Topical Corticosteroids for Treating Phimosis in Boys

Are topical corticosteroids effective in treating phimosis in boys?

Compared with placebo or no treatment, topical corticosteroids may increase the frequency of complete resolution (number needed to treat [NNT] = 5) and partial resolution (NNT = 11) of phimosis in boys after 4 to 8 weeks of treatment.¹ Compared with placebo, topical corticosteroids also may increase the probability of long-term complete resolution of phimosis in boys 6 months or more after treatment (NNT = 3). There is likely little to no difference in adverse effects compared with placebo.¹ (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Phimosis is a condition characterized by the inability to fully retract the penile foreskin past the glans. Physiologic phimosis is present at birth, includes normal preputial skin, and often resolves spontaneously during the first 3 to 4 years of life. Pathologic phimosis, defined by the presence of phimosis associated with an inability to retract the foreskin due to distal scarring of the prepuce, can occur because of infection or inflammation, among other causes. It can be difficult to clinically distinguish between physiologic and pathologic phimosis. Approximately 10% of 3-year-old boys and 1% of 16-year-old boys have phimosis.¹ Persistent phimosis may lead to complications such as penile inflammation, pain, sexual dysfunction, and, in rare cases, penile cancer.² Retraction of the foreskin in children with phimosis could lead to paraphimosis, in which foreskin is entrapped behind the coronal sulcus. Although uncommon, this is a medical emergency with an incidence of 0.2% in children.³

Treatment for phimosis traditionally has involved surgical interventions such as circumcision (preferred) and foreskin-preserving preputioplasty.⁴ In the past decade, studies have suggested that topical corticosteroids may be an effective treatment for phimosis.^1,5 The authors of this Cochrane review sought to determine the effectiveness of topical corticosteroids for phimosis in boys.¹

This review included 14 randomized controlled trials (RCTs) conducted in 11 countries outside the United States with 1,459 patients who were 18 days to 17 years of age with physician-diagnosed phimosis.¹ Descriptions of the severity and type of phimosis were not part of the inclusion criteria. The patients were treated with topical corticosteroids of varied potencies and included betamethasone, mometasone furoate, hydrocortisone, beclomethasone dipropionate, hydrocortisone butyrate, triamcinolone, and clobetasol propionate. The quantity, frequency, and potency varied, when reported. Treatment duration varied but ranged from 4 to 8 weeks with up to 30 months of follow-up.

Low-certainty evidence showed that topical corticosteroids increased complete resolution of phimosis in boys at 4 to 8 weeks of follow-up compared with placebo or no treatment (risk ratio [RR] = 2.73%; 95% CI, 1.79–4.16; absolute risk difference= 20.6%; NNT = 5; 10 RCTs; n = 834).¹

Low-certainty evidence showed that topical corticosteroids may increase partial resolution of phimosis compared with placebo or no treatment (RR = 1.68; 95% CI, 1.17–2.40; absolute risk difference = 9.5%; NNT = 11; seven RCTs; n = 745).¹ Low-certainty evidence also showed that topical corticosteroids may increase long-term complete resolution of phimosis at 6 months or more of follow-up (RR = 4.09; 95% CI, 2.80–5.97; absolute risk difference = 35.8%; NNT = 3; two RCTs; n = 280).