Lichen sclerosus (balanitis xerotica obliterans)
- Lichen sclerosus of the penis usually presents in middle age but can occur in children.
- Cause is unknown.
- Possible contributory factors include an uncircumcised or late (after puberty) circumcised penis, hormonal factors and autoimmune problems.
- Usually affects the glans and prepuce.
- Early symptoms include itching, burning, dysuria, painful intercourse, urethritis with or without discharge; late symptoms include phimosis or paraphimosis.
- A sclerotic white ring at the tip of the prepuce is diagnostic.
- Signs include ivory white papules, erosions, fissures, petechiae, telangiectasia and haemorrhagic bullae.
- Progresses to narrowing of urethral meatus and urinary retention.
- Has been associated with squamous cell carcinoma.
- Skin biopsy confirms diagnosis.
- If clinically active, treat with topical corticosteroids, but beware atrophic changes.
- Patients that do not respond to steroids require a circumcision.
- Recognition of psychosexual problems and need for counselling.
Zoon's plasma cell balanitis (balanitis circumscripta plasmacellularis)
Diagnosis requires skin biopsy
- Rare, benign penile dermatosis.
- More common in older men.
- Cause is unknown; possibly related to trauma, poor hygiene or chronic infection with Mycobacterium smegmatis.
- Patient usually presents with concerns about penile changes; often history >1 year.
- Mild symptoms: itching, tenderness, bloodstained underwear.
- Examination finds single, shiny red/orange plaque with 'cayenne pepper' spots on glans or prepuce of uncircumcised male.
- Occasional potential for malignant change.
- Diagnosis confirmed by skin biopsy.
- Surgery: treatment of choice is circumcision, which is usually curative.
- Topical corticosteroids; note antibacterials and antifungals are of limited use.
- Fusidic acid cream 2% can help suppress the condition.
- Other options used are carbon dioxide laser or radiotherapy.