II. Definition

  1. Idiopathic (possibly autoimmune), chronic inflammatory condition of peri-mucosal skin
  2. Typically vulvar involvement in women is more common

III. Epidemiology

  1. Average age of onset 42 years
  2. Prevalence: One in 300 males

IV. Symptoms

  1. Asymptomatic in one third of patients
  2. Pruritic foreskin
    1. May bleed
    2. May be severe enough to interfere with sleep
  3. Dysuria
  4. Urinary obstruction (long-standing cases)
  5. Painful Erections
  6. Painful Defecation (if Anal Fissures present)

V. Signs

  1. Initial
    1. Glans and foreskin is thick and white
    2. Contiguous edema may be present
  2. Later
    1. Foreskin in thin, Wrinkled and hypopigmented (like cellophane)
    2. Bruising may be present
  3. Last
    1. Foreskin and contiguous anatomy distorted
    2. May obscure surrounding antomy
      1. Phimosis may occur in men (may result in obstructive uropathy)

VI. Labs: Biopsy

  1. Biopsy especially indicated if squamous cell hyperplasia present
  2. Risk of developing Squamous Cell Carcinoma of the foreskin is 4-6% in Lichen Sclerosus
  3. Biopsy foreskin lesions that fail to heal with management (see below)

VII. Differential Diagnosis

  1. Penile Squamous Cell Cancer in-situ
  2. Penile Squamous Cell Cancer
  3. Scleroderma

VIII. Associated Conditions: Autoimmune Conditions (present in >20% of cases)

IX. Management (much of the supporting research was done in women with Vulvar Lichen Sclerosus)

  1. Topical Corticosteroids
    1. Initial (first 2-3 months until active inflammation has resolved)
      1. Level 1 High potency Corticosteroid (e.g. Temovate 0.05% ointment) applied daily
      2. Lorenz (1998) J Reprod Med 43:790-4 [PubMed]
    2. Later (maintenance)
      1. Taper high potency steroid to 1-2 times weekly or
      2. Level 5 Medium potency steroid (e.g. Valisone 0.1% cream) applied daily
  2. Clinic procedures for thickened lesions
    1. Intralesional Corticosteroid Injection (up to 10-20 mg of triamcinoline acetonide)
      1. Mazdisnian (1999) J Reprod Med 44:332-4 [PubMed]
    2. Cryotherapy (one freeze per lesion)
  3. Other topical management
    1. Tacrolimus or Pimecrolimus
    2. Tretinoin (e.g. Retin-A) applied topically to lesions
      1. Bracco (1993) J Reprod Med 38:37-40 [PubMed]
    3. Hormonal creams (Progesterone or Testosterone) are not effective
      1. Sideri (1994) Int J Gynaecol Obstet 46:53-6 [PubMed]
  4. Other systemic medications (severe refractory cases)
    1. Systemic Retinoids
    2. Methotrexate
  5. Surgical management
    1. Circumcision (if not already circumsized)
    2. Reconstructive surgery (severe cases)

X. Complications

  1. Penile squamous cell cancer
    1. Genital Lichen Sclerosus is considered premalignant (4-6% squamous cell cancer Incidence)
  2. Phimosis
  3. Painful Erection
  4. Urinary obstruction

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Ontology: Balanitis xerotica obliterans (C0152460)

Definition (NCI) A chronic and progressive inflammatory process that affects the glans penis and the foreskin. It presents with white atrophic patches in the glans of penis and foreskin and it is often associated with the development of a sclerotic, whitish ring in the tip of the foreskin that may lead to phimosis. It is also known as lichen sclerosus of the penis.
Concepts Disease or Syndrome (T047)
ICD9 607.81
ICD10 N48.6
SnomedCT 43790000, 198028006, 367113004, 700082001, 198033005
English Balanitis xerotica obliterans, Induratio penis plastica, BXO - Balan xerotica obliterns, Lichen sclerosus et atrophicus of glans penis and prepuce, balanitis xerotica obliterans (diagnosis), balanitis xerotica obliterans, Balanitis xerotica oblit, induratio penis plastica, balanitis obliterans xerotica, Lichen sclerosus et atrophicus of glans penis AND prepuce, Lichen sclerosus et atrophicus of glans penis AND prepuce (disorder), Lichen sclerosus of penis, Lichen sclerosus of penis (disorder), BXO - Balanitis xerotica obliterans, Balanitis xerotica obliterans (disorder), balanitis; xerotica obliterans, xerotica obliterans; balanitis, Lichen sclerosus et atrophicus of glans penis AND prepuce (disorder) [Ambiguous], Lichen Sclerosus of Penis, Lichen Sclerosus of the Penis, Penile Lichen Sclerosus, Balanitis Xerotica Obliterans
Spanish Balanitis xerótica obliterante, Liquen escleroso peneano, liquen escleroso y atrófico de prepucio Y glande, liquen escleroso y atrófico de prepucio Y glande (trastorno), balanitis xerótica obliterante (trastorno), balanitis xerótica obliterante, liquen escleroso del pene, liquen escleroso y atrófico de prepucio Y glande (concepto no activo)
Dutch balanitis xerotica obliterans, lichen sclerosus van penis, balanitis; xerotica obliterans, xerotica obliterans; balanitis, Balanitis xerotica obliterans
Italian Balanite xerotica obliterante, Lichene scleroso del pene
German Lichen sclerosus Penis, Balanitis xerotica obliterans
French Lichen scléreux du pénis, Balanitis xerotica obliterans
Portuguese Balanite xerótica obliterante, Líquen escleroso do pénis
Czech Balanitis xerotica obliterans, Lichen sclerosus penisu
Japanese 閉塞性乾皮性亀頭炎, ヘイソクセイカンピセイキトウエン, 陰茎硬化性苔癬, インケイコウカセイタイセン
Korean 성형성 음경 경화(페니스 플라스티카)
Hungarian balanitis xerotica obliterans, Lichen sclerosus a penisen