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Authors: Dr Olivia Charlton, Research Fellow; Prof Saxon Smith, Dermatologist, Royal North Shore Hospital, Sydney, NSW, Australia. Medical Editor: Dr Helen Gordon, Auckland. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. September 2020.
Lichen sclerosus is a common inflammatory dermatosis that in men typically involves the glans penis (tip or head of the penis) and the prepuce (foreskin). Perianal lichen sclerosus and extragenital lichen sclerosus are less common than in women.
Lichen sclerosus has been previously called balanitis xerotica obliterans.
Lichen sclerosus is poorly recognised; reported figures likely underestimate the prevalence of this disease.
Lichen sclerosus can occur at any age, but it commonly peaks in childhood and again when men are in their forties and fifties . In studies of foreskins removed for phimosis, 14–95% are found to have lichen sclerosus. Anogenital lichen sclerosus is approximately 10 times more common in women than men.
Lichen sclerosus can be associated with the uncircumcised state, obesity, anatomical abnormalities (such as hypospadias), and trauma (surgery, piercings).
Lichen sclerosus on the penis may be due the long-term effect of occlusion of urine causing irritation and inflammation on the glans and prepuce.
It is not a sexually transmitted disease and is not transmitted to sexual partners of patients. Lichen sclerosus does not occur in men who were circumcised at birth.
Lichen sclerosus can be asymptomatic, but is usually itchy. Other symptoms include:
Lichen sclerosus typically causes white plaques and induration of the glans, prepuce, and coronal sulcus. A sclerotic white ring may occur on the distal aspect of the prepuce (this is called ‘waisting’).
Early manifestations of lichen sclerosus may be subtle, presenting with:
The most common complications of lichen sclerosus are secondary to progressive sclerosis.
In the longer term, lichen sclerosus has been associated with penile cancer. Cancer may be more likely if lichen sclerosus does not receive treatment and there is ongoing active disease. One third to one half of all penile cancer is associated with lichen sclerosus with an incidence rate ranging from 0–12.5%.
The diagnosis of lichen sclerosus in men is usually made clinically and dermoscopy can provide further clues. It can be confirmed histologically (see Lichen sclerosus pathology). Biopsy may also assist in excluding differential diagnoses, such as lichen planus and subclinical penile intraepithelial neoplasia.
The differential diagnosis for lichen sclerosus in men includes:
Lichen sclerosus should be managed by a dermatologist, and in some cases, also by a urologist. The aim of treatment is to control symptoms, prevent scarring and malignancy, and maintain sexual and urinary function.
Treatment includes skin care with avoidance of contact irritants such as soap, urine, and pubic hair.
Follow up and self-examination should continue postoperatively.
Any persisting areas of erosion or erythema not responding to treatment should undergo biopsy to exclude carcinoma.
The patient should be referred to a urologist for urinary symptoms.
One retrospective study of 329 men found 59% of men were cured with one of more courses of ultrapotent topical steroids.
Circumcision was curative for 76% of men who failed this therapy. The remainder required ongoing medical treatment.
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