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Editor,—We have studied retrospectively 76 male cases of lichen sclerosus (LS) (formerly called balanitis xerotica obliterans), that presented over the period 1995–9 inclusive, in Leicester.
These cases were predominantly diagnosed on clinical grounds by experienced clinicians with eight (10.5%) proved by a biopsy.
A clinical diagnosis was made from the presence of combinations of clinical features.
From the literature it can be found that LS is the commonest cause of meatal stenosis in adults and children.1 Most men present with a phimosis so may require circumcision.1 Complications include meatal or urethral stricture and some lesions progress to malignancy.1
The fact that LS of male genitalia can involve the anterior urethra is highlighted by Barbagli et al.2 In their series of LS cases there was external meatus involvement in 19%, fossa navicularis in 16%, penile urethra in 3%, and notably panurethral disease in 52%.2
Nasca et al found that malignant changes were associated with 5.8% of the cases of penile LS in their series of 86 patents from Catania and Rome.3 They emphasise that patients with genital LS are at considerable risk for the development of penile squamous cell carcinoma, as well as verrucous carcinoma and erythroplasia of Queyrat.3 They also suspect that epithelial dysplasia per se may be precancerous.3 Reports in general on LS from GUM clinics are rare; notably Bingham reported a solitary malignancy in LS in 1978 from a GUM clinic in a 39 year old man.4
Recent studies on LS have shown that susceptibility to the disease may be partly genetically predetermined by having certain human leucocyte antigens—namely, class II loci HLAs, DQ7, or DR11.5 Also, Clifton et al 6 have recently postulated that there is evidence for the loss of androgen receptors with disease progression in LS; thus supporting a hormonal pathogenesis of LS. This assertion also provides a rationale for the use of testosterone creams in LS.
In Leicester, we have found that there is a tendency for cases to be referred to dermatologists and/or urologists early, and they are therefore lost to follow up by the GUM clinic. Eighty eight per cent of the men were white, with 9.2% being Asian; 84% were lost to follow up as at the year 2000, with 17% and 18% referred to dermatologists or urologists at any time respectively. Eighty four per cent used 1% hydrocortisone cream at any time; steroids creams stronger than 1% hydrocortisone were used in 21.1% of the cohort and 92.1% of the cohort were uncircumcised. Early referral means that procedures—for example, meatotomy or urethroplasty or therapeutic circumcision, are not recorded often in GUM notes. There was also a tendency for dermatology or urology not to “update” the GUM clinic with time. Despite this, phimosis was found in 40.8% with meatal stricture in 19.7%, therapeutic circumcision in 15.8%, and malignancy in one case. Anterior urethral involvement was present in only 7.9% in our series, meaning that it may represent a late stage phenomenon. Biopsies were found to be 100% confirmatory of diagnosis of LS—that is, 8/8 biopsies done.
One must conclude that a multidisciplinary approach to LS care should continue to operate, and that long term follow up is mandatory.
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