Lichen Sclerosus of the Male Genitalia and Urethral Stricture Diseases

INTRODUCTION

The true incidence of urethral involvement in patients with genital lichen sclerosus (LS) is unknown. We review the epidemiology and discuss the pathogenesis of LS and urethral stricture diseases.

MATERIALS AND METHODS

During the period 1991-2002, of 925 patients who underwent urethroplasty for anterior urethral stricture, 130 patients (14%) received the diagnosis of LS. In all patients with LS the histology was re-examined to confirm the clinical diagnosis. Retrograde and voiding urethrography was used to establish urethral involvement in the disease.

RESULTS

In 106 patients (82%) the histology provided the classical features of LS, and 24 patients (18%) showed some histological variations. In 49 patients (37%) the LS involved the pendolous urethra (meatus-navicularis-penile), and in 53 cases (41%) a panurethral stricture was evident.

CONCLUSIONS

LS urethral involvement appears to be a much more common and extensive disease than previously reported, and requires particular care in its early diagnosis.

Lichen sclerosus et atrophicus in pediatric and adult male patients with congenital and acquired phimosis

Lichen sclerosus et atrophicus is a chronic inflammatory sclerotic and atrophic disease of unknown cause that predominantly affects male and female genital skin. This study was designed to evaluate histological characteristics of congenital and acquired phimoses among pediatric (n=60) and adult (n=60) male patients who were admitted for circumcision to the Clinics of Urology and Pediatric Surgery of Kaunas University of Medicine Hospital between 2000 and 2003 and to determine the rate of lichen sclerosus et atrophicus and other histological diagnoses among them. This study demonstrates that 45.1% of congenital and 62.3% of acquired phimoses show histological signs of lichen sclerosus et atrophicus. The rate of lichen sclerosus et atrophicus was statistically significantly higher among patients with acquired than congenital phimosis. Boys with acquired narrowing of prepuce were statistically significantly 3.9 times more likely to develop lichen sclerosus et atrophicus than those with congenital phimosis. There were no statistically significant differences between rates of lichen sclerosus et atrophicus and other dermatological diagnoses among pediatric and adult male patients if the type of phimosis (acquired or congenital) was considered. Histological features of lichen sclerosus et atrophicus and other histological diagnoses in boys and men with phimosis were detected with equal frequency irrespective the age of the subjects. The rate of lichen sclerosus et atrophicus was similar among all boys (56.7%) and men (53.3%) treated for phimosis. Only the type of phimosis had a statistically significant influence on the rate of lichen sclerosus et atrophicus and other histological diagnoses.

Origin, clinical presentation, and diagnosis of hypomelanotic skin disorders

Hypomelanotic skin disorders are cutaneous pigmentary disorders characterized by a reduced melanin content in the skin that results in a lightening of the skin. Establishing the correct diagnosis for hypomelanotic skin disorders requires a good history, a detailed physical examination, the use of special lighting techniques, such as Wood's light, and sometimes a biopsy of the abnormally pigmented skin and the normally pigmented skin. This article focuses on the origin, clinical presentation, and diagnosis of acquired hypomelanotic skin disorders. An algorithm for the diagnostic approach to these hypomelanoses is given.

[The rare case of erosive lichen planus with large leasions in vulvar area and vagina]

The main aim of our paper was to point out the rare localization of erosive lichen planus in vulvar region and vagina. Moreover, these untreated lesions may be the starting point of squamous cell carcinoma.

[Lichen sclerosus in urological practice]

Lichen sclerosus in urological practice.

INTRODUCTION

Lichen sclerosus is a sclerosing, inflammatory skin disease with unknown origin which causes secondary phimosis of the foreskin and stricture of the urethra. In the case of long term existence of it the prevalence of intraepithelial squamous cell neoplasia is increased.

AIM

To identify the role of lichen sclerosus in adulthood phimosis and to categorize urological treatment. To define the proper therapy of lichen sclerosus, causing meatal and urethral stricture. To measure the incidence of lichen sclerosus in patients with squamous cell neoplasia.

METHOD

There was looked the incidence of lichen sclerosus in patient suffering with phimosis, recurrent urethral stricture, therapeutical options and presence of lichen sclerosus in patient with penile squamous cell neoplasia.

RESULTS

There were 123 foreskins sent for histological examination from 624 patients operated with circumcision in the last 5 years in the clinic. There were 76 (62%) times lichen sclerosus justified in 123 foreskins. There were lichen sclerosus found in 90% (9/10) of excised tissues of recurrent urethral strictures. There were lichen sclerosus noticed in 3 of 10 (33%) penile squamous cell carcinoma slides.

CONCLUSIONS

Lichen sclerosus can be detected in significant proportion of phimosis in adulthood. Lichen sclerosus can be found very often as the cause of recurrent urethral strictures, which takes necessary to perform 2 steps reconstructive operation with complete excision of the urethra and buccal graft emplacement. In the third of our all squamous cell carcinoma cases lichen sclerosus could be histologically shown, which give good reason for the opportunity of malignant disease development of this dermatological illness.

Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients

BACKGROUND

Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area. Studies on the epidemiology of causative factors are rare.

METHODS

Over a 4-year period we prospectively studied 126 patients with a presumptive diagnosis of anal eczema. The diagnostic algorithm comprised medical history, inspection, microbiology, laboratory chemistry, patch tests, proctoscopy, and biopsy if appropriate.

RESULTS

The age range was 7-82 years and the majority of patients were male (57.1%). Periods of anal symptomatology ranged from 6 days to 120 months and most of the patients (51.6%) had complaints for more than 12 months. The clinical diagnosis in 68 patients (54%) was: intertrigo/candidiasis (42.9%), atopic dermatitis (6.3%), pruritus ani (5.6%), psoriasis (3.2%), skin atrophy from steroid use (2.4%), lichen sclerosus et atrophicus (n = 2), herpes simplex (n = 1), and condylomata acuminata (n = 1). Contact eczema was suspected in 58 patients (46%), but 25 of these (43.1%) showed no contact sensitization.

CONCLUSION

The majority of patients with symptoms of anal eczema suffer from intertrigo/candidiasis, and relevant, causative contact sensitization may be found in only some of them. Patch-testing is a valuable investigative tool only when the patients' own products are included in the test series. Most patients suffer from their perianal complaints for more than 12 months, therefore diligent evaluation is warranted.

Vulvar disease update

In a busy dermatologic practice, it may be frustrating to encounter a vulvar disease patient, who must fully disrobe for examination. Further, the wet mounts, cultures, biopsies, and patient education required for treatment of vulvar disorders take up considerable time. However, most patients will respond to appropriate therapy, and can be very gratifying to treat.

Lichen Sclerosus Involving the Vagina

BACKGROUND

A review of the English literature since 1940 did not reveal a reported case of lichen sclerosus involving the vaginal mucosa. Diagnosis of lichen sclerosus involving the vagina must thus be a rare occurrence.

CASE

This report presents the findings on a 54-year-old white woman with a history of lichen sclerosus involving the vulva. She was found to have lichen sclerosus involving the vaginal mucosa extending to the posterior vaginal fornix. The patient was started on the use of topical clobetasol ointment 0.05% to the vulva to be used twice daily for 1 month, at bedtime for 2 months, and every other day for 3 months. At follow-up, the vulvar and vaginal lichen sclerosus was unchanged, but the patient was asymptomatic. She was using the clobetasol 1 to 2 times per week.

CONCLUSION

Lichen sclerosus involving the vagina is a rare occurrence. Each case must be assessed separately and therapy initiated accordingly in each circumstance. Biopsy must be performed in all cases to identify the disease process and rule out malignancy.

Early vulvar lichen sclerosus: a histopathological challenge

Vulvar lichen sclerosus (LS), a lymphocyte-mediated chronic skin disease, begins with uncharacteristic symptoms and progresses undiagnosed to atrophy and destructive scarring. Some patients with longstanding advanced LS have an increased risk of vulvar carcinoma. Early LS is treatable, although not curable, if diagnosed early. Therefore, patients with persistent vulvar symptoms should be biopsied to establish the diagnosis. In contrast to advanced LS, the histological features in early LS are quite subtle and often more prominent in adnexal structures than in interfollicular skin. Adnexal structures show acanthosis, luminal hyperkeratosis and hypergranulosis with/without dystrophic hair and basement membrane thickening. The epidermis/mucosa shows mild irregular, occasionally psoriasiform acanthosis and focal basement membrane thickening. Early dermal changes are homogenized collagen and wide ectatic capillaries in dermal papillae immediately beneath the basement membrane. The lymphocytic infiltrate can be sparse or dense, lichenoid or interstitial with epidermal lymphocyte exocytosis and lymphocytic/lymphohistiocytic vasculitis. Dermal melanophages indicate preceding keratinocyte/melanocyte destruction. Biopsy specimens of early LS rarely display all features. Therefore, serial sections and periodic acid-Schiff reactions are necessary for their identification. Recognition and treatment of these early stages of LS may result in longstanding remission. Progression to atrophic stages with their associated morbidity and even to squamous cell carcinoma may be prevented.

[Vulvar lichen sclerosus]

Vulvar lichen sclerosus is a frequent mucocutaneous disease especially affecting 50 to 60 year-old women but with a possible onset at very young age. Symptoms are most disabling including pruritus and dyspareunia. Vulvar mucosa gradually becomes more white and atrophied. Degeneration into epidermoid carcinoma is possible. Treatment only consists of topical corticosteroids.

Lichen sclerosus

Lichen sclerosus et atrophicus is a chronic inflammatory disease that mainly affects women in the 5th decade. Although lichen sclerosus most often affects the anogenital region, it may occur in other cutaneous or mucosal sites. Increased fibroblast activity causes cutaneous sclerosis. Recent studies have identified lichen sclerosus as an autoantibody-mediated chronic inflammatory dermatosis. Autoantibodies against the extracellular matrix protein-1 are present in up to 80% of affected patients. In addition to the well-accepted therapy with potent corticosteroids, promising results have been obtained using calcineurin antagonists in the treatment of lichen sclerosus. Interdisciplinary management with regular monitoring can improve the clinical manifestations and quality of life.

Connective tissue disease in children

As our understanding of connective tissue disease expands, so too does our therapeutic armamentarium. We have learned that autoimmunity triggers inflammation through unchecked, proliferative cell-mediated inflammation. By targeting this arm of the cytokine cascade, it may be possible to arrest further progression. Several biologic agents, such as etanercept, alefacept, infliximab, efaluzimab, and, recently, adalimumab, have come to market for adult psoriasis and are now undergoing trials for juvenile SLE, psoriasis, and psoriatic arthritis. Of note, etanercept has been used successfully in juvenile rheumatoid arthritis for more than 10 years. These agents target cell-mediated inflammation through various mechanisms and hold great promise for the treatment of many of the disease states discussed above. Moreover, the biologics carry an improved side-effect profile not seen with traditional agents such as corticosteroids and will be central in the evolution of targeted therapeutics for these complex immunologic diseases.