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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 in men — codes and concepts
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What is lichen sclerosus in men?

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.

Who gets lichen sclerosus?

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 [2]. 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).

What causes lichen sclerosus in men?

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.

What are the clinical features of lichen sclerosus in men?

Lichen sclerosus can be asymptomatic, but is usually itchy. Other symptoms include:

  • A burning sensation
  • Bleeding
  • Fissuring
  • Painful urination
  • Painful erections
  • Painful sexual intercourse
  • Poor urinary stream (dribbling or spraying).

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:

  • Non-specific hypopigmented or erythematous macules
  • Purple-white plaques with defined margins
  • Telangiectasia and purpura of the glans.

see Images of penile lichen sclerosus

What are the complications of lichen sclerosus in men?

The most common complications of lichen sclerosus are secondary to progressive sclerosis.

  • Primary or secondary phimosis, due to adhesion of the prepuce to the glans
  • Paraphimosis, in which retraction leads to constriction of the distal penile shaft and atrophy of the glans
  • Urinary retention
  • Urethral stenosis, and altered flow
  • Retrograde damage to the bladder and kidneys.

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%.

How is lichen sclerosus in men diagnosed?

The diagnosis of lichen sclerosus in men is usually made clinically. 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.

What is the differential diagnosis for lichen sclerosus in men?

The differential diagnosis for lichen sclerosus in men includes:

What is the treatment for lichen sclerosus in men?

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.

  • A soap substitute should be used for washing and a barrier cream applied to provide protection against contact with urine.
  • First line therapy is an ultrapotent topical corticosteroid, such as 1 fingertip unit of 0.05% clobetasol propionate ointment applied to affected areas at night for 1–3 months.
  • A 30g tube should last 3 months.
  • A cotton bud can be used to apply it to the meatus.
  • A flare can be retreated with the same topical steroid.

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.

  • Persistent phimosis or paraphimosis may be treated by circumcision.
  • Urethroplasty or meatoplasty may also be necessary in the event of meatal stenosis.

What is the outcome for lichen sclerosus in men?

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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References

  • Bunker CB, Porter WM. Dermatoses of the male genitalia. In: Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D (eds). Rook's Textbook of Dermatology [4 volumes] 9th edn, Wiley Blackwell, 2016:111.13-16.
  • Bolognia JL, Jorizzo JL, Schaffer JV (eds). Dermatology. 4th edition. Elsevier/Saunders.
  • Morris BJ, Krieger JN. Penile inflammatory skin disorders and the preventive role of circumcision. Int J Prev Med. 2017;8:32. doi: 10.4103/ijpvm.IJPVM_377_16. PubMed Central
  • Edmonds EV, Hunt S, Hawkins D, Dinneen M, Francis N, Bunker CB. Clinical parameters in male genital lichen sclerosus: a case series of 329 patients. J Eur Acad Dermatol Venereol. 2012;26(6):730-7. doi:10.1111/j.1468-3083.2011.04155.x. PubMed
  • Akel R, Fuller C. Updates in lichen sclerosis: British Association of Dermatologists guidelines for the management of lichen sclerosus 2018. Br J Dermatol. 2018;178(4):823-4. doi: 10.1111/bjd.16445. PubMed
  • Lewis FM, Tatnall FM, Velangi SS, et al. British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018. Br J Dermatol. 2018;178(4):839-53. doi: 10.1111/bjd.16241. PubMed
  • Dahlman-Ghozlan K, Hedblad MA, von Krogh G. Penile lichen sclerosus et atrophicus treated with clobetasol dipropionate 0.05% cream: a retrospective clinical and histopathological study. J Am Acad Dermatol. 1999;40(3):451-7. doi: 10.1016/s0190-9622(99)70496-2. PubMed

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