Cracks in the foreskin: causes in men and children, treatment

Fissures of the foreskin are linear tears in the thin skin at the corona, along the foreskin/frenulum junction, or along the constriction ring. They occur due to a combination of dryness, microtrauma, and inflammation. In adults, the most common causes are dermatoses (lichen sclerosus, psoriasis, contact dermatitis), candidal balanitis, and mechanical overload (intense sex, masturbation). In children, they are caused by pathological phimosis due to dermatosis or rough attempts at forced opening. It is important to distinguish skin fissures from ulcers and blisters: the latter often require examination for infections transmitted by close contact. [1]

The fissures themselves are painful, complicate hygiene, and may bleed and impede urination. In some patients, they "recur" in the same location (usually along the frenulum or the stenotic ring), indicating phimosis/microphimosis and chronic inflammation. In this case, treatment with creams alone often provides only a temporary effect: the cause must be treated, not the symptom. [2]

Lichen sclerosus (formerly known as balanitis xerotica obliterans, BXO) is one of the main "hidden" causes of fissures in men. It causes skin whitening, thinning, painful tears, cicatricial phimosis, and narrowing of the meatus; without treatment, it increases the risk of urethral strictures and even penile cancer. Early diagnosis and appropriate management (ultrapotent steroids and, if unsuccessful, circumcision) dramatically improve outcomes. [3]

In children, the vast majority of "non-opening" foreskin lesions are physiologically normal and do not require treatment; however, recurrent painful fissures, a "white ring" scar, a fan-shaped spur, and infections are reasons for treatment (topical steroids) or consideration of surgery if indicated. The key detrimental factor is forced attempts at early retraction. [4]

Code according to ICD-10 and ICD-11

In ICD-10, inflammation of the glans/prepuce is coded as N48.1 "Balanitis/balanoposthitis." For cicatricial phimosis, N47 is used ; for ulcerative lesions and other diseases of the penis, N48 ("Other diseases of the penis") is used. These codes are useful for documenting clinical scenarios where fissures are part of the picture of balanoposthitis or phimosis. [5]

ICD-11 uses GB06.0 "Balanitis or balanoposthitis" (there is a variant GB06.0Z "unspecified"), and associated diagnoses (e.g., lichen sclerosus) are coded separately under the skin disease section. This facilitates routing and statistics for dermato-urological conditions. [6]

If the fissures are caused by lichen sclerosus, it's important to include both conditions (dermatosis + local inflammation/phimosis) in the discharge summary to avoid missing the cancer risk and the need for follow-up. The opposite situation applies to contact dermatitis: here, the code for balanitis plus the external cause (irritant) is often sufficient. [7]

Table 1. Frequently used codes

Scenario	ICD-10	ICD-11
Balanitis/balanoposthitis	N48.1	GB06.0 / GB06.0Z
Cicatricial phimosis	N47.*	(under the section on phimosis in the male genital system)
Lichen sclerosus (men)	(codes for dermatoses of the skin/mucous membranes)	(relevant section of dermatoses)

Epidemiology

Balanoposthitis is one of the most common reasons for visits to a dermatovenerologist/urologist in uncircumcised men. In the adult population, the proportion of infectious, inflammatory, and dermatological causes varies, but the proportion of dermatoses is underestimated. Current European guidelines emphasize that non-infectious causes (lichen sclerosus, psoriasis, contact dermatitis) are very common. This is critical for treatment selection: the "default antibiotic" approach is not effective here. [8]

Lichen sclerosus occurs in men at any age, with peaks in childhood and 40-50 years. In studies of tissue removed from the foreskin due to phimosis, signs of lichen sclerosus were found in 14-95% of samples. The variation is due to sampling and methodology, but the trend is clear: dermatosis is the leading cause of cicatricial phimosis and fissures. After circumcision, the risk of urethral lesions and cancer is significantly reduced, but not eliminated, and observation is required. [9]

In boys, physiological phimosis is extremely common and gradually disappears by adolescence. According to large reviews and guidelines, by the age of 16-18, actual phimosis persists in approximately 1% of adolescents; between ages 5-13, the incidence of "incomplete retraction" can range from 9-20% and does not, by itself, require intervention. Recurring painful fissures, a "white ring," and infections are markers of a pathological process. [10]

The epidemiology of "home triggers" (harsh detergents, alcohol-based antiseptics, latex/lubricants, rough retraction) has been modestly studied, but is regularly noted in clinical series as a contributing factor to fissures. This explains why eliminating irritants and maintaining the skin barrier often yield rapid clinical benefits, even before specific therapy. [11]

Reasons

Adults: 1) inflammatory dermatoses - lichen sclerosus (the leading factor in fissures and cicatricial phimosis), genital psoriasis (often a "smooth" form without scales), contact dermatitis (gels, latex, spermicides, powders); 2) infectious conditions - candidal balanitis (often associated with diabetes/antibiotics), less often - bacterial; 3) mechanical overload/microtrauma (sex, masturbation, tight frenulum); 4) iatrogenic irritants (alcohol/iodine antiseptics, "prophylactic" antiseptic baths). [12]

Children: 1) physiological phimosis (painless "unwillingness" to retract) does not crack on its own; 2) pathological phimosis due to lichen sclerosus - produces a "white dense ring", painful tears during urination/erecions; 3) balanitis/balanoposthitis; 4) trauma from forced retraction. It is important to distinguish: "does not open" ≠ "pain and cracks". [13]

Metabolic factors (diabetes, obesity), humidity, and maceration increase yeast colonization and secondary inflammation, creating a "vicious cycle": itching → scratching/micro-tears → further inflammation → new cracks. Therefore, identifying and correcting the underlying cause is part of therapy, not an "add-on." [14]

Table 2. What is most often behind cracks in the foreskin?

Group of reasons	Examples	Inspection tips
Dermatoses	Lichen sclerosus, psoriasis, contact dermatitis	Whitish, dense skin, scar "ring"; smooth erythema; association with irritants
Infections	Candidal balanitis, bacterial balanitis	Plaque, erosions, cracks; often diabetes/antibiotics
Mechanics	Tight frenulum, intense contact	Linear ruptures along the frenulum/ring, fresh "tears"
Children	Pathological phimosis (LS), retraction injury	Pain, "white ring", "fan" shaped discharge, infections

Risk factors

Uncircumcised status, obesity, microincontinence/maceration, diabetes, poor hygiene (harsh detergents, alcohol-based antiseptics), and latex/fragranced lubricants increase the risk of balanoposthitis, candidiasis, and contact dermatitis. Lichen sclerosus has been associated with chronic maceration, microincontinence, and urotrauma. [15]

Behavioral factors: intense or "dry" coitus/masturbation, rough early retraction in children, piercings (as a trigger for LS). Adolescents often experience a "weekend symptom"—linear tears after a lot of contact or "dry" friction. Eliminating triggers is half the battle. [16]

Medical: recent antibiotics (candidiasis), topical strong steroids without diagnosis (masking the fungus), prolonged contact with urine (neurogenic bladder, post-occlusion leakage) - aggravate barrier damage and maintain cracks. [17]

In children - phimosis with LS, chronic balanoposthitis, diaper dermatitis, type 1 diabetes mellitus (rare, but important to exclude in case of recurrent candidiasis and fissures). [18]

Pathogenesis

The essence is "the barrier is broken": maceration, dryness, or inflammation make the epithelium vulnerable, and mechanical tension (erection, friction) "tears" the tissue along the line of greatest stress. With LS, collagen changes, sclerosis, and thinning further reduce elasticity—cracks become recurrent and difficult to heal. [19]

Candidiasis and bacterial colonization maintain inflammation and itching, increasing scratching and microtrauma. In contact dermatitis, chemical irritants (surfactants, fragrances, antiseptics) damage the lipid barrier, causing erythema and burning; eliminating the trigger often results in rapid resolution. [20]

In children with pathological phimosis, the "rigid ring" is mechanically traumatized during urination and nocturnal erections; each "stretching" without treatment adds scarring and worsens the phimosis, forming a "scarring cycle." Steroid treatments and/or surgery are needed here, not "stretching by force." [21]

In genital psoriasis, the scales in the folds are minimal, and the skin is smooth and very sensitive; cracks occur due to microtrauma (Koebner phenomenon). This requires careful, "gentle" regimens—lower doses of steroids, calcineurin inhibitors, and meticulous care. [22]

Symptoms

Pain when stretching the skin, burning, stinging with urine, pinpoint bleeding from the tear lines, cracks along the frenulum/corona, painful retraction of the foreskin. On examination: linear tears, sometimes with a whitish "dense" ring (LS), erythema and plaque (candidiasis/dermatitis), smooth bright red plaques (psoriasis of the folds). [23]

Accompanying symptoms: unpleasant odor, itching, "sticking" of the foreskin, pain during intercourse. Symptoms indicate the cause: severe itching and plaque - for candidiasis; sharp pain at the "narrow ring" - for phimosis/LS; connection with hygiene/products - for contact dermatitis. [24]

In children: crying during urination, a thin, fan-shaped stream, painful tears along the edge, bloody marks on underwear/diapers. When attempting forced retraction, fresh tears and fear of manipulation are observed. [25]

“Red flags”: rapidly increasing swelling and pain (risk of paraphimosis), deep ulcers/vesicles (atypical infection/STI), pain and fever (cellulitis), persistent erosions/suspected precancer - these are routes for emergency/urgent examination. [26]

Forms and stages

Working classification: 1) Dermatosis-associated fissures (LS, psoriasis, eczema/contact dermatitis); 2) Infectious-inflammatory (candidiasis/bacterial balanitis); 3) Mechanical (frenulum, microphimosis “ring”); 4) Pediatric (pathological phimosis/LS vs physiological condition). Combinations are common. [27]

By severity: superficial (local pain, minimal bleeding), multiple painful, recurring with scarring (suspected LS), complicated (infection, paraphimosis, strictures). LS stages range from superficial cracks to a dense "ring", narrowing of the meatus and damage to the urethra. [28]

Table 3. "Where should I take my patient?"

Option	Key Tips	The nearest route
Dermatosis	Whitish, dense skin, smooth plaques, association with irritants	Dermatologist/urologist, topical steroids/CI
Infection	Plaque, itching, maceration, diabetes	Antifungal/antibacterial + care
Mechanics	Localized tears along the frenulum/ring	Treatment of phimosis/frenulum, care
Childhood LS/phimosis	Pain, "white ring", "fan" jet	Steroid course → circumcision evaluation

Complications and consequences

Untreated LS leads to cicatricial phimosis, meatostenosis, urethral strictures, and, less commonly, neoplasia. Up to a third to a half of penile cancer cases are associated with LS. The risk decreases with adequate treatment and, if indicated, circumcision, but remains non-zero: observation is necessary. [29]

Repeated fissures are a gateway for secondary infection: pain and swelling increase, an unpleasant odor develops, and cellulitis and paraphimosis are possible. With severe pain, children may avoid urination, which can lead to urinary retention and infection. [30]

Chronic pain and fear of intimacy in adults are a common "non-medical" price. Adequate treatment for dermatosis/phimosis usually restores quality of life without long-term limitations.

In children, harsh attempts to stretch the marginal leaflet result in scarring and the need for surgery that could have been avoided with early steroid use and a gentle regimen.[31]

Diagnostics

Diagnosis is clinical: location/type of cracks, skin color and density (whitish "waxy" - think LS), plaque (candidiasis), smooth red plaques (psoriasis of the folds), connection with cosmetics/latex. If in doubt, dermatoscopy and photo documentation for dynamics are recommended. A biopsy is necessary if the picture is unclear, there is no response to therapy, or precancerous lesions are suspected; in LS, it often confirms sclerosis and inflammation. [32]

Laboratory tests as indicated: smears/cultures for Candida/bacteria in case of plaque and maceration, blood glucose/glycated hemoglobin in case of recurrent candidiasis, STI panel in case of ulcers/erosions/vesicles (to differentiate from fissures). In children, phimosis is diagnosed clinically; ultrasound and other methods are rarely needed (for example, if complications are suspected). [33]

If urethral involvement is suspected (thin “stream”, splashing stream, pain) - examination of the meatus; in case of LS and severe meatostenosis - assessment of the urethra by a urologist (uroflowmetry, urethroscopy/urethrography as indicated). [34]

Table 4. Mini-diagnostic algorithm

Step	What to do	For what
1	Specify localization, triggers, background	Dilute dermatosis/infection/mechanics
2	Examination: "white ring", plaque, plaque	Preliminary diagnosis
3	Target tests (Pos/glucose/STI)	Confirm the reason
4	Biopsy in case of uncertainty/failure	Exclude precancer, clarify dermatosis
5	If you have jet symptoms, see a urologist.	Assess the meatus/urethra

Differential diagnosis

Lichen sclerosus vs. "simple" contact dermatitis: with LS, the skin is dense, whitish, with a tendency to scarring and narrowing of the ring; with dermatitis, there is bright erythema, itching, a clear connection with the irritant, and rapid improvement after elimination. [35]

Genital psoriasis (sometimes "inverse") produces smooth, erythematous plaques with minimal scale, sensitivity is high; steroids are used in short courses of low/moderate strength, and outside of acute phases, calcineurin inhibitors. [36]

Candidal balanitis: plaque, maceration, fissures, itching; more common in diabetes and after antibiotics. If recurring, check blood sugar levels and eliminate moisture/friction. Bacterial balanitis is less likely to cause fissures but can complicate healing. [37]

Ulcerative-vesicular STIs (herpes, syphilis, rare dermatoses) are not "cracks," but have a different morphology; suspicion is a reason for rapid testing and specific therapy. Zoon balanitis (plasma cell) produces bright red "varnish" plaques; circumcision is effective, and lasers and photodynamics are being studied. [38]

Table 5. "Are these really cracks?" - differences in key states

Sign	Cracks in LS	Contact dermatitis	Genital psoriasis	Herpes
Color/texture	Whitish, dense, "waxy" skin	Bright erythema	Smooth red plaques	Blisters → erosions
Scarring	Yes (ring/narrowing)	No	No	No
Itching	+/-	Often expressed	Often	Severe pain/burning
Tactics	Ultrapotent steroids/circumcision	Elimination + soft topicals	Low-medium steroids/KI	Antiviral

Treatment

General principles. First, care and elimination of triggers: no soap or antiseptics on the glans, warm water + a mild soap substitute, daily barrier cream (petrolatum/ceramide based), gentle aeration. During healing, abstain from sex or use neutral lubricants; avoid latex/fragrances if you suspect an allergy. If pain occurs, take NSAIDs as directed. These measures are basic for all causes. [39]

Lichen sclerosus (adults). First-line therapy: ultrapotent topical steroids (clobetasol 0.05%, as per guidelines) for 1-3 months with gradual reduction in frequency. In case of failure or early relapses, circumcision; in case of meatal stenosis/strictures, urethro/meatotomy. Long-term maintenance "microdose" in men is used sparingly; cancer risk control is maintained. Experimental methods (lasers, plasma, photodynamics) are being discussed, but the evidence is insufficient for routine use. [40]

Genital psoriasis. Due to the thin skin, gentle regimens are recommended: low- to moderate-strength steroids in short courses, calcineurin inhibitors (tacrolimus/pimecrolimus) for bridging and maintenance, and active emollients. For systemic psoriasis, coordinate with a dermatologist (phototherapy/systemic agents). [41]

Candidiasis/infectious balanitis. Topical imidazoles (clotri-/miconazole); if severe inflammation occurs, brief "stop-inflammation" with a low-potency steroid under the cover of an antifungal; if relapses occur, seek diabetes and correct moisture/friction. Antibiotics should only be used if a bacterial process is proven. [42]

Mechanical fissures, short frenulum, microphimosis. Local healing therapy + addressing the underlying cause: frenuloplasty, gentle dilation/gradual retraction, and, in cases of recurrence and "rigid ring," circumcision. In LS, frenuloplasty without removal of the foreskin is often ineffective due to recurrence in scar tissue. [43]

Children and adolescents. For pathological phimosis, the first line is a 4-8 week course of topical steroids (usually betamethasone 0.05%) with gentle stretching. Studies show success rates of 67-95% and higher, and it is safe and inexpensive. In cases of failure, recurrence of LS, frequent fissures, and infections, circumcision is considered; forced stretching is contraindicated. [44]

Zoon balanitis and rare scenarios. Circumcision has been proven effective; in some studies, erbium/CO₂ laser and photodynamic therapy have been shown to result in remission, but these are niche solutions that require consultation with a specialist. [45]

Table 6. Tactics by reasons

Cause	First line	If it didn't help
Lichen sclerosus	Clobetasol 0.05% course	Circumcision; for strictures - urethral surgery
Genital psoriasis	Low/moderate steroids, tacrolimus	Dermatologist: Phototherapy/systemic
Candidiasis	Imidozoles locally	Looking for diabetes/humidity; rare oral
Mechanics (bridle/ring)	Healing + care	Frenuloplasty/circumcision
Childhood phimosis	Steroids 4-8 weeks	Circumcision according to indications

Prevention

Daily "gentle" care: warm water instead of soap, hypoallergenic substitutes, barrier cream after showering and before activity; drying/aeration after sports; neutral, fragrance-free lubricants; condoms made from latex alternatives if an allergy is suspected. Avoid aggressive antiseptics and "preventative baths" with alcohol/iodine. [46]

Background control: weight loss, correction of glycemic control in diabetes, treatment of urological dysfunction with urine leakage (microincontinence), which reduces maceration. In children, no forced retractions; if problems arise, the doctor will prescribe a steroid course and teach gentle exercises. [47]

Forecast

For dermatoses, timely topical therapy and, if necessary, circumcision offer a high chance of sustained remission. For LS, 60-70% of men achieve long-term control with medication; circumcision helps the rest; the cancer risk drops significantly after cure, but monitoring remains. [48]

In children, the prognosis is generally excellent: most cases resolve with steroid therapy and growth; surgery is required in a minority of cases of recurrence/LS. Worse outcomes are associated with late presentation, recurrent injuries, inadequate antiseptic self-treatment, and missed LS. [49]

FAQ

• Are cracks always an infection?

No. They are most often associated with dermatoses (lichen sclerosus, dermatitis, psoriasis) and mechanical problems. Infection (candidiasis) is often secondary. We treat the cause, not "throw antibiotics at everything." [50]

• When is surgery needed?

In cases of failure of ultrapotent steroids in LS, recurrent fissures associated with a "rigid ring," a frenulum that interferes with sexual intercourse, and complications (meatostenosis, strictures). Circumcision reduces the risk of recurrence and cancer, but observation is maintained. [51]

• Is it possible to cure phimosis in a child without surgery?

In many cases, yes: 4-8 week courses of 0.05% betamethasone with gentle stretching are effective in 67-95% of cases. Violence and "stretching by force" are contraindicated. [52]

• What red flags require urgent attention?

Rapid swelling and trapping of the foreskin behind the glans penis (paraphimosis), severe pain/fever, deep ulcers/vesicles, persistent bleeding areas, and suspicion of precancerous lesions. This requires in-person examination and possibly surgery/biopsy. [53]