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Lichen Sclerosus or Balanitis Xerotica Obliterans: Diagnosis and Treatment

Definition

Lichen sclerosus is an etiologically unclear skin disease with sclerosis of the dermis. The leading site of manifestation is the genital skin of both sexes, but perianal and extragenital involvement is also possible. Penile manifestation leads to patchy white skin lesions on the glans, prepuce, or penile shaft. Further scarring leads to phimosis. Meatal or urethral stricture due to narrowing of the navicular fossa is possible (Fergus et al., 2020). Other (older) names: balanitis xerotica obliterans, lichen sclerosus et atrophicans.

Epidemiology

Lichen sclerosus manifests much more frequently in women than in men. The prevalence in postmenopausal women has been described as high as 3%. The prevalence in children is around 0.1% in both sexes. Penile manifestation occurs primarily in uncircumcised men > 60 years, but lichen sclerosus is also identified as a cause in 10% of histologic examinations in scarring phimosis <10 years of age.

Pathology of Lichen Sclerosus

• Macroscopy: porcelain-white macules or papules, sharply demarcated, on the glans and prepuce. Atrophy leads to scarring phimosis.
• Histology: atrophic epidermis, increased homogeneous collagen deposits in the dermis, edematous or eosinophilic hyalinized lamina propria with lymphocytic infiltrates.

Signs and Symptoms of Balanitis Xerotica Obliterans

• Porcelain-white macules or papules, sharply demarcated.
• Itching, pain (during erection), obstructive LUTS
• Atrophy leads to phimosis or meatal stricture.
• Risk factor for squamous cell carcinoma.

Diagnosis

Biopsy:

Circumcision and/or glans biopsy. Epithelial atypia increases the risk of developing penile carcinoma.

Treatment of Genital Lichen Sclerosus

Complete circumcision is usually curative. In case of recurrence or involvement of the circumcised glans, topical application of a highly potent steroid (e.g., daily for three months, then tapering off). A new therapeutic option is the topical application of calcineurin inhibitors tacrolimus or pimecrolimus (off-label application). Significant meatal stricture is best treated with meatoplasty with oral mucosa grafting, see section urethral stricture.

References

Das und Tunuguntla 2000 DAS, S. ; TUNUGUNTLA, H. S.: Balanitis xerotica obliterans-a review.
In: World J Urol
18 (2000), Nr. 6, S. 382–7

K. B. Fergus et al., “Pathophysiology, Clinical Manifestations, and Treatment of Lichen Sclerosus: A Systematic Review.,” Urology, vol. 135, pp. 11–19, 2020.

Powell und Wojnarowska 1999 POWELL, J. J. ; WOJNAROWSKA, F.: Lichen sclerosus.
In: Lancet
353 (1999), Nr. 9166, S. 1777–83

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