Topical Triamcinolone for Persistent Phimosis

Topical corticosteroids for treating phimosis in boys

BACKGROUND

This is an updated version of a Cochrane Review first published in 2014. Phimosis is a condition in which the prepuce (foreskin) cannot be fully retracted past the head of the penis (glans). Phimosis is often treated surgically by circumcision or prepuce plasty; however, reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have suggested favorable outcomes.

OBJECTIVES

To assess the effects of topical corticosteroids applied to the stenotic portion of the prepuce for the treatment of phimosis in boys compared with placebo or no treatment.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, and ClinicalTrial.gov. We checked reference lists of included studies and relevant reviews for additional studies. There were no restrictions on the language of publication. The date of the last search was 4 October 2023.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared the use of any topical corticosteroid with placebo or no treatment for boys with any type or degree of phimosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data related to the review's primary and secondary outcomes, and assessed the studies' risk of bias. We used the random-effects model for statistical analyses and expressed dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We contacted the authors of the primary articles to request details of the study design and specific outcome data. We used GRADE to assess the certainty of evidence on a per-outcome basis.

MAIN RESULTS

In this update, we identified two new studies with 111 participants, bringing the total number of included studies to 14 (1459 randomized participants). We found that types of corticosteroids investigated, participant age, degree of phimosis, type of phimosis, and treatment duration varied considerably among studies. Compared with placebo or no treatment, topical corticosteroids may increase the complete resolution of phimosis after four to eight weeks of treatment (RR 2.73, 95% CI 1.79 to 4.16; I² = 72%; 10 trials, 834 participants; low-certainty evidence). Based on 252 complete resolutions per 1000 boys in the control group, this corresponds to 436 more complete resolutions per 1000 boys (95% CI 199 more to 796 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. Topical corticosteroids may also increase the partial resolution of phimosis at four to eight weeks of treatment compared with placebo or no treatment (RR 1.68, 95% CI 1.17 to 2.40; I² = 44%; 7 trials, 745 participants; low-certainty evidence). Based on 297 partial resolutions per 1000 boys in the control group, this corresponds to 202 more partial resolutions per 1000 boys (95% CI 50 more to 416 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. We are uncertain of the effect of topical corticosteroids compared to placebo on change in retractability score (standardized mean difference [SMD] -1.48, 95% CI -2.93 to -0.03; I²91%; 2 trials, 177 participants; very low-certainty evidence). We downgraded the certainty of the evidence by one level for serious study limitations, one level for serious heterogeneity, and one level for serious imprecision. Compared with placebo, topical corticosteroids may increase the long-term complete resolution of phimosis six or more months after treatment (RR 4.09, 95% CI 2.80 to 5.97; I² = 0%; 2 trials, 280 participants; low-certainty evidence). Based on 171 long-term complete resolutions per 1000 boys in the control group, this corresponds to 528 more complete resolutions per 1000 boys (95% CI 308 more to 850 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision. There may be little or no difference in the risk of adverse effects between topical corticosteroids and placebo or no treatment (RR 0.28, 95% CI 0.03 to 2.62; I² = 22%; 11 trials, 1091 participants; low-certainty evidence). Only two of 11 studies that recorded adverse effects reported any adverse effects; one event occurred in the corticosteroid group and six in the control group. We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision.

AUTHORS' CONCLUSIONS

Topical corticosteroids, compared to placebo or no treatment, may increase complete and partial resolution of phimosis when assessed after four to eight weeks of treatment, and may increase long-term complete resolution of phimosis assessed six or more months after treatment. Topical corticosteroids may have few or no adverse effects, and we are uncertain about their effect on retractability scores. The body of evidence is limited by poor reporting of methods in the studies, important clinical heterogeneity, and serious imprecision in the results. Future, higher-quality trials with long-term follow-up would likely improve our understanding of the effects of topical corticoids on phimosis in boys.

The efficacy of topical 0.1% mometasone furoate for treating symptomatic severe phimosis: A comparison of two treatment regimens

BACKGROUND

Twice daily 0.1% mometasone furoate is an effective treatment for phimosis in children. However, mometasone furoate has an important therapeutic advantage because it is effective in once-daily applications. This study was to compare the efficacy of two different topical 0.1% mometasone furoate regimens for the treatment of symptomatic severe phimosis in pediatric patients.

METHODS

A total of 1,689 patients with symptomatic severe phimosis classified by the Kikiros system were prospectively enrolled in the study from March 2018 to February 2021. A total of 855 patients received 0.1% mometasone furoate twice-daily (BID group) and 834 patients received 0.1% mometasone furoate once-daily (QD group) for 4 weeks.

RESULTS

A total of 1,595 boys completed the treatment (798 and 797 in the BID and QD groups, respectively). The success rate of the BID group was higher than that of the QD group at the end of week 2 (44.8% vs. 33.3%, P < 0.05), while there was no difference in the success rate at 4 weeks and 3 months between the two groups (70.7% vs. 69.7%, and 66.8% vs. 64.9%, respectively) (P > 0.05). In both treatment groups, the success rate of grade 5 phimosis was lower than that of grade 4 at 2 weeks, 4 weeks, and 3 months. A total of 83 patients experienced recurrence of phimosis. Only fifteen patients had local mild adverse drug reactions.

CONCLUSION

Topical application of 0.1% mometasone furoate once-daily or twice-daily for 4 weeks had comparable efficacy in children with symptomatic severe phimosis. A once a day regimen may be more suitable for children. Topical steroid application is more effective in children with low-grade phimosis than those with high-grade phimosis.

Efficacy of topical steroid treatment in children with severe phimosis in China: A long-term single centre prospective study

AIM

To evaluate the efficacy of topical steroid (0.1% mometasone furoate) therapy and factors affecting long-term outcome of paediatric severe phimosis in China.

METHODS

A total of 1550 patients with severe phimosis classified by Kikiros system were prospectively enrolled in the study from January 2016 to February 2020. They were prescribed with 0.1% mometasone furoate twice a day for 4 weeks. Patients were re-evaluated at the end of weeks 2, 4, 8 and 6 months follow-up.

RESULTS

A total of 1499 patients completed the treatment, 71.1% responded at the end of week 4. The long-term success rate was 66.0% over a mean follow-up of 26.9 months. The success rate of grade 4 phimosis was significantly higher than that of grade 5 at 4, 8 weeks and 6 months (P = 0.005, P < 0.001 and P < 0.001, respectively). Patients with balanoposthitis had a poorer outcome compared with patients without symptoms and patients symptoms by prepuce ballooning or urinary tract infections (P < 0.001). Initial grade of 5 phimosis and symptom with balanoposthitis were independent risk factors for recurrence. All patients had no systemic side effects, 23 cases developed local erythema or burning sensation.

CONCLUSION

Topical steroid (0.1% mometasone furoate) is an effective treatment for severe phimosis in children. The recurrence was related to the grade or symptoms of severe phimosis.

Topical corticosteroids for phimosis in children: a network meta-analysis of randomized clinical trials

BACKGROUND

Corticosteroids and hyaluronidase are trialed for treating phimosis in children. We carried out the present network meta-analysis to compare the therapeutic effect of these drugs.

METHODS

Electronic databases were searched for appropriate randomized clinical trials. Odds ratio (OR) with 95% confidence intervals (95% CI) was used as the effect estimate. A random-effects model was used for generating the pooled estimates. Rankogram plot was used for ranking the drugs.

MAIN OUTCOME MEASURES

Proportions of patients with remission (partial/complete) and with complete remission.

RESULTS

Mometasone (OR 6.53, 95% CI 2.85, 14.96), betamethasone/hyaluronidase (OR 12.1, 95% CI 4.27, 34.49), triamcinolone (OR 19.15, 95% CI 4.47, 81.96), dexamethasone (OR 21.38, 95% CI 5.71, 79.98), betamethasone (OR 23.02, 95% CI 6.92, 79.54), hydrocortisone (OR 23.2, 95% CI 5.91, 91.02) and methylprednisolone (OR 50.47, 95% CI 4.45, 572.72) were observed with significantly higher proportions of patients with remission (partial/complete) compared to placebo. Dexamethasone, triamcinolone, betamethasone, betamethasone/hyaluronidase, clobetasol, mometasone, and hydrocortisone were observed with significantly higher proportions of patients with complete remission compared to placebo. Beclomethasone was not observed to be superior to either placebo or other drugs. Rankogram plot revealed methylprednisolone followed by hydrocortisone had the maximum statistical probability of being 'the best' in the pool for remission and betamethasone followed by hydrocortisone for complete remission.

CONCLUSION

Topical methylprednisolone, hydrocortisone, and betamethasone were observed with better clinical resolution of phimosis compared to other corticosteroids. Very high potent corticosteroids like beclomethasone and clobetasol were not observed with superior benefits compared to other corticosteroids. Considering low-potency, hydrocortisone shall be preferred until further evidence emerges.

Randomized open-label trial comparing topical prescription triamcinolone to over-the-counter hydrocortisone for the treatment of phimosis

BACKGROUND

Phimosis is a common condition affecting most infant boys and generally resolves over time without symptoms. Severe cases of phimosis can lead to balanoposthitis, urinary tract infections, and urinary retention. Medical treatment for symptomatic phimosis includes topical corticosteroids with manual foreskin retraction.

OBJECTIVE

Over-the-counter hydrocortisone 1% cream was compared in a randomized controlled fashion with prescription triamcinolone 0.1% cream for the medical management of symptomatic phimosis.

METHODS

The study institution conducted a randomized open-label trial for the treatment of grades 4-5 phimosis (phimosis grade scale 0-5). Boys aged 3-13 years were randomized to hydrocortisone 1% cream or triamcinolone 0.1% cream dosed at least twice daily for a course of 12 weeks. Instructions were provided for appropriate application and manual retraction of the foreskin. Evaluations were performed at 4, 8, and 12 weeks. Successful completion of the study was determined by reaching phimosis grade 2 or less or after completing 12 weeks of treatment.

RESULTS

A total of 52 boys enrolled in the trial, with a total of 32 boys completing the 12-week duration. Of the 13 boys in the hydrocortisone arm, there was a 30.8% success rate at 4 weeks, 53.8% success rate at 8 weeks, and 61.5% success rate at 12 weeks. Of the 19 boys in the triamcinolone arm, there was a 31.6% success rate at 4 weeks, 52.6% success rate at 8 weeks, and 68.4% success rate at 12 weeks. There was no statistical difference between the two arms at each interval.

DISCUSSION

To the study authors' knowledge, this is the first open-label trial with direct comparison of hydrocortisone 1% cream with triamcinolone 0.1% cream. The study results support those reported in other studies when each topical steroid was compared with placebo. Limitations of the study include loss to follow-up, unblinded treatment allocation, and reduced power to detect differences by treatment frequency and duration.

CONCLUSION

Over-the-counter hydrocortisone 1% cream is not inferior to triamcinolone 0.1% cream when paired with manual retraction for the treatment of grade 4-5 phimosis. Successful treatment response may be seen up to 12 weeks.

Eficácia do uso de corticoides tópicos no tratamento da fimose primária em crianças e adolescentes

Introdução: A fimose primária é um problema frequente na consulta de saúde infantil, com prevalência de 11% aos 3 anos de idade. Objetivo: O objetivo desta revisão é avaliar a evidência da eficácia do uso de corticoides tópicos (CCT) na redução da limitação da retratilidade do prepúcio em crianças e adolescentes. Métodos: Pesquisa efetuada nas bases de dados National Guideline Clearing House, Canadian Medical Association Pratice Guidelines Infobase, Cochrane Library, DARE, Bandolier, Evidence Based Medicine Online, Trip Database Online e Pubmed, utilizando os descritores “Phimosis and steroids”. Pesquisaram-se normas de orientação clínica (NOC), meta-análises, revisões sistemáticas e ensaios clínicos aleatorizados e controlados (ECAC), nas línguas portuguesa, inglesa e espanhola. Foi usada a escala Levels of Evidence of Oxford Centre for Evidence Based Medicine. Resultados: Foram encontrados 148 artigos, dos quais 6 cumpriram os critérios de inclusão: 1 NOC e 5 ECAC. A orientação da Sociedade Europeia de Urologia Pediátrica publicada em 2013 recomenda o uso de CCT na fimose primária. Os ECAC incluíram no total 624 crianças e adolescentes entre os zero e os 15 anos. Foram testados diferentes CCT e esquemas terapêuticos. Verificou-se uma melhoria da retratilidade do prepúcio comparativamente com o placebo, com uma eficácia terapêutica dos CCT descrita entre 66% e 90%. Conclusão: Os estudos suportam a eficácia dos CCT no tratamento da fimose primária em crianças e adolescentes. No futuro é pertinente o desenho de estudos metodologicamente homogêneos e de maior dimensão para clarificar qual o melhor CCT e esquema terapêutico.

Benign penile skin anomalies in children: a primer for pediatricians

BACKGROUND

Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern.

DATA SOURCES

The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions.

RESULTS

Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age.

CONCLUSION

This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.

Topical corticosteroids for treating phimosis in boys

BACKGROUND

Until recently, phimosis has been treated surgically by circumcision or prepuceplasty; however, recent reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have been favourable. The efficacy and safety of topical corticosteroids for treating phimosis in boys has not been previously systematically reviewed.

OBJECTIVES

We aimed to 1) compare the effectiveness of the use of topical corticosteroid ointment applied to the distal stenotic portion of the prepuce in the resolution of phimosis in boys compared with the use of placebo or no treatment, and 2) determine the rate of partial resolution (improvement) of phimosis, rate of re-stenosis after initial resolution or improvement of phimosis, and the rate of adverse events of topical corticosteroid treatment in boys with phimosis.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Date of last search: 16 June 2014.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared use of any topical corticosteroid ointment with placebo ointment or no treatment for boys with phimosis.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed titles, abstracts and the full-text of eligible studies, extracted data relating to the review's primary and secondary outcomes, and assessed studies' risk of bias. Statistical analyses were performed using the random-effects model and results were expressed as risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). We contacted authors of primary articles asking for details of study design and specific outcome data.

MAIN RESULTS

We included 12 studies that enrolled 1395 boys in this review. We found that both types of corticosteroids investigated and treatment duration varied among studies.Compared with placebo, corticosteroids significantly increased complete or partial clinical resolution of phimosis (12 studies, 1395 participants: RR 2.45, 95% CI 1.84 to 3.26). Our analysis of studies that compared different types of corticosteroids found that these therapies also significantly increased complete clinical resolution of phimosis (8 studies, 858 participants: RR 3.42, 95% CI 2.08 to 5.62). Although nine studies (978 participants) reported that assessment of adverse effects were planned in the study design, these outcomes were not reported.Overall, we found that inadequate reporting made assessing risk of bias challenging in many of the included studies.Selection bias, performance and detection bias was unclear in the majority of the included studies: two studies had adequate sequence generation, none reported allocation concealment; two studies had adequate blinding of participants and personnel and one had high risk of bias; one study blinded outcome assessors. Attrition bias was low in 8/12 studies and reporting bias was unclear in 11 studies and high in one study.

AUTHORS' CONCLUSIONS

Topical corticosteroids offer an effective alternative for treating phimosis in boys. Although sub optimal reporting among the included studies meant that the size of the effect remains uncertain, corticosteroids appear to be a safe, less invasive first-line treatment option before undertaking surgery to correct phimosis in boys.

Congenital phimosis in patients with and without lichen sclerosus: distinct expression patterns of tissue remodeling associated genes

PURPOSE

Lichen sclerosus is a potentially important factor in the ongoing debate concerning the pathology of persistent congenital phimosis. We assessed the molecular differences of congenital phimosis in boys with and without lichen sclerosus compared to age matched boys with fully retractable foreskins to gain more insight into the pathogenesis of fibrotic remodeling of the prepuce.

MATERIALS AND METHODS

A total of 150 boys were circumcised in a prospective study between 2007 and 2009. Using target gene specific preamplification and quantitative real-time polymerase chain reaction based low density arrays, we measured the mRNA expression of 45 tissue remodeling associated genes in foreskins of boys with absolute phimosis and lichen sclerosus (8 patients) and those of an age matched group of boys with phimosis but no lichen sclerosus (8), as well as a control group with foreskins without delimitable changes (6). Complementary protein expression and inflammatory infiltrates were assessed by immunohistochemical analysis.

RESULTS

Cellular composition, inflammatory infiltrate and microenvironment as seen in histologically proven lichen sclerosis differed significantly from the other groups. In particular, lichen sclerosis was characterized by over expression of bone morphogenetic protein 2 and its corresponding receptor, matrix metalloproteinases 1 and 9 and tissue inhibitor of metalloproteinases 1, cytokine chemokine ligands 5 (RANTES) and interleukin 4, and transforming growth factor-β2 and its corresponding receptor. There were no major molecular differences between specimens from boys with congenital phimosis without signs of lichen sclerosis and controls.

CONCLUSIONS

Distinct expression patterns of tissue remodeling associated genes are evident in boys with congenital phimosis and lichen sclerosis, while congenital phimosis without lichen sclerosis represents a physiological condition.

[Assessment of topical steroid treatment for childhood phimosis: review of the literature]

OBJECTIVES

Questions concerning nonretractile foreskin are frequently asked by parents in infant consultations. Topical steroid treatment could be a less expensive and less traumatizing alternative to surgery.

AIM

To assess the effectiveness of topical steroid therapy in boys with phimosis.

METHODS

Literature review. All randomized controlled trials were selected, using the following research sources: Medline, Cochrane Library, Pascal, Embase, Blackwell Science, Google, Google scholar, SUDOC, international register of trials, and congress abstracts. Unpublished trials were also searched. The trials were analyzed using the ANAES guide from a therapeutic article.

RESULTS

Seven randomized controlled trials (n=714 patients) were in accordance with the inclusion criteria. The patients were between 1 and 12 years old. The treatment lasted for 4-8 weeks. The success rate at the end of the study was higher with the steroid (53.8-95%) than with the placebo (6.25-52%), P<0.05 for 6 randomized control trials.

DISCUSSION

According to the ANAES criteria, the level of scientific evidence is low (gradeC) because of the lack of power in clinical trials and numerous methodological shortcomings and biases, even when examining both randomized control trials and nonrandomized trials. Only a few local side effects were noted.

CONCLUSION

The use of topical steroids can be recommended in first-intention treatment before surgery for the management of phimosis.