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Experiencing rash on penis head. Diagnosed fungal infection. Prescribed Tricodex. Tried anti fungal creams. No improvement. Suggest?

Dec 2013
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Practicing since : 2002
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I am 28 yrs old Male, uncircumcised. I have been experiencing some form of rash on the head of my penis for over 9.5 months now. I had small tiny painless dots and went to a hospital here in Taiwan and the Urologist told me that I have a fungal infection but he gave me "Tricodex". It contained Neomycin Sulfate 3?, Diphenylpyraine XXXXXXX 1?, Nylidrin HCl(Buphenine)1?, and Hydrocortisone 5?. It seemed to work but within a couple of days the dots returned.

Another visit to another hospital's Urologist said the same thing and this time prescribed Sertaconazole which did not seem to work. I did not have any discharge or fever it was mainly a burning sensation and comestic problem for me. I kept on using Tricodex but the problem persisted. I also tried other anti fungal creams including Clotrimazole and Miconazole. I also took Ketaconazole orally and Fluconazole 150mg as a single dose. None of them cured the problem.

I can easily retract my foreskin all the way and wash it twice everyday and dry it properly. In March I finally saw a Dermatologist and she did a KOH test for candida and it was negative. She said it might be due to the fact that I've been medicating it so gave me Cutivate Cream to see if it would get better. It didn't help. I saw her again the next week and she did another KOH test and it was again negative. She said it didn't seem like a bacterial infection because there would be some discharge or pus so she said lets try Sertaconazole and see what happens. Sometimes it seemed like it went away but its always present if I look down there.

Being desperate I started to look at natural alternatives. I somehow believed I was still infected with Candida so I tried Gentian Violet down there. Big mistake as it gave me ulcer like wounds! I saw the doc and she prescribed some cream and with some time off it healed just fine. However, the original dots are still there.

I then went to a laboratory clinic and did a full panel STD test. AIDS(HIV)-1/2 Ab, RPR(STS) Test, TPHA(TPPA), Syphilis DNA(PCR), HSV DNA(PCR), Trichomonas DNA(PCR), Chlamydia DNA(PCR), Gonorrhea DNA(PCR), Candida DNA(PCR), HPV-DNA(PCR)(Typing), HPV High Risk ratio 0.33. Everything came back negative and I was well out of range for all window period. I also did a urine sample and everything came back just fine. The doctor took a sterile cotton and swabbed the irritated area around the head of my penis and did a culture. The result showed no Yeast or Parasites but found high levels of Staph and E-Coli. They also found out which antibiotics would work and I took the report back to my dermatologist and she was kind of not convinced by the report and told me to try Gentamycin cream anyway.

I tried the cream for a couple days and the redness and swelling lessened a lot. I was pretty convinced I was being cured. Until about a week later small red spots came up again. I did research and read that fungal infections are caused by an imbalance of good/bad bacteria so I thought maybe the use of antibiotics on my penis caused a fungal infection. I then started applying Sertaconazole on it but it didn't seem to help. I went back to lab and cultured myself there again. This time the report showed no E-Coli but still high on Staph and that this time Gentamycin was negative in reaction. I needed either Vibramycin (+) or Minocycline (2+)

I took the report to the dermatologist and she said the report isn't convincing because there could be contamination and Staph can be found anywhere on human. She's kind of unsure of what I have and suggested maybe I should get a biopsy done to see what's wrong. She said it would be very painful so I'm unsure about that......

I took the report to another dermatologist and she looked at my skin and said it doens't look to be infectious (it was not as irritated as the pictures when I showed her) She said it doesn't look that bad and if it wasn't giving me symptoms (at the time it wasn't) I should leave it alone. I wasn't convinced and showed her the report of my culture and she said its not reliable because it could be contaminated. She then did a KOH herself and looked under the microscope and said can't find any candida and it looks like healthy skin to her. She told me to leave it alone and see what happens. I was thinking maybe I've over medicated myself or had an allergic reaction to one of the many creams I've used. The most effective cream I've used this 9 months is a cream that consists of Nystatin, Neomycin Sulfate, and Triamcinolone Acetonide. But she said using steroid cream there long term is certainly not recommended.....

I've left my penis alone for the past week or so only sometimes applying some Vitamin E cream on it. I can masturbate just fine and have sex just fine but especially after activities the penis gets very red and the spots get very irritated. Not only is the spot irritated it has also spread to more areas around the head. Just yesterday a new spot near my urethra appeared and is causing me burning sensation while sitting and also while urinating.

A year prior to this I was prone to getting boils and had those cultured which was Staph. (actually had like boil a month over a period of 8 months) It finally stopped after this course of antibiotics. I'm pretty vulnerable to these little infections but is overall a quite healthy and athletic male.

I'm somewhat convinced that this is a staph infection and I should take some antibiotics as well as using bactroban on my penis. I did try fusidic cream and tetracycline XXXXXXX but they didn't seem to work at all. The previous dermatologist thinks it may be other causes like lichen planus or herpes but i've never had blisters or pus and i've tested negative for it. I can't neglect the problem because there is definitely something wrong and the problem is getting worse when I've stopped all medication.

Several questions I'd like answered:

1. What do you think is causing this problem given the information?
2. Should I try a course of Vibramycin and Bactroban?
3. Would you recommend doing a biopsy to the find the cause? How long does the biopsy take to heal? Is it that painful?
4. Would circumcision be a solution to this problem?

I'm eager to hear your thoughts and this has given a shot at my confidence level as a male and significantly lowered my sexual drive. Thanks for listening
Posted Fri, 9 Aug 2013 in Skin Hair and Nails
Answered by Dr. Sanjay Kumar Kanodia 12 hours later

Welcome and thanks for posting your query to XXXXXXX

I can understand your concern for the problem over the penile area. It is really distressing for a man to have anything unusual on genital area.

Now according to your query you have the problem of recurring small bumps over penis. As I can get from your history you have met multiple of doctors and then gone for multitude of tests to reach to the exact diagnosis of the problem. Presently you are stressed and confused about the exact nature of the problem.

To begin with let me reassure you by the most important thing that you do not have any major kind of sexually transmitted disease like HIV or syphilis or any other major dermatological problem. This is quite evident by all the tests done and which came negative. So any how what ever the thing might be on penis it is not at all XXXXXXX So what is the possibility of the problem then..!!

I have gone through the whole series of pictures sent by you. The spots on head of your penis are “Pearly Penile Papules” and spots on the undersurface of penis are “Fordyce spots”. Both of these are simple, benign and usual normal condition of the penile area.

The Pearly Penile Papules are small, pearly or flesh-colored, smooth, dome-topped bumps situated around the corona or sulcus of the glans.

Fordyce spots are pinhead size or slightly larger bumps present over mainly the under surface of the penis i.e. on the frenulum area. Basically these are proliferation of the normal oil glands which are present over this area. These are totally asymptomatic (without any problem) and are most commonly confused with genital warts in there initial course of appearance. A close examination is the must to differentiate one from another. There is no need of any treatment in this condition as it is totally normal condition. If at all some person are panicky then we do remove these with radiofrequency ablation.

Looking at the picture in detail, the closest possibility is of above two only. By puling of skin, it makes the foreskin stretched and therefore both of these become more prominent on stretching of the skin.

You should also know the fact that our penile skin is the thinnest skin on the body. It is such a thin skin that even the blood vessels are directly visible over it. This redness of the blood vessels is many times confused with some kind of skin problems. In your case also this redness appears to be the same. Mild to moderate redness is quite common in this area because of the friction during sexual intercourse or due to masturbation also. Even the condoms are known to produce redness because of the rubber content as well as certain chemicals on the condoms as lubricants and as fragrance.

Now regarding your questions:

1.     What do you think is causing this problem given the information? – I have answered your query above as the problem is simple usual thing which is found very commonly in uncircumcised males.

2.     Should I try a course of Vibramycin and Bactroban? – I don’t think that even taking the course of antibiotics will change the out look of the problem as it is not a disease in itself.

3.     Would you recommend doing a biopsy to the find the cause? How long does the biopsy take to heal? Is it that painful? – I would not be recommending biopsy for your problem directly. We do say biopsy as the ultimate diagnostic technique. Even for your satisfaction if you want to go then it takes around 2 weeks to get healed. It is bit painful for 4-5 days and as the scab forms the pain part subsides.

4.     Would circumcision be a solution to this problem?- Yes this is one of he smart questions you have asked. In my series of patients with such problem I definitely go for circumcision if this is of long standing duration or is a recurrent problem as in your case. Most of the times it works wonderfully in uncircumcised males. One good suggestion is when you go for circumcision then can go for a small biopsy in a single go which will heal together. And as I said in opinion it should come normal so would be giving a sense of relief for nothing serious at genital area.

I would like to provide you certain suggestions which would be very helpful in reducing the present symptoms and in future also:

1. As you are uncircumcised male so clean the genital area 3-4 times thoroughly and gently by retracting your prepuce completely backwards.

2. Do saline water compression meaning 1 glass of water with pinch of salt in it and then cotton soaked in the water and compressing for 5 minutes.

3. Stop application of any kind of medication without the advice of the doctor. Even do not apply multiple kinds of antifungal and steroids which itself can lead to sensitization of the area.

Lastly kindly reassure yourself for this simple problem which can be taken care of by simple meticulous methods.

I hope these information's will help you. If you have further queries I will be happy to help.

"Wish you good health"

Dr Sanjay Kumar Kanodia
MD (Dermatology and Sexually Transmitted Diseases)
Above answer was peer-reviewed by
Follow-up: Experiencing rash on penis head. Diagnosed fungal infection. Prescribed Tricodex. Tried anti fungal creams. No improvement. Suggest? 1 hour later
Hello Doctor XXXXXXX

I googled up pictures of Penile papules and Fordyce spots. The images doesn't seem to resemble the rash I have. If you look at the pictures I uploaded, none of them showed protruding bumps. The rash itself isn't bumpy and doesn't look anything close to warts.

The pictures aren't as accurate as seeing it in real life and it's more like a rash. There are no pearly like materials and the rash isn't exclusive to the bottom of the ring. More resembling of google images of psoriasis or eczema but it isn't dry and scaly. Its quite red and irritated.

Furthermore, they are not asymptomatic. They were for a little bit but everyday since a week ago the rash has spread and its starting to cause burning sensation when I'm just sitting. It is also causing some burning sensation when urinating. I also have a similar rash on the side of my scrotum and shaft of my penis. The rash on my penis has also spread to the outer layer of my penis so Fordyce and papules can't do that right?

I'm curious to know why you have excluded the possibility of a bacterial infection? Is it from sight? Or from lack of symptoms?

Also if it wasn't a bacterial infection then why would the Gentamycin cream work for awhile? And why would the rash respond to a cream of Nystatin+Neomycin+steroid but not to Cutivate alone?


Answered by Dr. Sanjay Kumar Kanodia 4 hours later
Hello Young man,

Welcome again to the forum and thanks for your prompt reply. By your prompt reply I can definitely make out the kind of stress in your mind regarding the problem.

The very first advice to you is to stop surfing on net for any possibilities without any guidance. The internet is flooded with so much of the informations that even some time an expert also gets mystified.

Now, firstly regarding pearly penile papules and the Fordyce spots. The pictures available on net are typical fully formed lesion images of person. There are so many of the variations in these conditions. Any how as these are totally simple and usual conditions and specifically in yourself just a initial part of the entity which I can make out in the pictures sent by you. As per your history the problem started with tiny painless dots. By the application of multiple of creams the things can get suppressed a bit. So you should be worried and baffled by the pictures on internet.

The part of fungal infection had already been nullified by multiple of KOH mount tests performed. Now for the part of bacterial infection- Our penile skin has multiple of the glands which secrets the normal secretion on daily basis. These secretions are deposited in the form of “smegma”. Now this is acted upon by bacteria known as “normal flora”. If there is proliferation of infection causing bacteria or we simply say as bacterial infection then the first sign is profuse discharge in form of pus then pain and then multiple of other sign and symptoms which are beyond our discussion. I can get from the picture as well as the series of events that it is not exactly the kind of bacterial infection as you are thinking.

Now what the problem is if it is not the XXXXXXX bacterial infection – it is simple irritation super-added by mild infection due to multiple of factors which we uncircumcised males get off and on. To explain you medically and scientifically, in uncircumcised males there can be deposition of smegma over the glans penis.

Along with this there can be retention of urine between two tightly apposed surfaces of glans penis and skin of prepuce. When this area is infrequently and inadequately separated and/or inappropriately bathed, it leads to excessive frictional trauma over the surface of glans penis. Adding to it, the thinnest skin of the body over glans is also sensitive to the friction plus the chemicals in day to day life as I discussed in previous post. All these factors lead to the kind of problem which you are facing.

Circumcision is one of the best measure in such kind of problem where all these factors are disposed off because of lack of skin and no factor of smegma or any other additional factors as discussed above.

By taking the course of antibiotics will not change the out look of the problem as it is not a disease in itself. The normal process of the body will again be starting so unnecessary exposure to antibiotics is not justified.

Basically hygiene maintenance is the most important part. That is why Gentamycin cream as well cream of Nystatin+Neomycin+steroid worked on it for a while but not the Cutivate alone. This was because of the fact that antibacterial cream works on the normal and abnormal flora of bacteria. There is lesser secretion of smegma and so less deposition so it gives a kind of temporary relief. Cutivate being a strong steroid has nothing to do with this kind of problem. There is no fungus present in normal flora of skin over penis- no, never!! Therefore none of the antifungal worked in your case.

To get relieved of the problem we try to exclude the offending factors enumerated above. So simple frequent washing (even after urination), saline compresses in moderate cases and in more problematic cases we suggest to go for circumcision as I already discussed in my previous Email.

I hope these information's will help you. If you have further queries I will be happy to help.

"Wish you good health"


Dr Sanjay Kumar Kanodia
MD (Dermatology and Sexually Transmitted Diseases)

Above answer was peer-reviewed by
Follow-up: Experiencing rash on penis head. Diagnosed fungal infection. Prescribed Tricodex. Tried anti fungal creams. No improvement. Suggest? 2 hours later

Thank you for your thorough and detailed reply. I appreciate your effort.

There are still some things that haven't been addressed.

First of all, I'd like to point out that it actually looks worse in real life compared to the pictures.

Secondly, if it was really these unharmful papules or spots, would they be causing symptoms of burning sensation on the skin and while urinating? And i've stopped all medication for about 8 days now and the condition has just gotten worse with more spots appearing daily. Does this seem normal for such a condition?

This rash has also spread to the outer layers of my penis. Like near the tip of my penis but on the outer skin and not the actual head. They are red rounded areas that takes away the natural brown color of the shaft. There is about 4-5 of those around the tip. Could you also comment on the rash on the inside of the shaft? It is on one of the pictures.

What about the reasoning for you to exclude other skin conditions such as psoriasis, eczema, or lichen planus? (a dermatologist mentioned them being possibilities)

Thank you Dr XXXXXXX for your patience and answer
Answered by Dr. Sanjay Kumar Kanodia 5 hours later
Hello young man,

Welcome to the forum again. I am really empathetic to the problem which you are facing. As a man I can very well understand the concern and agony which you are feeling for the problem.

Now let me again first reassure regarding the other of the possibilities of psoriasis, eczema, or lichen planus. The complete set of pictures I have gone through, do not match at all with any of the conditions. IN all these problem there is typical of presentation which we can not see in any of the single pictures. By seeing all your good resolution pictures I can not make out such kind possibilities.

What I can typically make out is “redness” in most of the pictures. This is also specifically present mainly at the sites of contact with glans penis and prepuce. Now this redness alone is not a disease entity in itself. Penile skin being quite sensitive and vascular skin, so the redness can come quite frequently due to repeated and frequent touching or cleaning with some antiseptic liquids. In sensitive skin mere contact with opposing surface of prepuce and glans can cause it. IN the pictures I can make out the redness preferentially present at the opposing surface of prepuce and glans and at the opening of the urethra. There are areas of normal skin interspersed between these red areas means it is not a uniform phenomenon all over.

I can also make out that the condition is even worse than what it is appearing in the pictures. It is also a common sequel to over medicated and over sensitized skin. You do simple saline compression which will regain the normal flora of the skin and maintain regular hygiene at the area. But do not apply any antiseptic lotion or something. Simple plane water wash is sufficient for 3-4 times a day. Do not apply even simple moisturizer creams as it contains fragrance in it which can further cause the problem. Wait for a least few day to take its natural course.

IF the things do not come in control then go for circumcision which in opinion would be the best choice of treatment in your case.

I hope I addressed your queries properly. If you have further queries I will be happy to help.

"Wish you good health"


Dr Sanjay Kumar Kanodia
MD (Dermatology and Sexually Transmitted Diseases)
Above answer was peer-reviewed by
Follow-up: Experiencing rash on penis head. Diagnosed fungal infection. Prescribed Tricodex. Tried anti fungal creams. No improvement. Suggest? 21 hours later
Hello doctor XXXXXXX

Again appreciate your detailed answer. I'm very satisfied with the service you are giving me. I just have a few more things that need to be addressed.

1. I've uploaded two more photos and the 1st one shows the rash on the inner shaft of my penis. What do you think this is? This has been around for quite a long time but seems to be getting worse whilst the onset of my penis gland rash in the last 9 months. There is also smaller round sized rashes around my scrotum and near the tip of my penis on the outer skin layer. I'm wondering if there is any relation between this and the rash on my glands.

2. In the other picture I've attached another photo of my glands to show you and please note that in real life it is very red that you can easily makeout the difference between normal and problmeatic skin. The problematic skin almost seems a little "raised" It also has a burning sensation near the urethra. I've gone a long time unmedicated and have started to use saline compresses to soothe the area but doesn't seem to be improving.

3. Another doctor mentioned to me about it being unspecified plasma cell balanitis and said it doesn't look like papules of fordyce spots. what do you think about this?

4. How long should I wait to see if there is any improvement before really going into thought about a circumcision? It seems that even the tip of the penis that is exposed to outside air is problematic. How would this suggest that a circumcision would be a cure all?

5. how do I contact you for further advice once this discussion is closed and reviewed?

Thanks a bunch

Answered by Dr. Sanjay Kumar Kanodia 15 hours later
Hello Dear,

Welcome again to the forum young man.

I was waiting for your latest photos to be uploaded to the site. I am sorry to say that these were not attached and uploaded with your latest query.

Even then there are some good resolution previous pictures which explain your query. I can see the raised things on the glans (image 0809), deep red areas on side of glans and prepuce (image 0810), redness on the tip of your penis (image 815) as well as rash on front of shaft (image 816).

The important thing is that I have discussed your problem along with the photographs with my panel of dermatologists. After long discussion and based on history and photographic evidences with all, the important points came out were as below:

1.     The majority of the symptoms and signs indicate us towards inflammation of the penis and surrounding areas, so the one important thing we can say is that you have “balanitis”.

2.     Now as per the long standing nature of the condition with waxing and waning the inflammation is still persisting. So the inflammation can be nonspecifically correlated to “plasma cell balanitis”. Though it would not be a right thing to diagnose plasma cell balanitis out rightly, but based on clinical experience of all and the features resembling the problem we can keep most probable diagnosis of the same.

3.     All your symptomatology can be explained on the basis of the above diagnosis. You should understand this is a probable diagnosis and not a direct compete diagnosis.

4.     As already discussed we agree with “Circumcision” is the best choice of treatment in all the patients having your kind of problem.

5.     A biopsy can be taken simultaneously with circumcision which can give the exact diagnosis of the problem as well as a help for future reference.

6.     You can wait for around 7-14 days of period without any medications so that the exact picture of the problem can be seen.

I think you have got all the answers to the latest of the queries. You can contact me further on the forum and ask me directly for any future help. I a really empathetic to your problem but also fully confident that this can be solved and cured very well.

Be in touch and do give us a follow up in future. We will be happy to help in you in any of your health queries.

Wish you early recovery to the problem and healthy life ahead.


Dr Sanjay Kumar Kanodia
MD (Dermatology and Sexually Transmitted Diseases)
Above answer was peer-reviewed by
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