Lichen sclerosus (LS) is a chronic, inflammatory, hypomelanotic, lymphocyte-mediated skin disorder that predominantly affects the genitalia — the prepuce, glans, urethral meatus, and fossa navicularis. In males it is associated with urethral strictures (via repeated instrumentation or pressure-voiding intravasation into the glands of Littre); in females, urethral stricture is uncommon. It was previously called balanitis xerotica obliterans.
Epidemiology
LS affects primarily middle-aged men (and can occur in boys), presenting mainly in the uncircumcised, and is the most common cause of adult meatal stenosis. (In male children, meatal stenosis is instead a consequence of circumcision causing ammoniacal meatitis.)
Risk Factors
The cause is undefined; proposed mechanisms include trauma, autoimmunity, genetics, and infection (Borrelia burgdorferi has been found in early disease). Affected patients are more likely to be active smokers with higher BMI, hypertension, diabetes, and coronary disease, and have longer strictures than non-LS cases.
Diagnosis and Evaluation
Symptoms include skin itching, bleeding, penile scarring with glanular adhesions, acquired buried penis, pain, dyspareunia, and painful erections; the lesion appears as a whitish plaque. Diagnosis is by biopsy. LS is capable of malignant transformation to squamous cell carcinoma in 2–8%, and 4–6% of penile SCCs have associated LS.
Management
- Dermatologic therapy reduces symptoms and progression. The 2023 AUA guideline recommends moderate- to high-potency topical steroids (clobetasol or mometasone); calcineurin inhibitors (tacrolimus) can regress external skin disease. (CUA 2019: 0.05% clobetasol propionate daily for 2–3 months.)
- LS-associated strictures tend to be longer and located in the penile urethra, making urethroplasty challenging. Because LS is a disease of genital skin, genital skin is not appropriate for reconstruction — oral mucosal grafting is the preferred tissue.
- Conservative therapy (topical steroid ± antibiotics, intermittent catheterisation) may suffice if the meatus is maintained at 14–16 Fr. Surgery is indicated for young patients with severe meatal stenosis; obtain a retrograde urethrogram first (long-standing meatal stenosis often masks proximal stricture disease). If only the foreskin is involved, circumcision may be curative.
Self-Test
1. What is the treatment of lichen sclerosus? Moderate- to high-potency topical steroids (e.g. clobetasol or mometasone); for LS-associated strictures, oral mucosal grafting (not genital skin) is preferred, and if only the foreskin is involved, circumcision may be curative.