Topical Corticosteroids in the Treatment of Phimosis in Children

Phimosis, the inability to retract the prepuce over the glans penis, is one of the most common reasons for referral of boys to pediatric surgeons and urologists, yet the great majority of cases represent a normal developmental stage rather than true disease. Distinguishing physiological non-retractility, which resolves spontaneously in almost all boys by adolescence, from pathological phimosis caused by scarring or balanitis xerotica obliterans (lichen sclerosus) is fundamental to rational management. Over the past three decades, topical corticosteroid therapy has emerged as an effective, inexpensive, and low-risk first-line alternative to circumcision for symptomatic phimosis. Pooled data from randomized controlled trials and the 2024 Cochrane systematic review indicate that corticosteroids applied to the stenotic preputial ring for four to eight weeks probably increase complete or partial resolution of phimosis compared with placebo, although the overall certainty of this evidence is limited by heterogeneity in the age of participants, baseline severity, corticosteroid preparation, and treatment duration. Individual studies report resolution in approximately 65% to 95% of treated boys, and treatment avoids the costs, anesthetic exposure, and complications of surgery. Betamethasone 0.05–0.1% is the most extensively studied agent, but clobetasol, mometasone, fluticasone, triamcinolone, and hydrocortisone have all been used successfully. In the relatively small studies available, measurable systemic absorption and suppression of the hypothalamic–pituitary–adrenal axis have not been detected at the doses and durations used, and local adverse effects are rare and reversible, although rare systemic or local effects cannot be entirely excluded, particularly with ultrapotent preparations or prolonged use. Recurrence after successful treatment is uncommon and generally responds to a repeat course. This narrative review synthesizes the anatomy and natural history of the prepuce, the classification and etiology of phimosis, and the mechanism, efficacy, safety, dosing, and cost-effectiveness of topical corticosteroids, and situates them within current international guideline recommendations and the specific role of circumcision in scarred and lichen sclerosus-associated disease.