What is lichen sclerosus in men?
Lichen sclerosus is an uncommon inflammatory dermatosis. In men, it typically involves uncircumcised genitalia ie, the glans (tip or head of the penis) and the prepuce (foreskin). Perianal lichen sclerosus and extragenital lichen sclerosus are much less frequently seen in men than in women.
Male genital lichen sclerosus has been previously called balanitis xerotica obliterans (BXO) but strictly speaking, BXO may be the endpoint of several chronic male genital dermatoses eg, lichen planus, and cicatricial (mucous membrane) pemphigoid.
Images of penile lichen sclerosus
Who gets lichen sclerosus?
Male genital lichen sclerosus seems poorly recognised; reported figures likely underestimate the prevalence of this disease.
Male genital lichen sclerosus can occur at any age, but it is probably triphasic with 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.
Genital lichen sclerosus is 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 to the long-term effect of occlusion of urine between susceptible epithelia causing irritation and inflammation on the glans and prepuce. Lichen sclerosus is rare in men who were circumcised at birth.
It is not a sexually transmitted disease and is not encountered in sexual partners of patients. There is no convincing evidence that it is an autoimmune disease nor that it is an infection, although its relationship to HPV in the development of penile intraepithelial neoplasia and penile cancer remains a fertile area of investigation.
What are the clinical features of lichen sclerosus in men?
Lichen sclerosus can be asymptomatic. Symptoms may be associated with urinary and sexual activity (amounting to male dyspareunia) or occur spontaneously. Patients should be listened to attentively and thoroughly questioned. Symptoms include:
- Pruritus, burning, soreness
- Bleeding, splitting, fissuring, tearing
- Blistering
- Dysuria
- Adhesions and scarring
- Tightness of the foreskin and painful erections
- Dribbling, spraying
- UTIs
- ‘Thrush’.
Signs of lichen sclerosus may be subtle or florid. Patients should be examined systematically and sedulously, paying sequential attention to the prepuce, coronal sulcus, frenulum, glans, meatus and navicular fossa. Examination of the male genitalia is incomplete without assessment of the scrotum and its contents, inguinal creases, regional lymph nodes, perineum and anal margin, and a rectal examination under certain circumstances.
Signs include:
- Lichenoid inflammation
- Zoonoid inflammation
- Constrictive posthitis (‘waisting’)
- ‘Thrush’
- Effacement or dulling of the coronal sulcus
- Subcoronal and transcoronal adhesions
- Frenular bunching, hyperkeratosis or effacement
- Hypopigmentation, etiolation, waxy pallor, and sclerotic patches or plaques
- Hyperpigmentation, mealosis/melanoderma
- Scarring
- Telangiectasia, ecchymosis, angiokeratomas
- Blisters and erosions (rare)
- Meatal narrowing
- Hypospadias or a forme fruste of hypospadias
Images of penile lichen sclerosus
Images of anogenital lichen sclerosus in skin of colour
What are the complications of lichen sclerosus in men?
The most common complications of lichen sclerosus are male dyspareunia and those due to progressive sclerosis. Other complications include:
- Phimosis
- Paraphimosis
- Penile lymphoedema and cellulitis
- Pseudoepitheliomatous keratotic and micaceous balanitis
- Urethral disease: stricture stenosis and altered flow
- Urinary retention
- Renal failure
- Penile intraepithelial neoplasia (differentiated type) and penile cancer
- Penile melanoma.
Cancer may be more likely if lichen sclerosus is not diagnosed accurately and early and does not receive adequate treatment so that 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%; this range probably reflects the timeliness of diagnosis and the effectiveness of treatment.
How is lichen sclerosus in men diagnosed?
The diagnosis of lichen sclerosus in men is usually made clinically by eliciting cardinal symptoms (eg, dyspareunia and urinary dribbling) and signs; dermoscopy can provide further clues.
Biopsy is rarely necessary or useful, because if signs are subtle the histology will almost certainly be non-specific. If the most florid signs are biopsied, histology will either demonstrate what is self-evident clinically or show zoonoid inflammation and lead to the erroneous diagnosis of Zoon balanitis. This may distract the clinician and pathologist from the true diagnosis.
Biopsy may legitimately assist in exploring the differential diagnosis, such as lichen planus and penile intraepithelial neoplasia.
See Lichen sclerosus pathology for more information.
What is the differential diagnosis for lichen sclerosus in men?
The differential diagnosis for lichen sclerosus in men includes:
- Other causes of balanitis (eg infective; NB candidosis in men is rarely if ever primary, but secondary to another dermatosis such as lichen sclerosus)
- Penile intraepithelial neoplasia
- Plasma cell (Zoon) balanitis (NB it is likely that true ZB does not exist and that almost all cases are actually lichen sclerosus)
- Lichen planus
- Genital psoriasis: including circinate balanitis, which may signify HLA B27 positivity and associated conditions
- Contact dermatitis
- Fixed drug eruption
- Extramammary Paget disease.
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 relieve symptoms, prevent scarring and malignancy, and maintain sexual and urinary function.
General measures
- Skincare 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.
- The urethra should be emptied assiduously after voiding.
- Patients should be referred to a urologist for urinary symptoms.
- Patients should stop smoking.
- Ideal BMI achievement and maintenance is important.
Specific measures
- First-line therapy is an ultrapotent topical corticosteroid eg, 1 fingertip unit of 0.05% clobetasol propionate ointment applied to affected areas twice daily for 1 month or once daily for 1–3 months.
- A 30g tube should last 3 months.
- A cotton bud can be used to apply it to the meatus.
- Patients should be warned about the risks or reactivation or worsening of HPV.
- Patients with a history of genital herpes should be treated with concurrent prophylactic aciclovir (or equivalent).
- There is no routine place for maintenance treatment with ultrapotent steroid treatment in male genital lichen sclerosus.
- Failure to respond to one or two courses of ultrapotent topical steroid, or early and florid relapses, are indications for circumcision.
- Any persisting areas of erosion or erythema not responding to treatment should undergo biopsy at the time of circumcision to exclude carcinoma.
- Circumcision is near-mandatory for phimosis and paraphimosis.
- Urethroplasty or meatoplasty may also be necessary in the event of meatal stenosis.
What is the outcome of lichen sclerosus in men?
About 60-70% of men with genital lichen sclerosus can be cured long-term by medical treatment. In the remainder, circumcision is curative. Following circumcision, the risks of urethral disease and penile cancer plummet but are never zero. Follow-up and self-examination should continue post-therapeutically whether medical or surgical (eg, circumcision).