RS. Please note : I believe Betamethasone and Clobetasol Propionate are effective methods of treatment in a certain percentage of cases. My criticism of these studies is that parents should not be advised to experiment with steroids on children, until conclusive, scientific, unbiased, and uncontradictory studies have been performed, and the methods tried and tested, - preferably on adults. Individual adults or parents who ecstatically praise steroids as the new wonder cure will not change my attitude.

Steroids - central index

Research is moving quickly in this area, these are the results of a MEDLINE search, last updated Jan. 2001

RS criticism of CHU
Appears to be a good study.

CHU CC, Chen KC, Diau GY
Topical steroid treatment of phimosis in boys.
Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.
J Urol 1999 Sep;162(3 Pt 1):861-3

Abstract: PURPOSE: We evaluate whether steroid application alone or retraction and hygiene are responsible for successful results in boys treated with topical steroids for phimosis. MATERIALS AND METHODS: A prospective study was performed, which included a control group of 42 patients with phimosis seen at our outpatient department from January to June 1997. During that time we trained the parent to retract and clean the foreskin only. From July 1997 to June 1998 topical steroid cream was prescribed in addition to retraction and hygiene in 276 boys with phimosis. All cases were divided into 3 subgroups of asymptomatic, symptomatic and buried penis. RESULTS: The response rate was greater than 95% in patients who received topical steroid treatment in addition to improved hygiene. Only 13 boys (less than 5%) had no response to steroid treatment. Of the control patients 23 (55%) had no response to gentle retraction and personal hygiene. There was a significant difference (p<0.001) in response rate between the study and control groups. However, the subgroup with a buried penis responded poorly to steroid, retraction and hygiene treatment. There was significant difference (p<0.001) in response rate between the buried penis and other steroid groups but no significant difference (p>0.05) in the control group. CONCLUSIONS: Phimosis is a physiological condition in neonates due to natural adhesion between the foreskin and the glans. Chronic infection due to poor hygiene is responsible for most cases of childhood phimosis. Circumcision is the traditional treatment of choice for phimosis or unretractable foreskin, although it is not always desired by parents or surgeons. Topical steroid cream is an easy, safe and nonsurgical alternative for phimosis. However, boys with a buried penis are not good candidates for steroid treatment.

RS criticism of VAN HOWE:
education, monitoring, the childs natural inquistive nature and stretching are not considered in this analysis of cheapest methods

VAN HOWE RS
Cost-effective treatment of phimosis.
Department of Pediatrics, Marshfield Clinic-Lakeland Center, Minocqua, WI 54548, USA.
Pediatrics 1998 Oct;102(4):E43

Abstract: OBJECTIVE: To determine the most cost-effective treatment for phimosis. DESIGN: The costs of three treatment strategies for treating phimosis were evaluated using a decision-tree analysis. Three therapeutic approaches were considered: circumcision, preputial plasty (the use of plastic surgical techniques to enlarge the preputial opening without removing tissue), and topical therapy with steroids and nonsteroidal antiinflammatories. Published failure and complication rates were used to calculate the cost per case. Outcome Measures. Cost in dollars to treat each case of phimosis. RESULTS: Topical steroid therapy was the most cost-effective strategy, costing between $758 and $800 per case. Preputial plasty cost between $2515 and $2580 per case. Circumcision cost between $3009 and $3241 per case. CONCLUSIONS: The most cost-effective management for treating phimosis is to initiate topical therapy. Daily external application from the tip of the foreskin to the glandis corona with betamethasone 0.05% cream for 4 to 6 weeks has been demonstrated to be very effective, resulting in a 75% savings compared with circumcision. Surgical intervention should not be considered until topical therapy has been given an adequate trial. When contemplating surgery, the lower morbidity, lower costs, and tissue preservation of preputial plasty may make it preferable.

RS Criticism of ORSOLA:
" Patients with a history of previous forcible foreskin retractions were considered to have secondary phimosis" a rather unscientific diagnosis and assumption. "No differences were seen in the response rate between those with primary and secondary phimosis" impossible. "It is effective both in primary and in secondary phimosis" and a rather unscientific conclusion

"We emphasize the importance of proper and regular foreskin care and hypothesize on the mechanism of action of the steroids." I agree with "We emphasize the importance of proper and regular foreskin care", but what does it prove about steroids?

A. ORSOLA; Caffaratti J, Garat JM
Conservative treatment of phimosis in children using a topical steroid.
Department of Pediatric Urology, Fundacio Puigvert, Barcelona, Spain.
Urology 2000 Aug 1;56(2):307-10

Abstract OBJECTIVES: From 1997 through 1998, we conducted a prospective study to evaluate the long-term outcome of using topical steroids in the treatment of childhood phimosis. METHODS: Both the parents and their children were instructed to apply 0.05% betamethasone cream topically twice a day for 1 month and to retract the prepuce after the fifth day of treatment. Results were evaluated at the end of the treatment and 6 months later. RESULTS: One hundred thirty-seven boys were evaluated. The median age was 5.4 years. At initial presentation, 61 boys had a phimotic but retractable prepuce, 37 had a nonretractable phimotic ring, and 39 had a pinpoint opening. Patients with a history of previous forcible foreskin retractions were considered to have secondary phimosis. By 6 months following treatment, 90% (124 children) had an easily retractable prepuce without a phimotic ring. No differences were seen in the response rate between those with primary and secondary phimosis. In all cases, the treatment was well tolerated without local or systemic side effects. All the patients with persistent or recurrent phimosis were found to be noncompliant with the suggested daily foreskin care. CONCLUSIONS: Topical steroid for the treatment of phimosis is a safe, simple, and inexpensive procedure that avoids surgery and its associated risks. It is effective both in primary and in secondary phimosis. We emphasize the importance of proper and regular foreskin care and hypothesize on the mechanism of action of the steroids.

RS criticism of GOLUBOVIC
"We strongly support the saying, "The fortunate foreskin of an infant boy will usually be left well alone by everyone but its owner",". If this is so, why did you treat these children twice a day? - This famous anti-circumcision saying strongly suggests a bias.

The abstract is so very convincing, however Im afraid I just cant accept that retraction, (with added vaseline), only works in 4 cases of 20. This is impossible unless we are referring to secondary phimotic ring. The inititial diagnosis of phimosis is very inexact, and it appears no histological examination for LSA etc. of the circumcised foreskins is offered, this histological examination is such an easy routine procedure that I feel a study which is meant to be taken seriously would not omit it.

Z GOLUBOVIC; Milanovic-D; Vukadinovic-V; Rakic-I; Perovic-S
The conservative treatment of phimosis in boys.
Department of Plastic and Reconstructive Surgery, University Children's Hospital, Belgrade, Yugoslavia.
Br-J-Urol. 1996 Nov; 78(5): 786-8

Abstract: OBJECTIVE: To further test the application of topical steroids in boys referred to a paediatric surgical practice with pathological, non-retractable foreskins diagnosed as phimosis. PATIENTS AND METHODS: This prospective study comprised two groups of 20 boys each (mean age 4.1 years, range 3-6) diagnosed as having phimosis; twice daily, a topical steroid (0.05% betamethasone cream) was applied on the narrowed preputial skin in the first group and a neutral cream (Vaseline) in the second (control) group. Patients were treated for 4 weeks and the retractability of the foreskin and any side-effects assessed. RESULTS: Good retraction of the foreskin was achieved in 19 patients treated with betamethasone cream and the response was unsatisfactory in 16 patients from the control group; these 16 boys and one 6-year-old boy treated with betamethasone were circumsized. There were no side-effects or problems after the application of either cream. CONCLUSION: Treatment with 0.05% betamethasone cream is a simple and safe method for the treatment of phimosis in boys older than 3 years. An early operation is necessary in cases of genuine phimosis when 1 month of treatment with topical steroids has failed. We strongly support the saying, "The fortunate foreskin of an infant boy will usually be left well alone by everyone but its owner".

RS criticism of PLESS MONSOUR RUUD
PLESS "Childhood phimosis can be successfully treated with steroid application, and the treatment should be offered prior to an operation."
MONSOUR "Our study demonstrates that the application of topical steroids is a viable alternative for treating phimosis in children."
RUUD "We recommend topical steroids as first treatment of choice for phimosis, when treatment is necessary. "

All studies conclusions appear devoid of scientific thought not taking into account twice daily attention and the education in retraction. There is no apparent histological examination, childhood phimosis, phimosis in children, is hardly an exact diagnosis, and I would expect higher response rates merely with education and a childs own experiments.

T.K. PLESS, Spjeldnaes N, Jorgensen TM
[Topical steroids in the treatment of phimosis in children].[Article in Danish]
Urologisk afdeling K, Arhus Universitetshospital, Skejby Sygehus.
Ugeskr Laeger 1999 Nov 22;161(47):6493-5

Abstract: The aim of this study was to evaluate the efficacy of steroid application in the treatment of childhood phimosis. In a consecutive study 91 boys were treated with application of topical betamethason 0.05% cream twice daily. The foreskin was treated for one month, with an attempt at foreskin retraction after fourteen days. Treatment was controlled after one month and six months. Sixty boys achieved full retraction of the foreskin and nine had partial retraction and relief of symptoms. Twenty-two boys had unsatisfactory response and had an operation. Forty-five boys were controlled after six months, 13 had recurrence, of these nine were satisfied and free of symptoms, two had a new steroid treatment with full success, and two wanted a circumcision. A total of 74% did not need an operation after topical steroid treatment. No side-effects or complications were registered. Childhood phimosis can be successfully treated with steroid application, and the treatment should be offered prior to an operation.

M.A. MONSOUR, Rabinovitch HH, Dean GE
Medical management of phimosis in children: our experience with topical steroids.
Department of Urology, Temple University Hospital, Philadelphia, Pennsylvania, USA.
J Urol 1999 Sep;162(3 Pt 2):1162-4

Abstract: PURPOSE: Circumcision has traditionally been regarded as primary therapy for persistent phimosis in boys. Recently groups in Europe and Australia have advocated the use of topical steroids as conservative treatment in children. We report our experience with this approach. MATERIALS AND METHODS: Between July 1997 and February 1998, 25 boys with a mean age of 8.3 years who presented to our clinic with phimosis were started on a topical steroid. After counseling the family regarding treatment options we prescribed a 1-month course of 0.05% betamethasone cream applied twice daily. RESULTS: Of the 25 patients 24 completed the treatment and were evaluated. A total of 16 boys (67%) had a normal appearing foreskin that was easily retracted, while in the remaining 8 the outcome was unsuccessful and circumcision was scheduled. CONCLUSIONS: Our study demonstrates that the application of topical steroids is a viable alternative for treating phimosis in children. Appropriate candidates for this therapy include boys older than 3 years who have persistent phimosis and no evidence of infection.

RUUD E, Holt J
[Phimosis can be treated with local steroids].[Article in Norwegian]
Barneavdelingen, Nordland Sentralsykehus, Bodo.
Tidsskr Nor Laegeforen 1997 Feb 10;117(4):513-4

Abstract: The effectiveness of topical steroid application in relieving phimosis was studied in 41 boys treated with a potent steroid ointment. 35 patients showed improvement initially but in 12 of them the phimosis recurred completely and in seven of them partly. There was significantly less recurrence in the patients who improved within one month. Most of the families were satisfied with the treatment. We recommend topical steroids as first treatment of choice for phimosis, when treatment is necessary.