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| <h2>What is the evidence for betamethasone cream versus circumcision in phimosis?</h2> | |
| <p class="tagged">Associated tags:<a href="default.aspx?criteria=&tagtrail=%2fchild+health%2f">child health</a>, <a href="default.aspx?criteria=&tagtrail=%2fmen's+health%2f">men's health</a>, <a href="default.aspx?criteria=&tagtrail=%2fcircumcision%2f">circumcision</a>, <a href="default.aspx?criteria=&tagtrail=%2fphimosis%2f">phimosis</a>, <a href="default.aspx?criteria=&tagtrail=%2ftreatment%2f">treatment</a>, <a href="default.aspx?criteria=&tagtrail=%2fcorticosteroid%2f">corticosteroid</a></p> | |
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| <p class="answered">Question answered:06/03/08 <span class="warning">Warning! this question is over two years old.</span></p> | |
| <p></p> | |
| <p>ATTRACT found three (1-3) randomised controlled trials involving betamethasone in phimosis.</p>\ | |
| <p> </p>\ | |
| <p>The most recent (2005) investigated 70 boys 1 to 12 years old with phimosis(1). These were randomly assigned to receive topical application of either betamethasone valerate 0.06% (a highly potent steroid) or clobetasone butyrate 0.05% (a moderatelypotent steroid). The abstract notes:</p>\ | |
| <p> </p>\ | |
| <p>“Parents of the boys were instructed to retract the foreskin gently without causing pain, and to apply the topical steroids over the stenotic opening of the prepuce twice daily for 4 weeks, then for another 4 weeks if no improvement was achieved. Retractibility of the prepuce was graded from 0 to 5. Response to treatment was arbitrarily defined as improvement in the retractibility score of more than 2 points. RESULTS: Mean treatment and follow-up periods were 4.3 and 19.1 weeks, respectively. The response rates in boys treated with betamethasone valerate and clobetasone butyrate were 81.3% and 77.4%, respectively (p = 0.63). Mean retractibility score decreased from 3.9 +/- 1.0 to 1.7 +/- 1.1, and 4.2 +/- 1.0 to 1.9 +/- 1.0 in the betamethasone and clobetasone groups, respectively. Both steroids were effective in all age groups. Pretreatment retractibility score did not affect treatment outcomes. No adverse effect was encountered.”</p>\ | |
| <p> </p>\ | |
| <p>Another trial evaluated patients using the Diagnostic and Statistical Manual-III-Revised (DSM-III-R) test (2). The abstract states:</p>\ | |
| <p> </p>\ | |
| <p>“One hundred and forty-nine children with phimosis who required circumcision were included in the study. The average age of the children was 4.47 years. All children underwent the DSM-III-R test and their parents were questioned. Patients were separated randomly into three groups. Group I comprised 51 children who would undergo circumcision; group II comprised 50 children who would be treated with a topical corticosteroid (0.05% bethamethasone cream) twice daily for 1 month; and group III comprised 48 children who would be treated with a topical placebo cream. On the 5th day of treatment, parents were told to retract the prepuce and were given hygiene routine instructions. Patients were seen immediately after treatment and again 2 months later. RESULTS: In group II, 16 of the 50 children had non-retractable prepuce. Forty-two cases of phimosis were corrected after treatment. Eight patients received further monthly treatment and five benefited from the second course of treatment. In group III, 17 of the 48 patients had non-retractable prepuce and four had satisfactory results. Forty-four patients received placebo treatment for another month and eventually, 40 children underwent circumcision in this group. DSM-III-R test results showed a significant shift to anxiety in the circumcision group. There were no significant differences in the other groups. “</p>\ | |
| <p> </p>\ | |
| <p>A 2001 study randomized 137 boys with non-retractile foreskin to betamethasone (n = 66) or placebo (n = 71 ) for 4 weeks with application of the cream twice daily (3). Non-responders to treatment were offered steroid treatment for a further 4 weeks. The authors report.</p>\ | |
| <p> </p>\ | |
| <p>“The mean pretreatment grade of the foreskin in the steroid and control groups was 5.08 +/- 0.66 and 4.97 +/- 0.70, respectively. At the 4-week follow-up, 49 of the former (74%) had a retractile foreskin (grade less than or equal to 3, mean 2.38 +/- 1.41). In contrast, only 31 of the control group (44%) had a retractile foreskin (less than or equal to 3, mean 3.55 +/- 1.55) (p < 0.001). Only 14 boys were circumcised because 43 of the remaining 57 boys had a retractile foreskin after 4 weeks of treatment.”</p>\ | |
| <p> </p>\ | |
| <p>A follow up study 18 months after the original study in 92 of the boys noted that 13 had suffered a relapse in this time (4). <br />\ </p>\ | |
| <p> </p>\ | |
| <p>eMedicine, an American online textbook has an article on Phimosis, Adult Circumcision and Buried Penis. (5) This states:</p>\ | |
| <p> </p>\ | |
| <p>“Pathologic phimosis may be due to BXO, a genital form of lichen sclerosus et atrophicus. This condition affects both men and boys and represents an absolute indication for circumcision, which may be curative. The etiology of BXO is unknown, and it may represent a premalignant state. Clinically, it presents as severe phimosis and possibly meatal stenosis, glanular lesions, or both….</p>\ | |
| <p> </p>\ | |
| <p>The main medical indication for circumcision in children is pathologic phimosis. In a prospective long-term study, 40% of boys treated for phimosis were found to have BXO, which has been linked to the development of penile squamous cell carcinoma (SCC). Although potent topical steroids may allow improvement and slow progression, total circumcision is the treatment of choice for BXO and may be curative.</p>\ | |
| <p> </p>\ | |
| <p>Recurrent balanoposthitis, which affects 1% of boys, is also considered a relative indication for circumcision. However, this condition tends to be self-limited, and even if balanoposthitis is recurrent, preputioplasty and topical steroids represent alternatives to circumcision. In patients with balanoposthitis who are sufficiently troubled to warrant surgical intervention, circumcision always solves the problem.”</p>\ | |
| <p> </p>\ | |
| <p>1. Yang SS, Tsai YC, Wu CC, Liu SP, Wang CC. Highly potent and moderately potent topical steroids are effective in treating phimosis: a prospective randomized study. J Urol. 2005 Apr; 173(4):1361-3.<br />\2. Yilmaz E, Batislam E, Basar MM, Basar H. Psychological trauma of circumcision in the phallic period could be avoided by using topical steroids. Int J Urol. 2003 Dec; 10(12): 651-6.<br />\3. Lund L, Wai KH, Mui LM, Yeung CK. Effect of topical steroid on non-retractile prepubertal foreskin by a prospective, randomized, double-blind study. Scand J Urol Nephrol. 2000 Aug; 34(4):267-9.<br />\4. Lund L, Wai KH, Mui LM, Yeung CK., An 18-month follow-up study after randomized treatment of phimosis in boys with topical steroid versus placebo, Scand J Urol Nephrol. 2005; 39(1):78-81.<br />\5 <a href="http:www.emedicine.com/med/topic2873.htm">http:www.emedicine.com/med/topic2873.htm</a></p>\ | |
| <p> </p> | |
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| <p><em>This document is presented for information purposes only. The document cannot and should not be used as a basis for diagnosis or choice of treatment, and is in no way intended to replace professional medical care or attention by a qualified practitioner. ATTRACT is not responsible or liable for, directly or indirectly, ANY form of damage whatsoever resulting from the use/misuse of information contained in or implied by these documents.</em></p> | |
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| <li class="tagLarge"><a href="default.aspx?criteria=&tagtrail=%2fGenitourinary%2f" title="Genitourinary">Genitourinary</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fGerontology%2f" title="Gerontology">Gerontology</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fguideline%2f" title="guideline">guideline</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fguidelines%2f" title="guidelines">guidelines</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fHaematology%2f" title="Haematology">Haematology</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fhistory%2f" title="history">history</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fHRT%2f" title="HRT">HRT</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fhypertension%2f" title="hypertension">hypertension</a></li> | |
| <li class="tagXLarge"><a href="default.aspx?criteria=&tagtrail=%2fInfectious+disease%2f" title="Infectious disease">Infectious disease</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2finteractions%2f" title="interactions">interactions</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2finvestigations%2f" title="investigations">investigations</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2flab+tests%2f" title="lab tests">lab tests</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2flong-term%2f" title="long-term">long-term</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fmanagement%2f" title="management">management</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fmen%2f" title="men">men</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fmenopause%2f" title="menopause">menopause</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fMen's+health%2f" title="Men's health">Men's health</a></li> | |
| <li class="tagLarge"><a href="default.aspx?criteria=&tagtrail=%2fMental+health%2f" title="Mental health">Mental health</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fmetformin%2f" title="metformin">metformin</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fmigraine%2f" title="migraine">migraine</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fmonitoring%2f" title="monitoring">monitoring</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fmultiple+sclerosis%2f" title="multiple sclerosis">multiple sclerosis</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fMusculoskeletal%2f" title="Musculoskeletal">Musculoskeletal</a></li> | |
| <li class="tagXXLarge"><a href="default.aspx?criteria=&tagtrail=%2fMusculoskeletal+disease%2f" title="Musculoskeletal disease">Musculoskeletal disease</a></li> | |
| <li class="tagXLarge"><a href="default.aspx?criteria=&tagtrail=%2fNeurology%2f" title="Neurology">Neurology</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fNSAIDs%2f" title="NSAIDs">NSAIDs</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fNutrition+%26+metabolic+diseases%2f" title="Nutrition & metabolic diseases">Nutrition & metabolic diseases</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fobesity%2f" title="obesity">obesity</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fOphthalmology%2f" title="Ophthalmology">Ophthalmology</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2foral+contraceptives%2f" title="oral contraceptives">oral contraceptives</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fosteoarthritis%2f" title="osteoarthritis">osteoarthritis</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fosteoporosis%2f" title="osteoporosis">osteoporosis</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fPOP%2f" title="POP">POP</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fpregnancy%2f" title="pregnancy">pregnancy</a></li> | |
| <li class="tagXLarge"><a href="default.aspx?criteria=&tagtrail=%2fPregnancy+and+childbirth%2f" title="Pregnancy and childbirth">Pregnancy and childbirth</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fprescribing%2f" title="prescribing">prescribing</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fprimary+care%2f" title="primary care">primary care</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fprognosis%2f" title="prognosis">prognosis</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fprophylaxis%2f" title="prophylaxis">prophylaxis</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fprostate+cancer%2f" title="prostate cancer">prostate cancer</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2frecurrent%2f" title="recurrent">recurrent</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fRespiratory+disease%2f" title="Respiratory disease">Respiratory disease</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2frisk%2f" title="risk">risk</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fsafety%2f" title="safety">safety</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fscreening%2f" title="screening">screening</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fstatins%2f" title="statins">statins</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fstroke%2f" title="stroke">stroke</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fsurgery%2f" title="surgery">surgery</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fteratology%2f" title="teratology">teratology</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2ftime+factors%2f" title="time factors">time factors</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2ftreatment%2f" title="treatment">treatment</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2ftreatment+duration%2f" title="treatment duration">treatment duration</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2ftreatment+initiation%2f" title="treatment initiation">treatment initiation</a></li> | |
| <li class="tagXLarge"><a href="default.aspx?criteria=&tagtrail=%2ftreatment+options%2f" title="treatment options">treatment options</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2ftype+2+diabetes%2f" title="type 2 diabetes">type 2 diabetes</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fvaccine%2f" title="vaccine">vaccine</a></li> | |
| <li class="tagMedium"><a href="default.aspx?criteria=&tagtrail=%2fwarfarin%2f" title="warfarin">warfarin</a></li> | |
| <li class="tagSmall"><a href="default.aspx?criteria=&tagtrail=%2fwomen%2f" title="women">women</a></li> | |
| <li class="tagXXLarge"><a href="default.aspx?criteria=&tagtrail=%2fWomen's+health%2f" title="Women's health">Women's health</a></li> | |
| </ul> | |
| <a class="expandBox" name="expandText">View full tag cloud</a> | |
| </div> | |
| </div> | |
| </div> | |
| </div> | |
| </div> | |
| <div class="box"> | |
| <div class="topLeft"> | |
| <div class="topRight"> | |
| <div class="content"></div> | |
| </div> | |
| </div> | |
| <div class="bottomLeft"> | |
| <div class="bottomLeft"></div> | |
| </div> | |
| </div> | |
| </div> | |
| <!-- end of col --> | |
| <!-- end of content --> | |
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document.all["ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqBody"] : document.getElementById("ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqBody");ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqBody.controltovalidate = "ctl00_ctl00_left_left_TabContainer1_TabPanel3_txtBody";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqBody.errormessage = "Message Required";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqBody.validationGroup = "grpEmail";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqBody.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqBody.initialvalue = "";var ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail = document.all ? document.all["ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail"] : document.getElementById("ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail");ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail.controltovalidate = "ctl00_ctl00_left_left_TabContainer1_TabPanel3_txtCodeEmail";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail.errormessage = "Code Required";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail.validationGroup = "grpEmail";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail.evaluationfunction = "RequiredFieldValidatorEvaluateIsValid";ctl00_ctl00_left_left_TabContainer1_TabPanel3_reqNumberEmail.initialvalue = "";]]></script> | |
| <script type="text/javascript"><![CDATA[document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_valHeader').dispose = function() {Array.remove(Page_ValidationSummaries, document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_valHeader'));}var Page_ValidationActive = false;if (typeof(ValidatorOnLoad) == "function") {ValidatorOnLoad();}function ValidatorOnSubmit() {if (Page_ValidationActive) {return ValidatorCommonOnSubmit();}else {return true;}}document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_ValidationSummaryComment').dispose = function() {Array.remove(Page_ValidationSummaries, document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_ValidationSummaryComment'));}Sys.Application.initialize();Sys.Application.add_init(function() {$create(AjaxControlToolkit.TabPanel, {"headerTab":$get("__tab_ctl00_ctl00_left_left_TabContainer1_TabPanel1")}, null, {"owner":"ctl00_ctl00_left_left_TabContainer1"}, $get("ctl00_ctl00_left_left_TabContainer1_TabPanel1"));});document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqEmail').dispose = function() {Array.remove(Page_Validators, document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqEmail'));}document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_regEmailFormat').dispose = function() {Array.remove(Page_Validators, document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_regEmailFormat'));}document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqName').dispose = function() {Array.remove(Page_Validators, document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqName'));}document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqComments').dispose = function() {Array.remove(Page_Validators, document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqComments'));}document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqCodeNumber').dispose = function() {Array.remove(Page_Validators, document.getElementById('ctl00_ctl00_left_left_TabContainer1_TabPanel2_reqCodeNumber'));}Sys.Application.add_init(function() {$create(AjaxControlToolkit.NoBotBehavior, {"ChallengeScript":"var e = $get(\\"ctl00_ctl00_left_left_TabContainer1_TabPanel2_NoBot1_NoBotPanel\\"); 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| </form> | |
| </div> | |
| <!-- end of wrapper --> | |
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| </body> | |
| </html> |
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