Balanitis Xerotica Obliterans Workup

Updated: Nov 11, 2019
  • Author: Amira M Elbendary, MBBCh, MSc; Chief Editor: William D James, MD  more...
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Laboratory Studies

A rapid protein reagin test helps exclude syphilis.



Skin biopsy aids in the diagnosis of male genital lichen sclerosus (balanitis xerotica obliterans [BXO]).


Histologic Findings

Histopathologic changes of genital lichen sclerosus are similar to those of nongenital lichen sclerosus.

Epidermal findings include orthokeratosis, hyperkeratosis with follicular plugging, hyperkeratosis without follicular plugging, and stratum malpighii atrophy.

In early balanitis xerotica obliterans (BXO), moderate lymphocytic infiltrate in the superficial dermis and basal epidermis, associated with the epidermal basal vacuolar interface, is noted. As lesions develop, there is loss of elastic fibers in the papillary dermis, the epidermis becomes atrophic with hyperkeratosis, and subepidermal edema and displacement of the dermal bandlike inflammatory infiltrate downward occur. The edema is later replaced by fibrosis, forming a wide homogenous zone extending from the subepidermal layer to the mid dermis. [10] Both morphea and radiation dermatitis can produce similar changes in the superficial dermis, but the lymphoid band is absent.

Follicular plugging is not apparent in mucosal BXO. Significant dermal edema and homogenization of the collagen in the upper dermis occurs, with dilatation of blood and lymph vessels and a loss of elastic fibers.

The immune cells moving into areas of BXO include lymphocytes, plasma cells, and histiocytes in the mid dermis. The inflammatory infiltrate is less pronounced in long-standing lesions.

Lester and Swick in 2014 studied 66 biopsies of BXO, [34] 30 from females and 36 from males. Nine were extragenital and 57 were genital. Spongiosis was noted in 14, epidermal hyperplasia in 28, and squamous cell carcinoma in 7. Early/transitional lichen sclerosis was noted in 35, with epidermal basement membrane thickening (97%), hyperplasia (57%), and epidermotropism of lymphocytes (97%). Eosinophils occurred in 35 specimens (53%) contained eosinophils (23 early/transitional lichen sclerosis). Increased eosinophils were in men (P  = .074), and squamous cell carcinoma (P  =0.014) was predictive of eosinophil number. The researchers concluded that epidermotropism of lymphocytes, epidermal hyperplasia, and basement membrane thickening were useful features in pointing out early lichen sclerosis. Eosinophils commonly occurred in lichen sclerosis and were most common in genital male eruptions and in lichensclerosis associated with squamous cell carcinoma.