PEDIATRIC UROLOGY

Phimotic ring topical corticoid cream (0.1% mometasone furoate) treatment in children
Pileggi Fde O, Vicente YA
Department of Surgery and Anatomy, University of Sao Paolo, Ribeirao Preto, Brazil
J Pediatr Surg. 2007; 42: 1749-52

• Background/Purpose: Phimosis, owing to the presence of a preputial fibrotic ring, is surgically treated in 1% of children. During the last decade, however, topical steroid treatment has been proposed for phimosis.
• Methods: We present a double-blind study comparing 0.1% mometasone furoate topical cream vs moisturizing cream (placebo) for the treatment of phimosis. Children aged from 2 to 13 years (n = 110) presenting with phimosis (Kikiro’s classification grade 5) and scheduled for circumcision were included in this trial. The patients were evaluated after 8 weeks of topical treatment with moisturizing cream (n = 54) or steroid cream (n = 56). Nonresponders from both groups received an additional 8 weeks of steroid cream treatment.
• Results: In the steroid group, the ring disappeared and glans exposure was obtained in 49 (88%) of 56 patients vs 28 (52%) of 54 patients in the placebo group (P < .05). After a second treatment, in the steroid group, 5 of the 7 patients were finally cured vs 22 of the 26 in the placebo group (P < .05). Two children with persisting phimosis (Kikiro’s retractability grade 5 and appearance grade 3) in the steroid group (4%) vs 4 children in the placebo group (7%) ended up receiving postectomy.
• Conclusions: The present investigation adds up and supports the effectiveness of phimosis topical corticoid treatment. Nevertheless, hygiene and preputial traction, when appropriately performed, seem to play an important role in the disappearance of the phimotic ring as well. New studies are necessary to confirm if this is true or not.
  
  
• Editorial Comment
  These authors did a double-blind placebo controlled study on boys 2-13 years-of-age with a mean of 4.6 years, with symptomatic phimosis with degree 5 phimosis according to the classification of Kikiros (1). An eight week trial was undertaken with either mometasone or a placebo moisturizing cream, being lightly applied to the preputial ring and during the first four weeks, parents were instructed to add “just a light preputial retraction maneuver” and during the second four weeks, the preputial retraction was “increased to a moderate degree”. After eight weeks, boys showing total absence of preputial ring, Kikiros grade 1 or 2 were considered cured and degrees 3, 4, and 5 were considered non-responders and entered a second eight-week-long treatment session, all with mometasone. Four groups were then examined. The placebo group that were cured in the first eight weeks, the placebo group that were non-responders in the first eight weeks and treated with mometasone for another eight weeks. Group 3, the mometasone cured group in the first eight weeks and then Group 4 was mometasone treatment for an additional eight weeks.
  Results - Of the initial 130 patients, 110 were available at the end of the study. 88% of the steroid cream patients were considered successes, while 52% of the placebo group patients were considered successes. 19 of the 26 placebo failures responded during the second treatment period to the corticosteroid and 5 of 7 of the mometasone failures were cured with a second eight weeks of treatment.
  Comments - The mometasone is a moderate-strength topical corticosteroid and this study shows that it may be a good alternative to the betamethasone that has been reported in the literature and with less side effects. None of these patients had any side effects. It is interesting to note that 52% of the placebo group had success with gentle to more moderate retraction of the foreskin without the benefit of any steroids. It is likely that this is an important adjunct to the treatment regimen, regardless of the medication chosen. I believe that one of the important aspects of this study is that the patients who were chosen for the study were severely phimotic and are often thought not to be good candidates for medical treatment, and yet the success rates were excellent. It is refreshing to see physician scientists doing high quality double-blind placebo studies and they should be applauded for their efforts.

Reference
1. Kikiros CS, Beasley SW, Woodward AA: The response of phimosis to local steroid application. Pediatr Surg Int. 1993; 8: 329-32.

Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu