus circumcision in pediatric patients with phimosis: A prospective randomized placebo controlled clinical trial. World J Urol 2008;26:187-90.  Back to cited text no. 10
    
11.
Letendre J, Barrieras D, Franc-Guimond J, Abdo A, Houle AM. Topical triamcinolone for persistent phimosis. J Urol 2009;182:1759-63.  Back to cited text no. 11
    
12.
Cold CJ, Taylor JR. The prepuce. Br J Urol 1999;83:34-44.  Back to cited text no. 12
    


    Figures

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    Tables

  [Table 1]



 

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