Redness, Itching and Burning on the Head of the Penis (Balanitis): What Causes It and How Is It Treated?

Noticing redness, itching, burning or a white coating on the head of the penis is something that worries many men and that they are often reluctant to talk about. The first thought is frequently a sexually transmitted infection, yet a common cause of these complaints is a condition known medically as balanitis, meaning superficial inflammation of the head of the penis. Balanitis is common, is usually not a sign of serious disease and can generally be brought under control with an approach suited to its cause.

This article explains the causes of balanitis, the differences between circumcised and uncircumcised men, its relationship with phimosis and paraphimosis, the assessment process and the treatment approach.

What are balanitis and balanoposthitis?

Balanitis is inflammation of the thin skin covering the head of the penis (the glans). When the inflammation also involves the foreskin that covers the glans, the condition is called balanoposthitis; this is more common in uncircumcised men.

Common complaints include:

• Redness on the head of the penis, sometimes with shiny or spotty patches
• Itching, burning and stinging; discomfort that increases when passing urine or during intercourse
• A white, curd-like coating or a foul-smelling discharge
• Swelling, tenderness, cracks in the skin or peeling

What causes balanitis?

There is often no single cause; moisture, friction and a disrupted skin barrier act together. The most common factors seen in practice are:

• Yeast (candida) infection: One of the most frequent causes. It shows itself with itching, redness and a white coating; a warm, moist environment, antibiotic use and high blood sugar all make it more likely.
• Bacterial infections: These may present with more marked redness, swelling, a foul-smelling discharge and pain.
• Irritant substances: Perfumed soaps, shower gels, wet wipes, detergent residues, lubricants and spermicides can irritate the skin.
• Allergy (contact dermatitis): An allergic reaction to condom latex or to certain care products can cause redness and itching.
• Over-washing: Scrubbing the area with soap several times a day strips the protective oily layer and increases irritation. Excessive cleaning can pave the way for balanitis just as much as poor hygiene.

How is diabetes linked to balanitis?

Diabetes is an important risk factor, particularly for yeast-related balanitis. When blood sugar runs high, sugar may be passed in the urine; drops of urine remaining on the head of the penis create a favourable environment for yeast to multiply.

For this reason, checking blood sugar is recommended in balanitis that recurs or does not clear despite treatment. Balanitis can sometimes be the first sign of previously unrecognised diabetes. In people with known diabetes, improving blood sugar control is an integral part of treatment.

Can circumcised men get balanitis too?

Balanitis is more common in uncircumcised men, because the space under the foreskin favours the build-up of moisture, secretions and urine residue. However, given that the great majority of men in Turkey are circumcised, it is worth stressing that circumcised men can get balanitis too. In these men, irritant products, allergy, yeast infection, diabetes and skin conditions come to the fore.

In uncircumcised men, two conditions deserve particular attention:

• Phimosis: The foreskin is too tight to be pulled back. It makes cleaning difficult and so encourages balanitis; recurrent inflammation, in turn, can cause hardening of the skin and further narrowing, creating a vicious circle.
• Paraphimosis: A tight foreskin that has been pulled back becomes trapped behind the head of the penis and cannot be returned to its normal position. It causes rapidly increasing swelling and pain in the glans; because it can impair blood flow, it is an emergency and the person should go to an emergency department without delay.

How is it distinguished from sexually transmitted infections and skin conditions?

Not every patch of redness on the head of the penis is balanitis. Some sexually transmitted infections can begin with a similar appearance: genital herpes with small, painful blisters and sores; syphilis usually with a sore that does not hurt with firm edges; and gonorrhoea and chlamydia mainly with discharge and burning from the urethra. When complaints begin after a new sexual partner, these possibilities should always be considered.

Certain skin conditions can also affect the head of the penis. Lichen sclerosus presents with whitish, thin and fragile areas of skin and can lead to narrowing of the foreskin; psoriasis, lichen planus and some drug-related skin reactions can cause similar complaints as well.

Assessment starts with a detailed history and examination. Where necessary, a swab and culture are taken to look for yeast or bacteria, blood sugar is measured and, when appropriate, tests for sexually transmitted infections are carried out. In lesions that do not heal despite treatment, or that harden, bleed or change colour, a biopsy may rarely be needed.

How is balanitis treated?

Treatment is planned according to the cause and usually combines several steps:

• Adjusting hygiene: Gently washing the area once a day with lukewarm water, choosing a non-irritating cleanser instead of soap and drying it thoroughly are recommended. Uncircumcised men should pull the foreskin back without force to clean underneath, and always return it to its normal position afterwards.
• Topical treatment directed at the cause: A cream containing an antifungal medicine for yeast infection, a suitable antibiotic for bacterial infection, or condition-specific treatment for skin diseases is decided by the doctor.
• Controlling underlying disease: If diabetes is present, blood sugar is brought under control.
• The option of circumcision: In frequently recurring balanoposthitis, phimosis or narrowing due to lichen sclerosus, circumcision can be considered together with the doctor as an option aimed at preventing recurrence.

In recurrent yeast-related balanitis, assessing the partner as well is important. The partner may carry yeast even without symptoms, and the infection can pass back and forth between the couple. In that case it may be advised that the partner is assessed by their own doctor and that intercourse is paused, or condoms are used, during treatment.

Why is applying a steroid cream on your own a problem?

Because they reduce itching quickly, creams containing steroids (cortisone) are often used without medical advice. Yet the skin of the penis is thin and absorbent, so steroids act more strongly in this area. In a yeast infection, a steroid cream may temporarily suppress the complaints while making it easier for the yeast to spread, and it can alter the appearance so that the condition becomes hard to recognise. Long-term use can also cause thinning and sensitivity of the skin.

Stopping treatment as soon as the complaints ease also paves the way for recurrence. Steroids can be part of treatment in some skin conditions, but that decision should be made by a doctor after examination.

When should you see a doctor?

Assessment is recommended in the following situations:

• Redness, itching or burning that does not improve within a few days, or gradually worsens
• Episodes of balanitis recurring several times a year
• A sore, blisters, a wart-like growth or a firm lesion that does not hurt on the head of the penis
• Complaints that begin after a new sexual partner, or discharge from the urethra
• A foreskin that cannot be pulled back, or whitish, hardened areas of skin
• A foreskin that has been pulled back and will not return, with swelling of the head of the penis: in this case go to an emergency department
• Lesions that do not heal despite treatment, or that bleed or change colour

Redness, itching and burning on the head of the penis are most often due to balanitis and can generally be brought under control with an approach suited to the cause. What matters is that possibilities such as yeast, irritation, diabetes, sexually transmitted infection and skin disease are distinguished through examination, and that a doctor is consulted rather than trying creams on one's own. Assoc. Prof. Zülfü Sertkaya practises in urology and andrology in Istanbul; assessment and treatment planning in balanitis and complaints affecting the head of the penis are carried out with individual assessment and confidentiality.

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