Balanitis Xerotica Obliterans Treatment & Management

  • Author: Noah S Scheinfeld, MD, JD, FAAD; Chief Editor: William D James, MD   more...
 
Updated: Aug 2, 2011
 

Medical Care

  • No consistently effective treatment has been developed for penile lichen sclerosus (balanitis xerotica obliterans [BXO]); however, the following therapies have varying degrees of reported success:
    • Topical and intralesional steroids: Topical steroids can offer a reliable option only in the management of mild BXO limited to the prepuce in boys with minimal scar formation. Patients and their families must have realistic expectations with regard to the success of such treatments. Steroid-based creams are ineffective in persons with established scarring. Studies have shown that applying a potent topical steroid improves BXO in the histologically early and intermediate stages of disease and may inhibit further worsening in the late stages. Kiss[12] questioned the utility of topical steroid-based creams for the treatment of clinical BXO. Differences in success rates may relate to an unwillingness to use superpotent corticosteroids.
    • Topical steroids and skin stretching: Ghysel et al reported on successful therapy with topical steroid application and skin stretching on prepubertal boys with unretractable foreskin and phimosis.[13]
    • Tacrolimus: Successful treatment of BXO with topical tacrolimus has been reported.
    • Etretinate (no longer available): Acitretin is the current equivalent.
    • Carbon dioxide laser treatment[14]
  • Ebert et al,[15] in a retrospective analysis of 13 children with BXO published in 2007, reported that the relapse rate was lower after topical tacrolimus therapy than with betamethasone therapy.
  • In a case series of 3 patients, 2 had softening of the skin and pruritus, tenderness, and inflammatory change resolution within 3 weeks of receiving oral and intramuscular penicillin. Dirithromycin at 500 mg/d abated BXO in a third patient; the BXO returned when dirithromycin was discontinued but it improved again upon resumption of therapy.
  • Further treatment, or treatment of circumcised patients, is more challenging.
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Surgical Care

A variety of surgical techniques can be used to treat more severe penile lichen sclerosus (balanitis xerotica obliterans [BXO]).

  • 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.
  • Dubey et al[16] report that in BXO-related strictures with a viable urethral plate, 1-stage dorsal onlay buccal mucosal urethroplasty achieves superb medium-term results. They also state that the intervention created a normal, wide-caliber, slitlike glans, and a 2-stage procedure provides effective treatment but is associated with a higher revision rate.
  • Full-thickness skin grafts from eyelids to penis, plus split-thickness grafts in chronic BXO have been reported.
  • Buccal mucosa appears to be a durable source of nongenital tissue for urethral replacement. Attention to detail in terms of graft harvest, graft preparation, and graft fixation helps to avoid major postoperative complications. Onlay grafts appear to be preferable to tube grafts, and patients with a diagnosis of BXO do not appear to be candidates for the 1-stage urethral reconstruction using buccal mucosa.
  • Circumferential laser vaporization for severe meatal stenosis secondary to BXO reportedly is effective.
  • In 2007, Levine et al[17] reported on buccal mucosa graft urethroplasty for anterior urethral stricture repair. They evaluated the impact of stricture location and lichen sclerosus on surgical outcome. When lichen sclerosus affects the penis, complete excision of the diseased urethra with multistage repair decreases the rate of stricture recurrence associated with a 1-stage repair.
  • Palminteri et al[18] treated 17 patients, performing y resurfacing or reconstruction of the glans penis for benign, premalignant, and malignant penile lesions (5 glans skinning and resurfacing; 5 glans amputation and reconstruction of the neoglans, and 7 partial penile amputation and reconstruction of the neoglans). Four patients had lichen sclerosus. Glans resurfacing and reconstruction were performed with the use of a skin graft harvested from the thigh. Patients who received glans resurfacing reported glandular sensory restoration and complete sexual ability. Patients receiving glansectomy or partial penectomy with neoglans reconstruction maintained sexual function and activity, albeit with reduced sensitivity secondary to glans/penile amputation. Palminteri et al concluded that glans resurfacing or reconstruction can ensure a normal-appearing and functional penis, without jeopardizing cancer control.
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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
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Activity

In some cases of male genital lichen sclerosus, painful erections may limit sexual function.

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Contributor Information and Disclosures
Author

Noah S Scheinfeld, MD, JD, FAAD  Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, and New York Eye and Ear Infirmary; Private Practice

Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Optigenex Consulting fee Independent contractor

Coauthor(s)

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

Disclosure: Nothing to disclose.

Daniel S Lehman, MD  Fellow in Minimally Invasive Urology/Oncology, Department of Urology, Columbia University Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark W Cobb, MD  Consulting Staff, WNC Dermatological Associates

Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Society of Dermatopathology

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

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Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.
 
 
 
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