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Balanitis Xerotica Obliterans

Last Updated: February 9, 2005
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Synonyms and related keywords: BXO, penile lichen sclerosus, male genital lichen sclerosus, lichen sclerosus et atrophicus, LS, penile LS, sclerosing inflammatory dermatosis, Koebner phenomenon, vitiligo, thyroid disease, diabetes, alopecia areata, pseudoepitheliomatous keratotic and micaceous balanitis, PKMB

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Author: George C Keough, MD, Chief, Clinical Assistant Professor, Department of Medicine, Dermatology Service, Eisenhower Army Medical Center

George C Keough, MD, is a member of the following medical societies: American Academy of Dermatology, and American Medical Association

Editor(s): Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates; Richard Vinson, MD, Chief, Department of Dermatology, William Beaumont Medical Center; Jeffrey Meffert, MD, Program Director, Dermatology Service, San Antonio Uniformed Services Health Education Consortium; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; and William D James, MD, Program Director, Vice-Chair, Albert M Kligman Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Disclosure
  INTRODUCTION Section 2 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Background: Lichen sclerosus (LS) is a chronic, progressive, sclerosing inflammatory dermatosis of unclear etiology. Most reported LS cases (83%) involve the genitalia. In men, this genital involvement has traditionally been known as balanitis xerotica obliterans (BXO). A more accurate term is male genital or penile LS.

Pathophysiology: The etiology of male genital LS is unknown but is thought to be multifactorial.

Frequency:

Race: Male genital LS has no known predilection for any racial or ethnic group.

Sex: Male genital LS occurs most frequently in those who are uncircumcised and middle-aged. One study revealed that 51 (98%) of 52 patients diagnosed with penile LS were uncircumcised (Mallon, 2000).

Age: Although, males with genital LS are most frequently middle-aged, the condition may appear in children as well, from young boys to adolescents.
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History: Early in its course, penile LS is relatively asymptomatic with only mild visually observable changes of the penis and glans. Physical changes occur over months or years and may include color or textural changes. Early symptoms are more prevalent in uncircumcised patients.

Physical: Early penile LS demonstrates only subtle physical findings (eg, mild, nonspecific erythema; mild hypopigmentation).

Causes: The etiology of male genital LS is unknown but is thought to be multifactorial. Several contributing factors are possible, as follows:

  DIFFERENTIALS Section 4 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Balanitis Circumscripta Plasmacellularis
Candidiasis, Mucosal
Erythroplasia of Queyrat (Bowen Disease of the Glans Penis)
Lichen Planus
Psoriasis, Plaque
Reiter Syndrome
Vitiligo


Other Problems to be Considered:

Pseudoepitheliomatous keratotic and micaceous balanitis

Pseudoepitheliomatous keratotic and micaceous balanitis (PKMB) is a very rare papulosquamous dermatosis of the glans penis. PKMB presents in elderly, uncircumcised men as a slowly growing, coarsely scaling, micaceous, white-to-gold, laminated, well-demarcated plaque. The lesion may grow to involve the coronal sulcus and the distal penile shaft. Symptoms include phimosis, pain, and interference with sexual activity. PKMB is considered to be a premalignant condition. Nearly all reported patients have had malignant degeneration. Reported associated malignancies include squamous cell carcinoma (SCC), verrucous carcinoma, and fibrosarcoma.

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Related Articles
Balanitis Circumscripta Plasmacellularis

Candidiasis, Mucosal

Erythroplasia of Queyrat (Bowen Disease of the Glans Penis)

Lichen Planus

Psoriasis, Plaque

Reiter Syndrome

Vitiligo


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  WORKUP Section 5 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Procedures:

  • Skin biopsy aids in diagnosis of male genital LS.
Histologic Findings: Histopathologic changes of genital LS are similar to those of nongenital LS. Epidermal findings include orthokeratotic hyperkeratosis with follicular plugging, atrophy of the stratum malpighii, hydropic degeneration of the basal layer, and occasional dermal-epidermal clefting. Follicular plugging is not apparent in mucosal lesions. The dermis reveals significant edema and homogenization of the collagen in the upper dermis with dilatation of blood and lymph vessels and a loss of elastic fibers. An inflammatory infiltrate consisting of lymphoid cells, plasma cells, and histiocytes occurs in the mid dermis. The inflammatory infiltrate is less pronounced in long-standing lesions.

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Medical Care:

Surgical Care:

  • Uncircumcised patients usually benefit from therapeutic circumcision. Provide regular follow-up care to observe any changes in involved areas suggestive of malignancy.
  • Consider surgical intervention for symptoms or signs of urethral meatal stenosis.

Consultations:

  • Consider consultation with urologists for the following:
    • Therapeutic circumcision
    • Circumcision for symptomatic phimosis or paraphimosis
    • Significant narrowing or obstruction of the urethral meatus or changes in urinary flow

Activity: In some cases of male genital LS, painful erections may limit sexual function.
  MEDICATION Section 7 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
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Topical steroids, especially superpotent topical steroids, are the mainstay of medical therapy. Topical testosterone is mostly ineffective and is not discussed further. Etretinate has been used with limited success but is no longer available for prescription in the United States.

Drug Category: Topical corticosteroids -- Help reduce inflammatory lesions and may reduce or resolve lesions.
Drug Name
Clobetasol propionate (Temovate) -- Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Used in most studies dealing with treatment of LS.
Adult DoseApply to affected areas qd for up to 12 wk, although continuous treatment for >2 wk may begin to cause atrophic changes; atrophic changes will be more pronounced in genital area than other areas of the body; not to exceed 50 g/wk
Pediatric DoseNot established
ContraindicationsDocumented hypersensitivity; viral or fungal skin infections
InteractionsNone reported
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsSteroid atrophy commonly occurs when superpotent topical steroids are used in genital area for even short periods; observe patients for any such changes; may suppress adrenal function in prolonged therapy
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Further Outpatient Care:

Deterrence/Prevention:

Complications:

Prognosis:

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Medical/Legal Pitfalls:

  • Failure to diagnose male genital LS early is a potential pitfall.
    • Delay in diagnosis or follow-up of patients with urinary symptoms may lead to irreversible damage to the urinary system.

    • No singularly effective therapy exists; however, treatment with surgical and/or medical techniques should be quickly instituted upon diagnosis of this often progressive condition.
  • Failure to provide regular follow-up care is a potential pitfall. Care should include biopsy of ulcerating or nonhealing areas to detect malignancies (rare) developing from lesions of male genital LS.

Special Concerns:

  • Men with genital LS may delay presenting to a physician because of fear or embarrassment. Accurate diagnosis, aided with appropriate biopsy, helps calm anxiety.
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Caption: Picture 1. Balanitis xerotica obliterans (lichen sclerosus). Image courtesy of Wilford Hall Medical Center Slide collection.
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  BIBLIOGRAPHY Section 11 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page
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  • Bainbridge DR, Whitaker RH, Shepheard BG: Balanitis xerotica obliterans and urinary obstruction. Br J Urol 1971 Aug; 43(4): 487-91[Medline].
  • Beljaards RC, van Dijk E, Hausman R: Is pseudoepitheliomatous, micaceous and keratotic balanitis synonymous with verrucous carcinoma? Br J Dermatol 1987 Nov; 117(5): 641-6[Medline].
  • Bingham JS: Carcinoma of the penis developed in lichen sclerosus et atrophicus. Br J Vener Dis 1978 Oct; 54(5): 350-1[Medline].
  • Chalmers RJ, Burton PA, Bennett RF: Lichen sclerosus et atrophicus. A common and distinctive cause of phimosis in boys. Arch Dermatol 1984 Aug; 120(8): 1025-7[Medline].
  • Drut RM, Gomez MA, Drut R: Human papillomavirus is present in some cases of childhood penile lichen sclerosus: an in situ hybridization and SP-PCR study. Pediatr Dermatol 1998 Mar-Apr; 15(2): 85-90[Medline].
  • English JC 3rd, Laws RA, Keough GC: Dermatoses of the glans penis and prepuce. J Am Acad Dermatol 1997 Jul; 37(1): 1-24; quiz 25-6[Medline].
  • Jenkins D, Jakubovic HR: Pseudoepitheliomatous, keratotic, micaceous balanitis. A clinical lesion with two histologic subsets: hyperplastic dystrophy and verrucous carcinoma. J Am Acad Dermatol 1988 Feb; 18(2 Pt 2): 419-22[Medline].
  • Ledwig PA, Weigand DA: Late circumcision and lichen sclerosus et atrophicus of the penis. J Am Acad Dermatol 1989 Feb; 20(2 Pt 1): 211-4[Medline].
  • Mallon E, Hawkins D, Dinneen M: Circumcision and genital dermatoses. Arch Dermatol 2000 Mar; 136(3): 350-4[Medline].
  • Meffert JJ, Davis BM, Grimwood RE: Lichen sclerosus. J Am Acad Dermatol 1995 Mar; 32(3): 393-416; quiz 417-8[Medline].
  • Meyrick Thomas RH, Ridley CM, Black MM: Clinical features and therapy of lichen sclerosus et atrophicus affecting males. Clin Exp Dermatol 1987 Mar; 12(2): 126-8[Medline].
  • Mikat DM, Ackerman HR Jr, Mikat KW: Balanitis xerotica obliterans: report of a case in an 11-year-old and review of the literature. Pediatrics 1973 Jul; 52(1): 25-8[Medline].
  • Nasca MR, Innocenzi D, Micali G: Penile cancer among patients with genital lichen sclerosus. J Am Acad Dermatol 1999 Dec; 41(6): 911-4[Medline].
  • Ratz JL: Carbon dioxide laser treatment of balanitis xerotica obliterans. J Am Acad Dermatol 1984 May; 10(5 Pt 2): 925-8[Medline].
  • Read SI, Abell E: Pseudoepitheliomatous, keratotic, and micaceous balanitis. Arch Dermatol 1981 Jul; 117(7): 435-7[Medline].
  • Staff WG: Urethral involvement in balanitis xerotica obliterans. Br J Urol 1970 Apr; 42(2): 234-9[Medline].
  • Wallace HJ: Lichen sclerosus et atrophicus. Trans St Johns Hosp Dermatol Soc 1971; 57(1): 9-30[Medline].

NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

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