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Authors: Nicole S Kim, Medical Student, University of Toronto, Toronto, Canada; Dr Yuliya Velykoredko, Dermatology Resident, University of Toronto, Toronto, Canada. DermNet NZ Editor in Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell/Maria McGivern. September 2018.
Lichen simplex of the scrotum is a pruritic form of dermatitis in which excessive scratching or rubbing leads to lichenification. Characteristically, there are well-demarcated, erythematous or hyperpigmented plaques with marked skin thickening on one or both sides of the scrotum. Lichen simplex is typically secondary to an underlying skin condition or neuropathy causing extreme itch, such as allergic contact dermatitis.
Lichen simplex is also known as lichen simplex chronicus and neurodermatitis. Lichen simplex of the scrotum is also known as lichen simplex of the male genitalia and 'wash leather scrotum' [1–5].
Lichen simplex of the scrotum is most often diagnosed in men between the ages of 35 and 50 years .
Lichen simplex of the scrotum is attributed to a persistent itch–scratch cycle. Underlying pruritus, a cutaneous or systemic condition, or neuropathy or psychiatric disorder can induce intractable scratching that leads to hypertrophy of the scrotal skin. Contributing factors to scrotal lichen simplex may include [1–3,5]:
Lichen simplex of the scrotum manifests with clearly demarcated thickening of the scrotal skin with hypopigmentation and hyperpigmentation and variable scale. It is often unilateral, but it may also be bilateral. Coalescing papules form solitary or multiple plaques. Other features may include [3–5]:
Signs of an underlying skin disorder may also be noted adjacent to lichen simplex of the scrotum and on another body site.
More areas of lichen simplex may also be found, most commonly on the neck, the scalp, the extensor surfaces of extremities, or the lower legs and ankles [1,2].
Complications of lichen simplex of the scrotum may include:
Lichen simplex of the scrotum has also been suspected of contributing to reduced fertility .
Adverse effects from treatment can also arise, particularly atrophy due to extended use of a potent topical corticosteroid on the a thin scrotal skin. Topical steroids can also cause pigmentation abnormalities [2,5].
The clinical features of scrotal lichen simplex are generally sufficient to establish the diagnosis. When findings are atypical, further tests can be considered to make a definitive diagnosis or to exclude other similar dermatoses; such tests to be considered include:
If the scrotal lichen simplex is associated with generalised pruritus, a workup for systemic causes can be undertaken (as outlined on our pruritus page).
Other disorders that should be considered in a patient with lichen simplex of the scrotum include [1–3]:
The main goals of treatment for scrotal lichen simplex are:
Short-term topical corticosteroids are used as first-line therapy to break the itch–scratch cycle. Treatment principles for lichen simplex of the scrotum include using a medium potency topical steroid such as triamcinolone ointment until there is a resolution of active lesions. If the disease is refractory after 2–3 weeks of an intermediate-strength corticosteroid, more potent topical steroids can be used on a short-term basis. As the condition improves, the application frequency and potency of the corticosteroid should be decreased to minimise the adverse effects [3,4].
Aim to repair the barrier function of the skin with the frequent application of emollient creams and moisturisers. Minimise environmental triggers such as:
Identify and treat underlying disorders that cause or worsen scrotal lichen simplex [2–5]. Other treatment recommendations include those below.
The clinical course of scrotal lichen simplex is chronic and protracted, and patients may suffer indefinitely without appropriate treatment. As recurrences occur during psychological stresses or the flare-up of underlying dermatoses, long-term management may be required in some patients .
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