At a Glance - Lichen sclerosus versus Zoon's balanitis

Contributed by Dr Jean Watkins, a retired GP in Hampshire.

An early symtom is itching
An early symtom is itching

Lichen sclerosus (balanitis xerotica obliterans)

Aetiology

  • 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.

Presentation

  • 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.

Management

  • 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

Aetiology

  • Rare, benign penile dermatosis.
  • More common in older men.
  • Cause is unknown; possibly related to trauma, poor hygiene or chronic infection with Mycobacterium smegmatis.

Presentation

  • 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.

Management

  • 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.

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