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Suggest treatment for balanitis

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Posted on Wed, 2 Dec 2015
Question: Please forward this question to Dr. XXXXXXX Hanif. It's about balanitis inflammation. He has been responding to my questions. The previous thread was closed

Thank you

Please check attached two pictures

1) Now the RED patches at night were all cherry RED, look less RED now. However the width and length of the BAD has not changed at all in last 10 days. It's becoming RED and pink in that area only. The width of the BAND is same all throughout. Why the BAND has not enlarged ?. It's fixed - EQ tend to have fixed band with well demarcated area _ I see demarcation clearly from rest of the penis

2) Do you also think the changing RED color everyday of these patches from morning to evening is a sign this is not EQ, with EQ it may not be so rapid. This answer may actually confirm this is simple inflammation and not EQ

I also noticed I did not apply neosporin/cotrimazole yesterday - The inflammation may have continued, I wanted to see putting coconut oil and Vaseline alone will help it not because I am little reluctant to use steroids on penis, but looks like no other way. I think I will apply for few days - both of them with bentonvate - C.

3) Do you think oral dose (Antibiotic/ 1 Diflucan dose) will help reduce inflammation - sometimes systemic dose may help



Thanks
doctor
Answered by Dr. Muhammad Hanif (1 hour later)
Brief Answer:
Don't stop applying ointments, and don't do experiments please!!!

Detailed Answer:
Welcome back to HCM and thanks for consulting me through this portal.

YOUR QUESTIONS AND THEIR ANSWERS IN SEQUENCE:-
1) Now the RED patches at night were all cherry RED, look less RED now. However the width and length of the BAD has not changed at all in last 10 days. It's becoming RED and pink in that area only. The width of the BAND is same all throughout. Why the BAND has not enlarged ?. It's fixed - EQ tend to have fixed band with well demarcated area _ I see demarcation clearly from rest of the penis

ANS:-
As I told you it will change color in the morning and there it goes less red. In EQ you are unable to retract the foreskin backwards from glans, coronal sulcus of glans in also involved and many times it also involves the urethra and there is painful urination too. The lesion is not only red but also it is crusty, scaly, bleeds, weeps, sticky, painful, nonhealing ulcers etc.
Band width is same due to the steroid and other ointments. Don't stop applying them. Otherwise band may increase in size.

2) Do you also think the changing RED color everyday of these patches from morning to evening is a sign this is not EQ, with EQ it may not be so rapid. This answer may actually confirm this is simple inflammation and not EQ

ANS:-
The symptoms overlap and based only on the redness changing in the morning and evening we can't make a differential diagnosis. If we really want to differentiate, we have to go for histological examination through biopsy of the area.
As suggested you needed Tacrolimus that day. If you can manage to get please have that for fast recovery. But remember the lesions will take their time to go away.

Q. I also noticed I did not apply neosporin/clotrimazole yesterday - The inflammation may have continued, I wanted to see putting coconut oil and Vaseline alone will help it not because I am little reluctant to use steroids on penis, but looks like no other way. I think I will apply for few days - both of them with bentonvate - C.

ANS:-
The ointments are necessary for you in the long run. Don't hesitate and don't do experiments with the glans skin. Do as prescribed and it needs your cooperation. This change of color may also be a depiction of lack of adherence to treatment by the patient and it happens in many cases. I gave you a list of foods. Please try to keep them in diet plan.

3) Do you think oral dose (Antibiotic/ 1 Diflucan dose) will help reduce inflammation - sometimes systemic dose may help

ANS:-
No I don't think that way for Fluconazole. But Metronidazole has beneficial effects in this case and Oral Metronidazole is in practice but how it affects to help in recovery, this mechanism is still under research. But it is beneficial for sure. If you can have a prescription you may also take Metronidazole.



Hope I answered all of your questions. Let me know if you have further clinical concerns or doubts. I will be more than happy to get back to you with expert opinion. Please don't forget to give Five Star rating to help me assist my patients in a better way; and, please don't forget to 'Close This Discussion'.
For any disease you have, a timely follow-up is very necessary regarding the treatment efficacy and to see if there is a need to change the treatment options. So keep a follow up to see how you doing (Always write down my name in the start of your questions at this forum & I will be with you in no time).


Regards!
DR. XXXXXXX HANIF
USA

Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Muhammad Hanif (1 hour later)
1) What is the typical clean up period for Balanitis (weeks, months) ? You said this will take long time to go away. Is it the case for general balanitis ? takes longer to heal, what's typical time period. So that I can set expectations. I know time may vary from person to person. still some number will help be get an idea. I read few balanitis go away in a week after treatment.

2) You also said ointments are necessary for you in long run ?. Do you see that as chronic case based on what's going on that may last years ?, may or may not come back. I know the answer depends - but still like to know your view.

3) Will taking more probotics help ?. I am trying to see if I can start eating all immune booster foods as well.

4) Should I clean this up with Hydrogen peroxide before taking bath ?

5) I believe in that case any sexual activities are out of questions for months if this problem continues. The REDness and constant appearance does bother me and will me make me reluctant in future

Thank you
doctor
Answered by Dr. Muhammad Hanif (1 hour later)
Brief Answer:
No intercourse until you become symptom free !!!

Detailed Answer:
Welcome back...

1) What is the typical clean up period for Balanitis (weeks, months) ? You said this will take long time to go away. Is it the case for general balanitis ? takes longer to heal, what's typical time period. So that I can set expectations. I know time may vary from person to person. still some number will help be get an idea. I read few balanitis go away in a week after treatment.

ANS:-
You already have OLP--means low immunity state. I have seen a wide range of time for recovery that is affected by many factors including patient adherence to treatment. In such patients it may take some more time extending from weeks to months but definitely will take less time than OLP. OLP is more like a chronic condition.

2) You also said ointments are necessary for you in long run ?. Do you see that as chronic case based on what's going on that may last years ?, may or may not come back. I know the answer depends - but still like to know your view.

ANS:-
Not typically that long as OLP can go, but may go long. And yes it may recur or get cured once for all.

3) Will taking more probiotics help ?. I am trying to see if I can start eating all immune booster foods as well.

ANS:-
You will see miraculous effects once you keep the food guidelines in consideration. Yes it will help you a lot.


4) Should I clean this up with Hydrogen peroxide before taking bath ?

ANS:-
Pyodine or Hydrogen peroxide is good antiseptic. You may, but DON'T apply pressure. Just soft rub to do antiseptic cleaning. No peeling. care needed.

5) I believe in that case any sexual activities are out of questions for months if this problem continues. The REDness and constant appearance does bother me and will me make me reluctant in future

ANS:-
Yes--keep away from sexual intercourse until you get better and free of the symptoms.


Hope I answered all of your questions. Let me know if you have further clinical concerns or doubts. I will be more than happy to get back to you with expert opinion. Please don't forget to give Five Star rating to help me assist my patients in a better way; and, please don't forget to 'Close This Discussion'.
For any disease you have, a timely follow-up is very necessary regarding the treatment efficacy and to see if there is a need to change the treatment options. So keep a follow up to see how you doing (Always write down my name in the start of your questions at this forum & I will be with you in no time).


Regards!
DR. XXXXXXX HANIF
USA


Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Muhammad Hanif (35 minutes later)
if you talk about immunity. I have never been sick - cold, cough, fever, no other illness in past 15 years - EVER. People kind of ask me what is the secret..

Other than anxiety, worries and stress I have never had even fever/flu in past 15 years or any infection. I believe my immunity is fine, it's just the stress levels I go through on worries is higher. I do think I have higher inflammation due to imbalance of stress and anxiety, it's also possible I am allergic to something. However all patch testing I had done were fine. I have had vague issues in my body, hard to pin point and they are not what normal people get such as cold, flu..fever etc. However my multiple skin conditions such as constant itching in groin, artmpit tell me when I am stressed the first thing that gets attacked is my skin.

I believe my immune system gets triggered quickly due to higher cortisone/stress levels and that's possible cause for weird illnesses like OLP. I had some eosinophil esophigitis with multiple endoscopies, one fine day it was gone..I could never tolerate any spicy food, tea for coffee almost three years, then it just went away, no idea. They put me on all sorts of PPI, it was complete joke, I never believed it was physical, and it just like it showed up , it went away

may be this too will some day, that's my guess. May be it's just partial imbalance and higher cortisone or stress altered this immune system response. Even with OLP I stopped bothering too much, the lines have faded magically..that tells me there is mind-body connection. The more I focus on diseases, worse it gets
doctor
Answered by Dr. Muhammad Hanif (42 minutes later)
Brief Answer:
Yes--You need to relax in the first place !!!

Detailed Answer:
Welcome and greetings on consultation at my virtual clinic!


Yes--very rightly said by you that you need to keep relaxed and calm. There is definitely a clear connection of our body and mind. That's how people defeat even cancers and proudly say "we are the cancer survivors". Your self-determination and controlling anxiety levels count a lot.


Meditation; recreation; Yoga; breathing exercises; aerobics help a lot in keeping the anxiety under check.

I hope you get free of this situation very soon Mr. XXXX!


Let me know if you have further clinical concerns or doubts. I will be more than happy to get back to you with expert opinion. Please don't forget to give Five Star rating to help me assist my patients in a better way; and, please don't forget to 'Close This Discussion'.
For any disease you have, a timely follow-up is very necessary regarding the treatment efficacy and to see if there is a need to change the treatment options. So keep a follow up to see how you doing (Always write down my name in the start of your questions at this forum & I will be with you in no time).


Regards!
DR. XXXXXXX HANIF
USA

Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Muhammad Hanif (27 hours later)
I am afraid there is ULCER formed in one side and it's painful. I suspect it formed because I had used hydrogen peroxide on it. I am applying antibiotic and clotirmazole. I also noticed a new RED dot formed on the ring of penis - see the small RED dot on backside. Do you think this is bacterial infection of balanitis and main cause here is bacteria. You are sure this is not EQ ? why the small RED spot appeared on other side(picture Nov 11-2) and I wonder if that spread too..

Can you please advise. I have attached picture
---------------------------------------------------
Anaerobic infection

The features of anaerobic balanitis are superficial erosions, foul smelling subpreputial discharge, preputial oedema an inguinal adenitis. More minor forms also occur. Resolution is normally rapid with metronidazole treatment.
doctor
Answered by Dr. Muhammad Hanif (30 minutes later)
Brief Answer:
Histologic examination through biopsy is needed for the ulcer !!!

Detailed Answer:
Welcome back Mr. XXXX and thanks for the consultation at my virtual clinic. Thanks for uploading the pictures. Once again I have thoroughly reviewed all of the previous and these new ones in slide show.


The ulcer you are talking about isn't due to the use of hydrogen peroxide. But still I must say very careful hands are needed if you want to apply hydrogen peroxide. I would rather say if you don't have a nurse or a healthcare provider in range for this purpose, just don't use hydrogen peroxide. Just wash the penis with Lukewarm water and dry it out. Apply the ointments and it is sterile.

We need to go for a histologic examination of the lesion:
As aforementioned, once again I want to add there is need for Biopsy and histologic examination of the lesion especially the ulcer area.

What will we do with that biopsy:
We will be able to resolve all of your worries by excluding the possibilities Mr. XXXX. The pathologist will go for fungal and bacterial tests and will also see if it is EQ (the XXXXXXX disease of Glans) and many more possibilities. The results will give us a clear way out. Otherwise there are always some doubts left behind. That's why we have devised this test.


The new red dot has not appeared separately in reality. It is in the same sequence of prior disease and glans has all the same blood supply, venous and lymphatic drainage. This organ piece works as a unit and so are the diseases.

This is a place where multitude of pathogens may attack and when they get overcome the immunity; viral, fungal and bacterial infections are the most common ones throughout the skin. Again in histologic study we will tackle this pathogen identity issue and will decide which pathogen is involved. The Treatment thence can go more effective and yes as aforementioned Metronidazole has a role in resolving infections like this.


Hope I answered all of your questions. Let me know if you have further clinical concerns or doubts. I will be more than happy to get back to you with expert opinion. Please don't forget to give Five Star rating to help me assist my patients in a better way; and, please don't forget to 'Close This Discussion'.
For any disease you have, a timely follow-up is very necessary regarding the treatment efficacy and to see if there is a need to change the treatment options. So keep a follow up to see how you doing (Always write down my name in the start of your questions at this forum & I will be with you in no time).


Regards!
DR. XXXXXXX HANIF
USA

Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Muhammad Hanif (2 hours later)
why do you think biopsy is needed ? You are scaring me, are you pointing to EQ. There was no ulcer yesterday and I got a full ulcer today. EQ etc are slow growing non-painful ulcers and they don't form overnight I guess. I clearly see fluid under the ulcer and seems to be more like bacterial form. EQ ulcers grow over period of time, not just 2 days.

The ulcer did get worse after I poured hydrogen peroxide. The skin there has eroded and may have inflamed yesterday due to infection and after I poured hydrogen peroxide it just bubbled up quickly and got big due to underlying inflammations. I think it's possible Hydrogen peroxide there may be too hash for glans sensitivity and already inflamed skin.

I feel is bacterial and partially some fungal. It may need dose of antibiotic to clean it up and may be some antifungal, but dampness, may be over medication made it worse. I am not so sure . I am going to see dermatologist tomorrow. He may not directly go for biopsy.

You are really scaring me with EQ, you have seen this in past 10 days and I posted every picture, how can be overnight ulcer if this is EQ. I don't get it..Please see the picture thread. I suspect it is some sort of bacterial problem. Things get worse quickly in bacterial infections. I don't think EQ can change quickly so much in 2 days. There was almost healing in that area and two days later a sort of small ulcer ?

Please advise
You have scared me with EQ now..I don't think I can sleep peacefully
doctor
Answered by Dr. Muhammad Hanif (52 minutes later)
Brief Answer:
Please don't go paranoid. Biopsy will just help us treat you even better !!

Detailed Answer:
Welcome back Mr. XXXX and thanks for the consultation at my virtual clinic.

Please don't get scared as I don't mean from biopsy that you are having EQ straight. Let me explain and make you feel relax.

There are more than a dozen diseases that overlap the same symptoms which you have and we do biopsy for all of them. Biopsies are just like a blood test to see the reason of the disease. That also include the simplest ones like drug induced bullous eruptions and allergic contact dermatitis, irritant contact dermatitis that is also very common in this area and prevalent in males all over the world.

Other diseases that we can need a biopsy for and have the same overlapping symptoms as you have are:-
Mucosal fungal infections.
Lichen planus.
Balanitis Xerotica Obliterans.
EQ (Bowen).
Balanoposthitis.
cicatricial pemphigoid.
SCC.

Getting scared only of EQ is just because that you are getting paranoid as you have searched a lot and everything you have seen on internet, seems as you have that. This is making you scared.

Yes it can be bacterial and I pointed on that earlier that it may be fungal or bacterial too. So, if it is bacterial, getting a culture and sensitivity test is even more better as we can give you oral antibiotics accordingly.


No hydrogen peroxide has again nothing to do with it. It is rather antiseptic and is used for such skin lesions to keep the wound clean. Cleaning technique also matters here.

This seems to be a bacterial Pus pocket, not an EQ. EQ really doesn't erupt so fast--yes it is true. You were very scared of EQ in the first place. In such a scenario it is always recommended to go for aggressive diagnostics and aggressive treatments to take the patient out of trouble. Patient feels relief when there is a clear lab report from histopathology. That was the reason behind all that.


Hope I answered all of your questions. Let me know if you have further clinical concerns or doubts. I will be more than happy to get back to you with expert opinion. Please don't forget to give Five Star rating to help me assist my patients in a better way; and, please don't forget to 'Close This Discussion'.
For any disease you have, a timely follow-up is very necessary regarding the treatment efficacy and to see if there is a need to change the treatment options. So keep a follow up to see how you doing (Always write down my name in the start of your questions at this forum & I will be with you in no time).


Regards!
DR. XXXXXXX HANIF
USA
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Muhammad Hanif (2 hours later)
Do you think the additional circe spot that showed up and now quickly growing invalidates the while EQ thing, the band thing we have been talking ?. The entire thing seem to be some sort of fast fungal/bacterial spread. I am also going to test my sugar to see if there is any diabetic issue here

Interestingly there is pain in that ulcer and red area and I suspect when I showed you earlier it was just start of balanitis, so it looked milder. Now it may be spreading and that's why new spot on back side has appeared. I wonder with EQ it's not that quick and rapid fire. Those EQ/Bownes lesions grow slow and don't erupt this quickly, they are also solitary and take years. This is just 2 week rapid fire round for me out of nowhere, it started just 12 days ago. I was also traveling all over the world. I wonder I picked up germs from some unclean locations, god knows. The bathing water, whatever used may have caused problems, the travel for 2 days nonstop made it worse since I did not take proper bath during travel. It just exploded after I came back, it could be combined fugal/ or just anaerobic bacterial. I suspect that more due to travel, my guess.

Anyway, I will be seeing dermatologist tomorrow, lets see what he says. I may need oral systemic treatment. I suspect that. I just hope it's not something serious. This whole thing has really hit me hard out of nowhere. I was just coming out of OLP fears and was able to manage it. Now this comes out of nowhere, as soon as I got over that, this new crap appeared..Life is miserable when these disease started popping up. I was fine last year, and since then this OLP and all that hell..has just made me so depressed.. indeed..You want peace and here God throws more surprises..
doctor
Answered by Dr. Muhammad Hanif (13 minutes later)
Brief Answer:
Yes checking the Fasting blood sugar levels will be a good idea !!!

Detailed Answer:
Welcome back and thanks for the consultation at my virtual clinic!


Yes getting a test screening for diabetes is a good idea:
Fasting blood sugar levels from a laboratory.
HbA1c levels.
(Let me know the results).

Yes it seems to be like that and more toward bacterial and fungal. Viral infections also present like that and then they get secondarily infected by bacteria.

You are giving the history of travel and unhygienic durations so late. It is a big factor and is very common reason for fungal and bacterial infections Mr. XXXX.

Yes oral medications will help here like Ibuprofen, Metronidazole, Cephalexin if not allergic to.

I can feel the distress you have with the issue. I hope everything gets fine soon for you. I am always here to share this pain and will do my best to help you and give some relief from the painful situation you are facing.

For better outcome in this case, have a good night's sleep please and get it examined in-person by the Dermatologist and let me know what he says. Hope all goes fine for you tomorrow.


Hope I answered all of your questions. Let me know if you have further clinical concerns or doubts. I will be more than happy to get back to you with expert opinion. Please don't forget to give Five Star rating to help me assist my patients in a better way; and, please don't forget to 'Close This Discussion'.
For any disease you have, a timely follow-up is very necessary regarding the treatment efficacy and to see if there is a need to change the treatment options. So keep a follow up to see how you doing (Always write down my name in the start of your questions at this forum & I will be with you in no time).


Regards!
DR. XXXXXXX HANIF
USA

Above answer was peer-reviewed by : Dr. Sonia Raina
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Suggest treatment for balanitis

Brief Answer: Don't stop applying ointments, and don't do experiments please!!! Detailed Answer: Welcome back to HCM and thanks for consulting me through this portal. YOUR QUESTIONS AND THEIR ANSWERS IN SEQUENCE:- 1) Now the RED patches at night were all cherry RED, look less RED now. However the width and length of the BAD has not changed at all in last 10 days. It's becoming RED and pink in that area only. The width of the BAND is same all throughout. Why the BAND has not enlarged ?. It's fixed - EQ tend to have fixed band with well demarcated area _ I see demarcation clearly from rest of the penis ANS:- As I told you it will change color in the morning and there it goes less red. In EQ you are unable to retract the foreskin backwards from glans, coronal sulcus of glans in also involved and many times it also involves the urethra and there is painful urination too. The lesion is not only red but also it is crusty, scaly, bleeds, weeps, sticky, painful, nonhealing ulcers etc. Band width is same due to the steroid and other ointments. Don't stop applying them. Otherwise band may increase in size. 2) Do you also think the changing RED color everyday of these patches from morning to evening is a sign this is not EQ, with EQ it may not be so rapid. This answer may actually confirm this is simple inflammation and not EQ ANS:- The symptoms overlap and based only on the redness changing in the morning and evening we can't make a differential diagnosis. If we really want to differentiate, we have to go for histological examination through biopsy of the area. As suggested you needed Tacrolimus that day. If you can manage to get please have that for fast recovery. But remember the lesions will take their time to go away. Q. I also noticed I did not apply neosporin/clotrimazole yesterday - The inflammation may have continued, I wanted to see putting coconut oil and Vaseline alone will help it not because I am little reluctant to use steroids on penis, but looks like no other way. I think I will apply for few days - both of them with bentonvate - C. ANS:- The ointments are necessary for you in the long run. Don't hesitate and don't do experiments with the glans skin. Do as prescribed and it needs your cooperation. This change of color may also be a depiction of lack of adherence to treatment by the patient and it happens in many cases. I gave you a list of foods. Please try to keep them in diet plan. 3) Do you think oral dose (Antibiotic/ 1 Diflucan dose) will help reduce inflammation - sometimes systemic dose may help ANS:- No I don't think that way for Fluconazole. But Metronidazole has beneficial effects in this case and Oral Metronidazole is in practice but how it affects to help in recovery, this mechanism is still under research. But it is beneficial for sure. If you can have a prescription you may also take Metronidazole. Hope I answered all of your questions. Let me know if you have further clinical concerns or doubts. I will be more than happy to get back to you with expert opinion. Please don't forget to give Five Star rating to help me assist my patients in a better way; and, please don't forget to 'Close This Discussion'. For any disease you have, a timely follow-up is very necessary regarding the treatment efficacy and to see if there is a need to change the treatment options. So keep a follow up to see how you doing (Always write down my name in the start of your questions at this forum & I will be with you in no time). Regards! DR. XXXXXXX HANIF USA