Clinical parameters in male genital lichen sclerosus: a case series of 329 patients

EuroGuiderm guideline on lichen sclerosus-introduction into lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness. It may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are redness and oedema, typically followed by whitening of the genital skin; sometimes fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS, highlight important aspects in the care of LS patients (part 1), generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness; it may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are usually a whitening of the genital skin, sometimes preceded by redness and oedema; fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS (part 1), highlight important aspects in the care of LS patients, generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

[Lichen sclerosus in clinically relevant phimosis: incidence, risk factors, and association with squamous cell carcinoma of the penis]

BACKGROUND

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease. It is frequently diagnosed following circumcision. Diabetes mellitus (DM) is a known risk factor in men. Malignant pathology is more common in patients with LSA. Data on LSA in men are very limited.

OBJECTIVE

This study investigated the incidence of LSA in men who had undergone circumcision. Risk factors and likelihood of malignancy were captured.

MATERIALS AND METHODS

Data of 215 patients were retrospectively analyzed. As potential risk factors, age, body mass index (BMI), DM, coronary heart disease (CHD) and arterial hypertension were identified. Data were analyzed and displayed graphically as spike histograms. Logistic regression was applied. Age and BMI were transformed using cubic spline function.

RESULTS

Mean age of patients was 37 years (± 22 years). Mean BMI was 26.4. In all, 24% of the patients had a BMI > 30. Of the patients, 11% had DM, 5.1% had CHD, and 19% had arterial hypertension. Pathology revealed LSA in 47% of patients. Malignant disease was apparent in 3.3% of patients (2.7% without concomitant LSA, 4% with concomitant LSA). Age (55 vs 20 years, odds ratio [OR]: 3.210 [1.421, 7.251]) was a significant risk factor for LSA. BMI (30 vs 22 kg/m2, OR 1.059 [0.614, 1.828]) and DM (OR: 0.42 [0.148, 1.192]) elevated the risk for LSA.

CONCLUSION

We saw high rates of LSA in patients had undergone circumcision. Higher age represents a significant risk factor. In 3.3%, final pathology revealed squamous cell carcinoma of the penis. Therefore, pathologic work-up of circumcision specimen is mandatory.

Photodynamic therapy for male genital lichen sclerosus with urethral stricture-Case report

Male genital lichen sclerosus (MGLSc) typically impacts the external genitalia, resulting in balanitis, erectile pain, urination symptoms, and/or urinary retention. Urethral stricture develops in up to 20 % of these patients, which is usually found in the distal part of the urethra but can, in severe instances, impact the entire urethra and cause structural changes. Patients with skin lesions limited to the foreskin and partially extending to the glans can typically be cured by circumcision, but the recurrence rate of stricture is high when the glans or urethra is extensively involved. In the following case report, we describe a 45-year-old man with a history of MGLSc for 3 years and urethral stricture for 2 years, and these conditions remained untreated after circumcision. We emphasize that treatment with 5-aminolevulinic acid-induced photodynamic therapy (ALA-PDT) may further improve outcomes in such severe cases.

[Genital lichen sclerosus and lichen planus]

Lichen sclerosus (LS) and lichen planus (LP) are chronic inflammatory dermatoses of unknown aetiology. They pose the most important differential diagnoses of inflammatory dermatoses in the genital area. There is often a delay in diagnosing LS and LP and subsequently treatment is initiated late in the course of the disease, which will lead to scarring and a decreased quality of life. There is an increased risk of the development of malignancies in the genital area in both diseases; however, early and continuous treatment with potent topical steroids will decrease this risk.

Comorbidities in Male Patients With Lichen Sclerosus: A Case-Control Study

OBJECTIVE

Lichen sclerosus (LS) is a chronic inflammatory skin disease. In male patients, it usually involves the glans penis and foreskin and can cause phimosis or meatal stenosis. The aim of this cross-sectional case-control study was to identify clinically important comorbidities in male patients with LS.

MATERIALS AND METHODS

By searching Turku University Hospital electronic health records, the authors identified 630 male patients diagnosed with LS between 2004 and 2020. To investigate possible comorbidities, the authors compared this patient group to a 10-fold larger control group.

RESULTS

The incidence of LS increased during the study period, from 5 to 27.5 per 100,000 men. Patients were most often diagnosed at 21 to 25 years of age. Patients with LS exhibited markedly increased risks of penile carcinoma (odds ratio [OR], 81.0; 95% CI = 10.82-3516.7; p < .001) and carcinoma in situ of the penis (OR = 60.5; 95% CI = 7.32-2738.9; p < .001). Patients also more commonly exhibited lichen planus (OR = 16.8; 95% CI = 8.97-32.39; p < .001), psoriasis (OR = 3.3; 95% CI = 1.80-5.70; p = .004), angina pectoris (OR = 1.8; 95% CI = 1.10-2.81; p = .013), obesity (OR = 2.6; 95% CI = 1.72-3.77; p < .001), type 2 diabetes (OR = 2.3; 95% CI = 1.74-3.09; p < .001), and hypertension (OR = 1.9; 95% CI = 1.53-2.37; p < .001). The most commonly performed urological procedures were operation for phimosis, uroflowmetry, and ultrasound measurement of residual urine.

CONCLUSIONS

Genital malignancies, other dermatological conditions, and diseases related to metabolic syndrome should be considered when treating patients with LS.

Immunohistological Analysis of Lichen Sclerosus of the Foreskin in Pediatric Age: Could It Be Considered a Premalignant Lesion?

BACKGROUND

A major worry of juvenile penile LS is potential malignant degeneration to spinocellular carcinoma (SCC) in adulthood. LS is characterized by increased CD8+ and CD57+ cells, dermal sclerosis, epidermal atrophy, and hyperkeratosis. p53 and Ki67 are reliable premalignant markers. Our aim was to define the LS immunohistochemical profile of foreskin in children, focusing on tissue immune response and cell proliferation.

METHODS

Thirty specimens of foreskins removed from pediatric patients during circumcision were included: six from ritual operation (A), twelve from phimosis (B), and twelve from phimosis with LS (C). Formalin-fixed paraffin-embedded sections were stained for histomorphology and immunohistochemistry. A quantitative evaluation for CD8, CD57, p53, and Ki-67 and a statistical analysis were performed.

RESULTS

As compared to groups A and B, the samples from group C patients showed an acanthotic epidermis, a dermal band of lymphoid infiltrate with a significant enhancement of CD8+ CD57+ lymphocytes, and a keratinocytic hyperplasia with an overexpression of Ki67+ and p53+ cells.

CONCLUSIONS

Immunohistological findings confirmed an immune reaction and proliferative behavior in juvenile LS of foreskin. We believe that radical circumcision should be the first treatment of choice in pediatric patients with clinical suspicious of LS for the potential risk of transformation to SCC in adulthood.

2022 European guideline for the management of balanoposthitis

BACKGROUND

This guideline is an update to the 2014 edition of the European guideline for the management of balanoposthitis. Balanoposthitis describes inflammation of the glans penis and prepuce and is caused by a range of disparate conditions including infection, dermatoses and premalignancy.

OBJECTIVE

The main objectives of this guideline are to aid recognition of the symptoms and signs and complications of penile skin conditions and to offer recommendations on the diagnostic tests and treatment for a selected group of these conditions.

METHODS

The previous guideline was updated following a literature review and priority was given to randomized controlled trial and systematic review evidence.

RESULTS

The updated guideline includes amended management for infective balanitis to provide clear guidance for Group A streptococcal infections, management of on going Lichen sclerosus (to include circumcision and supportive management to reduce the recurrence of genital herpes and warts), additional regimens for Zoonoid change, use of calcineurin inhibitors in management and risk of premalignancy and change of nomenclaturefrom Premalignant conditions to Penile Intraepithelial neoplasia (PeIN).

CONCLUSION

Balanoposthitis has a widerange of causes high quality evidence specific to the management of penile disease is not available for all the conditions described.

A Potential Protective Effect of Alcohol Consumption in Male Genital Lichen Sclerosus: A Case-Control Study

Introduction and Objectives. Lichen sclerosus (LSc) is a chronic inflammatory process of the skin characterized by its unique histological features. It affects men and women of all ages, mainly in the anogenital area. The etiologies and exact pathophysiology are not well-known; however, LSc can be considered a precursor to male genital squamous cell carcinoma. We aim, through this case-control study, to potentially associate genital LSc with risk factors and certain patient characteristics in Lebanese adult males. Materials and Methods. A nested case-control study design was chosen. Subjects enrolled were adult male patients who had a circumcision between January 2010 and December 2020 at our university hospital, with a confirmed LSc diagnosis on pathology. Cases were matched with controls by age with a ratio of 1 : 1, all of whom were circumcised and had a negative pathology report. Data collection consisted of sociodemographic, behavioral, and past medical and familial history characteristics. Results. A total of 94 patients were enrolled. The mean age was 49.81 (±22.92) in the group of men with LSc. No significant differences in sociodemographic characteristics (age and BMI) were found between the two compared groups. Smoking cannot predict LSc as opposed to alcohol consumption, which we found to be a protective factor against the appearance of LSc ( $p=0.027$ ). Men with LSc had significantly higher rates of diabetes ( $p=0.021$ ) and hypertension ( $p=0.004$ ). No associations were found between LSc and the presenting chief complaints, family history of LSc, and past penile trauma. Conclusion. In this study, we were able to compare multiple variables between 47 circumcised patients diagnosed with LSc and a control group. We found that LSc patients showed higher rates of diabetes and hypertension. A potential protective effect of alcohol consumption is to be explored in future projects with bigger sample sizes and higher statistical powers.

The self-assessment of genital anatomy, sexual function, and genital sensation (SAGASF-M) questionnaire in a Belgian Dutch-speaking male population: A validating study

INTRODUCTION

Penile and genital surgery for congenital or acquired conditions is daily practice in reconstructive urology. These procedures, which carry the risk of disrupting nerves and blood vessels, may impair the genital sensation, and affect the capacity for sexual pleasure. Self-reported tools are needed to systematically assess the male genitalia before and after reconstructive surgeries in terms of genital sensation and sexual experience.

AIM

This study validated the Dutch translation of the "self-assessment of genital anatomy and sexual functioning in male" (SAGASF-M) questionnaire and investigated the perceptions of healthy men regarding their genital anatomy and sensory function.

METHODS

Eight hundred and eight sexually active men with a median age of 39 years (18-79 years) and no history of genital procedures other than circumcision filled out an online version of the questionnaire. Twenty-four participants were randomly recruited to confirm the responses of the "self-assessment of genital anatomy and sexual functioning in male" questionnaire by a clinical evaluation.

MAIN OUTCOME MEASURES

The "self-assessment of genital anatomy and sexual functioning in male" questionnaire comprises of multiple-choice questions and clarifying illustrations asking men to rate their genital appearance, overall sexual sensitivity, and pain perception as well as the intensity and the effort to reach orgasm. Prespecified regions of the glans, penile shaft, scrotum, perineum, and anus are evaluated through this questionnaire.

RESULTS

Only slight variability in anatomical ratings was observed. Overall discrimination between different genital areas in terms of genital sensation was significant. The bottom of the glans or frenular area was rated the highest contributor to "sexual pleasure," followed by the other regions of the glans and shaft. The same distribution was found for "orgasm intensity" and "orgasm effort." The anal region was generally rated the lowest. "Discomfort/pain" was rated lower than any of the other sensory function indicators and the top of the glans and anal region were rated most likely to perceive this unpleasant sensation. Participants reported significantly more sexual pleasure and intense orgasms when stimulated by a sexual partner than self-stimulation. Homosexual and bisexual men reported a higher contribution of the perineal and anal regions in sexual pleasure and orgasm. No significant difference between circumcised and uncircumcised individuals regarding overall genital sensation could be found.

CONCLUSION

The Dutch translation of the SAGASF-M questionnaire is a valuable and reliable tool for self-assessment of genital anatomy and sensation, providing a site-specific attribution of a patient's perceived sexual function. Further prospective research with this questionnaire could aid in the patient-centered improvement of genital surgery.

Lichen sclerosus: The 2023 update

Lichen sclerosus (LS) is an underdiagnosed inflammatory mucocutaneous condition affecting the anogenital areas. Postmenopausal women are predominantly affected and, to a lesser extent, men, prepubertal children, and adolescents. The etiology of LS is still unknown. Hormonal status, frequent trauma and autoimmune diseases are well-known associations for LS, yet infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype. Furthermore, there is a distinct expression of tissue remodeling associated genes as well as microRNAs. Oxidative stress with lipid and DNA peroxidation provides an enabling microenvironment to autoimmunity and carcinogenesis. Circulating IgG autoantibodies against the extracellular matrix protein 1 and hemidesmosome may contribute to the progression of LS or simply represent an epiphenomenon. The typical clinical picture includes chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. In addition to genital scarring, and sexual and urinary dysfunction, LS may also lead to squamous cell carcinoma. Disseminated extragenital LS and oral LS are also reported. The diagnosis is usually clinical; however, a skin biopsy should be performed in case of an unclear clinical picture, treatment failure or suspicion of a neoplasm. The gold-standard therapy is the long-term application of ultrapotent or potent topical corticosteroids and, alternatively, topical calcineurin inhibitors such as pimecrolimus or tacrolimus. Collectively, LS is a common dermatological disease with a so far incompletely understood pathogenesis and only limited treatment options. To foster translational research in LS, we provide here an update on its clinical features, pathogenesis, diagnosis and (emerging) treatment options.

Lichen Sclerosus: A Current Landscape of Autoimmune and Genetic Interplay

Lichen sclerosus (LS) is an acquired chronic inflammatory dermatosis predominantly affecting the anogenital area with recalcitrant itching and soreness. Progressive or persistent LS may cause urinary and sexual disturbances and an increased risk of local skin malignancy with a prevalence of up to 11%. Investigations on lipoid proteinosis, an autosomal recessive genodermatosis caused by loss-of-function mutations in the extracellular matrix protein 1 (ECM1) gene, led to the discovery of a humoral autoimmune response to the identical molecule in LS, providing evidence for an autoimmune and genetic counterpart targeting ECM1. This paper provides an overview of the fundamental importance and current issue of better understanding the immunopathology attributed to ECM1 in LS. Furthermore, we highlight the pleiotropic action of ECM1 in homeostatic and structural maintenance of skin biology as well as in a variety of human disorders possibly associated with impaired or gained ECM1 function, including the inflammatory bowel disease ulcerative colitis, Th2 cell-dependent airway allergies, T-cell and B-cell activation, and the demyelinating central nervous system disease multiple sclerosis, to facilitate sharing the concept as a plausible therapeutic target of this attractive molecule.

Penile Lichen Sclerosis: A Surgical Perspective of its Aetiology and Treatment

Penile lichen sclerosis is a longstanding inflammatory disease of the skin with a controversial aetiology. Penile lichen sclerosis (PLS) is a growing, inflammatory dermatitis of the anogenital region, which involves the meatus, prepuce, penile shaft, and glans penis. Although the accurate aetiology of PLS is contentious, multiple factors including genetics, autoimmunity, infections of human papillomavirus, hepatitis C, Epstein-Barr virus, risk factors (hormonal and trauma), etc., can be considered to be a part of the etiopathogenesis of PLS. The initial clinical presentations of penile lichen sclerosis are white plaques, atrophied skin, erythema, erosions, and sclerosis in the anogenital region. When the disease advances, the following can occur, including meatal constraints, telangiectasia, petechiae, soreness, papular lesions, tightness of the foreskin, difficulties in passing urine, itching, tenderness on erections, pain, cracking, bleeding, redness, rashes, tightness at frenulum, and dysuria. This disease has a dangerous course of action and if untreated it may be linked with severe urologic and sexual morbidities. PLS is usually treated with medical and surgical interventions like topical or intralesional steroids and circumcision. The role of circumcision is very critical in the course of action and prognosis of PLS, and its treatment is dependent on the stage of the disease. This review brings up the knowledge regarding epidemiology, etiopathology, clinical presentation, and management of PLS with an emphasis on the role of circumcision.

The distribution of the clinical variables in a population of adult males circumcised for phimosis: A contribution to the clinical classification of phimosis

BACKGROUND

The literature regarding the quality of the sex life in adult males after circumcision, due to phimosis, is scarce and sometimes contrasting. This could be due to comparisons of a nonhomogeneous distribution of the clinical variables of men who have undergone circumcision.

OBJECTIVE

The objective of this study was to evaluate the distribution of the clinical variables in the adult male population who had circumcision for phimosis, and to propose a clinical classification of the phimosis to characterize it in adult males in more homogeneous sub-groups for the common clinical variables.

MATERIALS

A population of 244 adult male patients with phimosis was evaluated retrospectively. The mean age was 50.7 years. Each patient was classified according to the most common clinical variables. The variables that make up this classification of the phimosis were: Position (P1-2) to indicate if phimosis is present when the penis is at rest (P2) or only during an erection (P1); Grade (G 0-4) in relation to the extent of glans visibility; Complexity (Co 0-4) of comorbidities; Timespan (T 1-10) of the phimosis.

RESULTS

The distribution of the variables was the following: Position P1:30.73%, P2:69.26%; Grade G0:30.73%, G1:23.77%, G2:27.45%, G3:12.29%, G4:5.73%; Complexity (associated penile comorbidities): C0:48.36%, C1:4.5%, C2:0.8%, C3:43.03%, C4:3.27% Timespan: 57.78% of the patients had phimosis for less than a year; 18.03% between 1 and 2 years; 11.88% between 2 and 10 years; and 12.29% for more than 10 years.

CONCLUSIONS

The distribution of the clinical variables in the adult male population who underwent circumcision due to phimosis was not homogeneous regarding the appearance, severity, comorbidity, and timespan. This non-homogeneity could explain, in some cases, the contrasting results regarding the quality of sex life after circumcision in the literature. The proposed classification can offer an objective tool for researchers and clinicians group the patients into more homogeneous subgroups.

Pseudoepitheliomatous keratotic and micaceous balanitis: a series of eight cases

BACKGROUND

Pseudoepitheliomatous keratotic and micaceous balanitis (PEKMB) is a clinicopathological entity characterized clinically by micaceous scale on the glans, and histologically by acanthosis, hyperkeratosis and pseudoepitheliomatous hyperplasia. We present a series of eight cases of this rare condition, the first series of more than two cases to be reported.

OBJECTIVES

To determine the clinical and histological characteristics of cases of PEKMB, and evaluate treatments used and clinical course.

METHODS

This monocentric case series was conducted at the University College London Hospitals tertiary male genital dermatology clinic between April 2018 and August 2020. Eight patients with PEKMB were evaluated. Data were collected on demographics, clinical presentation, histological features, presence of human papilloma virus (HPV), history of lichen sclerosus, treatment of PEKMB and subsequent response, and presence or development of squamous cell carcinoma (SCC) or penile intraepithelial neoplasia (PeIN) during follow-up.

RESULTS

Eight Caucasian males presented with clinical and histological evidence of PEKMB. Seven had a background of lichen sclerosus; two had failed treatment with superpotent topical steroids and four had symptoms for three or more years prior to circumcision. There was no clinical or histological relationship with HPV infection, and p16 staining was negative. HPV PCR, performed in two cases, was negative. Basal atypia, insufficient to amount to PeIN, was present in six patients. One patient progressed to PeIN during follow-up, and no patient progressed to invasive malignancy. Five patients were treated successfully with glans resurfacing and split skin graft reconstruction.

CONCLUSIONS

Our observations demonstrate that PEKMB represents a form of chronic, undiagnosed or misdiagnosed, inadequately treated or treatment refractory, unstable lichen sclerosus. The significant potential for squamous carcinogenesis (differentiated PeIN and verrucous carcinoma) can be mitigated by timely diagnosis and treatment. Glans resurfacing and split skin graft reconstruction appears to be a successful treatment modality in patients with refractory disease.

An evaluation of the pharmacotherapeutic options for the treatment of adult phimosis. A systematic review of the evidence

INTRODUCTION

Topical pharmacotherapy is often practiced in the treatment of adults with phimosis or Lichen Sclerosus (LS). However, it is unclear if it is effective.

AREAS COVERED

The authors review pharmacological treatments in adults with phimosis or LS using the Preferred Reporting of Items for Systematic Reviews and Meta- analysis (PRISMA) methodology. They searched seven databases using key words phimosis, drug treatment, medical, treatment, lichen sclerosis, pharmacological treatment, medications, comparison study for all English language articles from 1962-2021. Inclusion criteria were patients >18 yr., and the use of topical medical treatment with outcome data. The article includes the authors' expert opinion and their perspectives for the future.

EXPERT OPINION

There is limited research, with significant heterogeneity, which suggests the probable safety of topical steroids with some potential to reduce the signs and symptoms of LS. However, good quality research, with patient reported outcome data, is required to establish its true role and effectiveness.

Lichen sclerosus following genital piercing

Male genital lichen sclerosus (MGLSc) is a chronic inflammatory dermatosis that predominantly affects uncircumcised males. Several aetiological factors have been described, with growing evidence supporting chronic urine exposure of susceptible epithelium being crucial to its pathogenesis. We describe a 45-year-old man with a 2-year history of MGLSc at the site of a urethrocutaneous fistula secondary to a penile piercing. To our knowledge, this is the first documented case of MGLSc occurring at the site of a genital piercing.

Male genital lichen sclerosus, micro incontinence and occlusion: mapping the disease across the prepuce

INTRODUCTION

Male genital lichen sclerosus (MGLSc) can lead to significant sexual dysfunction and urological morbidity and is also a risk factor for premalignant disease (PeIN) and penile cancer (PeCa). Although the precise aetiopathogenesis of MGLSc remains controversial, accumulated evidence indicates that it is related to chronic, intermittent, occluded exposure to urine.

METHODS

Preputial samples were collected from ten patients with clinically diagnosed MGLSc undergoing circumcision. Samples were then divided into a grid and ten punch biopsies were obtained from each to determine the extent and distribution of the disease process across each prepuce.

RESULTS

All ten patients reported having urinary micro-incontinence, and all were histologically confirmed as having MGLSc. The most proximal aspect of the prepuce was found to be universally affected by LSc in all patients, whereas the most distal part was overwhelmingly shown to be the least affected area. Of the 63 LSc-affected regions, 62 were in direct physical contiguity with one another. The histological extent of the disease was not found to be congruent with either the severity of the symptoms reported by the patients or the clinical examination.

DISCUSSION

In uncircumcised men with urinary micro-incontinence, after the prepuce has been replaced post micturition, small amounts of urine pool between the juxtaposed epithelial surfaces. The proximal aspect of the prepuce is subjected to the maximum amount of occlusion and maximal contact with accumulated urine, whereas the distal prepuce is subjected to the least. Our findings suggest that accentuated contact between urine and susceptible penile epithelium due to occlusion can lead to MGLSc. Furthermore, contiguity data suggest that once established, it is possible that MGLSc advances across tissues by physical contact. This is the first study examining the changes in the preputial landscape in patients with LSc and contributes to our understanding of disease aetiology and progression.

Extragenital lichen sclerosus arising in tattooed skin

Lichen sclerosus (LSc) is a chronic inflammatory condition commonly affecting the anogenital area, with extragenital involvement seen in less than 1%-20% of cases. Concomitant extragenital and genital LSc is extremely rare in male patients. The Koebner phenomenon is a recognised feature of LSc; here we present a rare case of extragenital LSc occurring in tattooed skin.

Male genital lichen sclerosus associated with urological interventions and microincontinence: a case series of 21 patients

BACKGROUND

Male genital lichen sclerosus (MGLSc) is an acquired, chronic, inflammatory cutaneous disease associated with significant morbidity and squamous cell carcinoma of the penis. Consideration of all of the evidence suggests that chronic exposure of susceptible epithelium to urinary occlusion by the foreskin is the most likely pathomechanism. MGLSc never occurs in men who were circumcised at birth, and has been associated with trauma, instrumentation and anatomical abnormalities, e.g. frank hypospadia that results in microincontinence.

AIM

To describe 21 patients who developed MGLSc following urological diagnoses and procedures.

METHODS

We conducted a retrospective review of patients with a diagnosis of MGLSc whose symptoms related to urological procedures who attended or saw one of the authors (CBB) privately during the period June-October 2018.

RESULTS

In total, 21 patients (mean age 59 years) were identified. The referrals came from the local urology departments, primary care or extramural dermatology services. Most of the patients were uncircumcised men. All had developed symptoms and signs of MGLSc within 5 years following their urological procedure; on examination, 30% of the patients were found to have damp penile skin due to microincontinence. Of the 21 patients, 10 had undergone radical prostatectomy for prostate cancer, 4 had a diagnosis of Peyronie disease, 4 had undergone multiple cystoscopies and urethroscopies, 2 had undergone surgery on the bladder neck and 1 had undergone implantation of a penile prosthesis to treat erectile dysfunction.

CONCLUSION

This case series further strengthens the urinary occlusion hypothesis for the causation of MGLSc. It is important to recognize that urological interventions can create incompetence of the naviculomeatal valve post voiding. In uncircumcised men, this creates a risk factor for MGLSc that was not previously present. Occlusion, the phenomenon of koebnerization and currently unelucidated epithelial susceptibility factors lead to inflammation, sclerosis and cancer. Patients and urologists should be aware of these possibilities and preventative measures instituted, e.g. adaptive voiding habits and barrier protection.

Vulvar Lichen Sclerosus from Pathophysiology to Therapeutic Approaches: Evidence and Prospects

Vulvar lichen sclerosus (VLS) is a chronic, distressing, inflammatory disease with an enormous impact on quality of life. Treatment goals are relieving symptoms, reversing signs and preventing anatomical changes. Despite the availability of numerous therapeutic options, treatment outcome may not be entirely satisfactory and a definitive cure does not exist. This may be due to the fact that the exact VLS etiopathogenesis remains unknown. The objectives of this paper were to review the most up-to-date knowledge on VLS etiopathogenesis and to consider the available therapies through the lens of a plausible pathogenetic model. An electronic search on both VLS etiopathogenesis and its treatment was performed using the National Library of Medicine PubMed database. Based on current knowledge, it is conceivable that various, heterogeneous environmental factors acting on a genetic background trigger an autoimmune, Th-1 response, which leads to a chronic inflammatory state. This, in turn, can determine both tissue and micro-vascular injury and activation of signaling pathways involved in fibroblast and collagen metabolism. This pathogenetic sequence may explain the effectiveness of anti-inflammatory treatments, mostly topical corticosteroids, in improving VLS clinical-pathological changes. Further deepening of the disease pathways will presumably allow key mediators to become new therapeutic targets and optimize the available treatments.

Male genital lichen planus: A retrospective study of 89 cases

BACKGROUND

Unlike other types of lichen planus (LP), there are no series concerning male genital LP.

OBJECTIVE

To describe the clinical characteristics, diagnosis, and response to treatment of male genital LP.

PATIENTS AND METHODS

A retrospective study of male patients with genital LP consulting a dermatologist specialized in anogenital diseases between January 2010 and 2019. Demographic data, history, functional signs, clinical characteristics, pathology, complications, and treatment efficacy were collected.

RESULTS

Eighty-nine patients were included at four centers. The median age was 51 years. Most patients were uncircumcised and asymptomatic. In 88.8% of cases, only the genital mucosa was involved. Erythema (71%), papules (21.3%), lacy network (15.7%), atrophic lesions (15.7%), erosions (14.6%), and post-inflammatory hyperpigmentation (2.2%) were less frequently observed. Biopsy results confirmed LP in 61.3% of cases but could not rule out other inflammatory genital dermatoses in other cases. Anatomic complications were observed in 30.3% of patients. Topical corticosteroids (TCS) induced remission in most cases. Tacrolimus efficacy was comparable to that of TCS.

CONCLUSION

Male genital LP is a rare inflammatory disorder chiefly affecting uncircumcised men. It is found predominantly on the mucosal component of the penis and presents as non-erosive inflammatory balanitis in most cases, with frequent partial or complete remission on treatment with TCS.

Diagnosis and management of cutaneous and anogenital lichen sclerosus: recommendations from the Italian Society of Dermatology (SIDeMaST)

Lichen sclerosus (LS) is a disabling chronic inflammatory disease of skin and genital mucous membrane causing itch, pain, dysuria and restriction of micturition, and significant sexual dysfunction and dyspareunia both in women and men. If left untreated, LS is associated with a high degree of sclerosis and scarring, as well as with an elevated risk of cancer in the genital area. Although a central role of autoimmunity is suggested, the pathogenesis of LS is still not clearly understood and the disease remains difficult to treat. The goals of treatment of LS are to alleviate symptoms and discomfort, prevent anatomical changes and prevent malignant transformation. This guideline has been developed by an Italian group of experts. It summarizes evidence-based and expert- based recommendations. The highest level of evidence favors the use of topical high potency corticosteroids; second and third lines' treatments include topical calcineurin inhibitors and topical retinoids, respectively. Surgical treatment has become the treatment of choice in male genital LS with persistent phimosis not responsive to medical treatment. The aim of this paper is to offer evidencebased and easily applicable recommendations for the management of LS.

Sexual function is adversely affected in the majority of men presenting with penile lichen sclerosus

Male genital lichen sclerosus (MGLS) is a chronic inflammatory condition that can present with a range of debilitating symptoms. Sexual dysfunction is reported by most women with lichen sclerosus but by relatively few men. This prospective study looked at 78 men with MGLS. Sexual difficulties were experienced by 64 (82%) patients, with 54 of the 64 attributing their sexual dysfunction directly to their MGLS. Sexual dysfunction appears to be more common in MGLS than other genital diseases such as psoriasis and sexually transmitted infections. Penile soreness due to active inflammation is the commonest cause of dyspareunia. Psychological factors are also important. Assessment and management of MGLS must include sexual history as men will not usually volunteer this information. Monitoring sexual function may be useful to assess disease outcome.

Is urinary incontinence associated with lichen sclerosus in females? A systematic review and meta‐analysis

Background

Lichen sclerosus (LS) is a scarring chronic inflammatory disease with a predilection for genital skin in both sexes. The aetiology of LS is controversial, but evidence increasingly suggests that the occluded exposure of susceptible epithelium to urine is involved in the pathogenesis of genital LS in males. This theory has not yet been robustly investigated in females.

Objectives

This review and meta‐analysis examined whether there is an association between urinary incontinence (UI) and genital lichen LS in females.

Methods

We performed a comprehensive search of MEDLINE, Embase and CINAHL to identify observational studies assessing the prevalence of UI in females with LS. DerSimonian and Laird random‐effects models were used to estimate the overall pooled prevalence and risk ratio compared to controls. Heterogeneity was assessed.

Results

In total, eight studies met the inclusion criteria and five studies were included in a meta‐analysis. Three studies were graded as moderate quality and five were poor. The pooled prevalence for UI in LS was 0.35 (95% confidence interval [CI] 0.13–0.58, I² = 98.4%). The risk ratio of UI in LS was 0.97 (95% CI 0.53–1.75, I² = 87.5%).

Conclusion

There appears to be no difference between patients with LS and those without LS in terms of UI. Studies are limited by clinical and methodological quality and heterogeneity is high. Well‐designed prospective studies are needed.

Lichen Sclerosus and Phimosis - Discrepancies Between Clinical and Pathological Diagnosis and Its Consequences

OBJECTIVE

To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis.

MATERIALS AND METHODS

The 92 adult male patients who were qualified for circumcision due to phimosis, were included in the study. The patients were diagnosed clinically by a urologist and dermatologist before the surgical procedure. After the circumcision, the resected foreskins were examined by 2 independent uropathologists.

RESULTS

Preoperative clinical diagnosis of LS was established in 54 patients (58.7%); healthy-looking skin in 26 (28.3%) and other penile diseases in 12 (13.1%) patients. After histopathological examination, the diagnosis of LS was established in 62 patients (67.4%), but only in 44 patients with previous LS clinical diagnosis. LS was histopathologically confirmed in 18 other patients with clinically diagnosed healthy skin (n = 17) or lichen planus (n = 1). Healthy skin was histopathologically confirmed in 10 cases in patients diagnosed clinically before as LS. Other 15 histopathological diagnoses were Zoon balanitis (n = 3), nonspecific balanitis (n = 5), lichen planus (n = 1), psoriasis (n = 1), invasive penile cancer (n = 3), Bowen's disease (n = 1), penile intraepithelial neoplasia 2 usual type (n = 1).

CONCLUSION

LS has been revealed as the most common histopathological diagnosis in patients undergoing circumcision in our study. Histopathological examination seems to be necessary to exclude this disease.

Immunogenetics and human papillomavirus (HPV) in male genital lichen sclerosus (MGLSc)

BackgroundThe pathogenesis of male genital lichen sclerosus (MGLSc) is controversial. Incriminated factors include infection with human papillomavirus (HPV) and autoimmunity (e.g. Human Leukocyte Antigen [HLA]). To address the roles of HLA and HPV in MGLSc we studied adult Caucasian males with a clinical and histological diagnosis of MGLSc. The men in the study attended two specialised Male Genital Dermatoses Clinics between July 2011 and September 2012 and were selected and phenotyped from the clinical records. DNA was extracted from blood and paraffin-embedded biopsy sections, for HLA and HPV typing, respectively. HLA allele frequencies were compared with those derived from the UK-based Caucasian population. Eighty-eight cases of MGLSc were identified. HPV DNA was detected in 33/88 (37.5%) cases of MGLSc. HPV16 was the most prevalent type found: 11/88 (12.5%) MGLSc. No statistically significant HLA associations were established but HLA-B*35, -B*51, -C*15, -DRB1*04, -DRB1*10 (predisposition) and -DQA1*01 (protection) were revealed as alleles of interest. HPV16-associated MGLSc cases showed no statistically significant association with HLA genotype. The relationship between HPV and MGLSc suggests a passenger effect rather than a pathogenic role. HLA is not associated with MGLSc nor co-existent HPV16.

Penile intraepithelial neoplasia, penile cancer precursors and human papillomavirus prevalence in symptomatic preputium: a cross-sectional study of 351 circumcised men in Sweden

Objectives

To investigate the prevalence of pathological disease and spectrum of human papillomavirus (HPV) types among symptomatic foreskin tissue.

Patients and Methods

Consecutively excised symptomatic foreskins from 351 men were sent for histopathological evaluation. During the surgical procedure, a fresh biopsy was taken for HPV analysis by modified general primer polymerase chain reaction. A medical questionnaire regarding medication, smoking habits, number of lifetime sexual partners, former diseases and surgery performed on penis was completed by all participants.

Results

The most common clinical diagnosis and cause for circumcision was phimosis, seen in 85.2%. Histopathologically inflammatory dermatological conditions were present in 87% of the men. The most common histopathological diagnosis was lichen sclerosus (LS) observed among 58.7%. Notably, penile intraepithelial neoplasia (PeIN) was present in 2% without former clinical suspicion. Overall, HPV was detected in 17.1% of the men and 28 different HPV types were found. High‐risk (HR) HPV types were identified in 9.1% and HPV16 was present in 2.3%. Current smoking increased the risk of HPV (crude odds ratio [OR] 2.8, confidence interval [CI] 1.4–5.6; P = 0.005). Having >15 lifetime sexual partners increased the risk of HPV (crude OR 2.6, 95% CI 1.4–5.1; P = 0.003) and when adjusted for current smoking the OR was substantially increased (OR 6.0, 95% CI CI 2.2–16.8; P < 0001).

Conclusions

Histopathological evaluation of circumcised symptomatic foreskin revealed PeIN in 2% of the men without any clinical suspicion of malignancy and that treatable dermatological conditions were present in 87%, LS being the most common. HR‐HPV types were present in 9%. Due to risk of malignant development both in PeIN and in inflammatory skin diseases we recommend sending all excised foreskins from patients with symptoms for histopathological evaluation as guidance for further clinical management.

Platelet-rich plasma for male genital lichen sclerosus resistant to conventional therapy: First prospective study

Ultrapotent topical corticosteroids and circumcision are usually effective for male genital lichen sclerosus (MGLSc); however, refractory cases are often referred to our Male Genital Dermatology Unit. Treatment with autologous platelet-rich plasma (TPRP) has recently been advocated as a safe and effective treatment option, but there have been no prospective studies in men to date. The objective of this study is to assess the safety and efficacy of TPRP for MGLSc resistant to conventional therapy. A prospective, open-label, single-arm, therapeutic study was carried out in this study. Inclusion criteria: resistant to conventional therapy for at least 6 months. Procedure: infiltration of 0.1 mL/cm² PRP every 8 weeks. Monthly data recording: visual appearance with photographs and external scoring by an expert using Investigator's Global Assessment Scale (IGA scale 0-5), symptoms (scale 0-5), quality of life (QoL; Dermatology Life Quality Index [DLQI]), and complications. No. of patients included was n = 5. No. of patients excluded during treatment was n = 1. Mean initial IGA: 3.6. Mean initial DLQI: 6. TPRP n = 34 (range: 2-9; average: 6.8 per patient). Mean IGA at 18 months: 3.25. Mean DLQI at 18 months: 1.25. All patients reported being completely asymptomatic at 10 months. No. of patients with complications is n = 1 (balanitis). TPRP seems to be safe and effective, regarding symptom control and improvement in QoL; however, visual changes were minimal.

An epidemiologic overview of a tertiary referral practice for male paediatric lichen sclerosus

Within the paediatric population, changing patterns of circumcisions have confounded the epidemiology and presentation of lichen sclerosus (LS). We sought to evaluate the incidence, demographics, and clinical features of patients presenting to a single Albertan paediatric urologist with LS. This retrospective descriptive analysis evaluated all paediatric patients referred for phimosis to a single paediatric urologist in Edmonton, Alberta. Chief complaints/symptoms, date of birth, and date of circumcision were identified. The primary outcome of interest was the proportion of circumcisions with pathologically confirmed LS. From July 2006 to March 2016, 4,163 patients were seen for phimosis of the approximate 12,000 new referrals. Hundred phimosis patients had clinically suspected LS. Of those adequately reported, 81 (81/83) were microscopically confirmed to be LS with a mean age of 9.6 years and median age of 8.9 years (range 4.1 to 16.1 years). This cohort represented 2.0% of phimosis referrals and approximately 0.7% of all referrals to our paediatric urologist. When compared to physiologic phimosis, these patients had higher rates of dysuria (n=28, 34.6% versus n=1, 1.0%, P<0.0001) and urinary retention (n=18, 22.2% versus n=1, 1.0%, P<0.0001) as presenting complaints. LS of the paediatric male genitalia is an uncommon, albeit clinically significant disease entity. The clinical diagnosis for the trained practitioner is very accurate.

Recent advances in understanding and managing Lichen Sclerosus

Lichen sclerosus (LS), or balanitis xerotica obliterans as it was previously known, is a chronic inflammatory lymphocyte-mediated scarring dermatosis that often affects the preputial skin and glans, leading to phimosis and urethral strictures if left untreated. We present a narrative review of the literature assessing its aetiology and pathogenesis and discuss its links to penile cancer and its medical and surgical management. Possible hypotheses for the development of LS include chronic exposure to trapped urine, leading to changes in the epithelial structure. This is supported by the fact that circumcision is often curative in the early stages of the disease. Although circumcision can be curative, the use of topical steroids is typically the first-line treatment and may preserve the foreskin and forgo the need for circumcision altogether. Patients should be made aware of a possible association with penile cancer. Although the majority of cases can be treated by medical therapy and circumcision, a significant number of patients may also require penile reconstructive procedures.

The risk of developing squamous cell carcinoma in patients with anogenital lichen sclerosis: A systematic review

INTRODUCTION

Lichen sclerosis (LS) is a chronic inflammatory skin disease, mostly affecting the anogenital region. Patients with LS have a higher risk of developing anogenital squamous cell carcinoma (SCC), although exact numbers are not known.

OBJECTIVE

To systematically review the absolute risk (AR) and incidence rate (IR) of developing SCC in patients with anogenital LS, as well as patient characteristics that influence the risk of developing LS associated SCC.

METHODS

A search was performed through the databases of Pubmed and Embase. Five reviewers independently screened the articles on title/abstract and full text published before 31st of July 2019. The selected articles were critically appraised using the Quality In Prognostic Studies tool.

RESULTS

Of 2238 titles and abstracts assessed, 15 studies were selected to be analysed. The AR of developing SCC in patients with LS varied between 0.21 and 3.88% for women and 0.00-0.91% for men across the included studies. The IR was 0.65-8.89/1000 person-years for women and 0.00-6.49/1000 person-years for men. This risk for women seemed to be increased by age, the presence of vulval intra-epithelial neoplasia (VIN), a long history of LS, late diagnosis of LS and partial compliance of treatment with topical corticosteroids. For men, no determinants were found.

CONCLUSION

We found fair evidence that the AR of developing SCC in patients with anogenital LS varied between 0.21 and 3.88% for women and 0.00-0.91% for men. Therefore, we recommend regular follow up and compliant treatment with topical corticosteroids, especially in older women.

[Lichen sclerosus in children]

Lichen sclerosus (LS) is a chronic inflammatory disease of the skin. It mainly affects the anogenital area. More knowledge of the disease is needed to avoid delay in diagnosis as early treatment may cure the disease in some and reduce or prevent scarring. Initial treatment for girls and boys comprises the daily application of a potent cortisone ointment for 3 months. After remission the treatment should be continued long-term intermittently. If there is no complete remission in boys complete circumcision is recommended. LS usually cannot be healed but only well suppressed, and also after circumcision recurrences may occur years later. Therefore, patients have to be well informed and should be followed up long-term.

Topographical Evaluation of Penile Lichen Sclerosus Reveals a Lymphocytic Depleted Variant, Preferentially Associated With Neoplasia: A Report of 200 Cases

Since the seminal study of Hart and Helwig in 1975, there are few detailed pathological studies of lichen sclerosus (LS). The aims of this study were to provide a detailed histopathological description of penile LS, as well as to explore its relationship with penile intraepithelial neoplasia (PeIN) or invasive carcinoma. We evaluated 200 patients and designed a topographical approach for the histological evaluation focusing in alterations of the following anatomical layers: squamous epithelium, lamina propria, dartos, and corpus spongiosum. We documented the quantity and topographical location of stromal lymphocytes. The prevalent lesions found were epithelial hyperplasia, atrophy, PeIN, basal cell vacuolization, lamina propria sclerosis, and variable patterns of lymphocytic infiltration. Various unique patterns of stromal sclerosis were described: perivascular, globular, linear, and solid fibrosis/hyalinization; any of them were found to be diagnostic for LS. The variation in the topography and density of lymphocytes was determinant for the identification of LS morphological variants: lichenoid, band-like, lymphocytic depleted, and mixed. A major finding was the identification of the variant designated as lymphocytic depleted LS, which we considered as the morphological prototype of LS associated with penile neoplasia. The detailed description of this complex lesion presented in this study may help pathologists in practice to identify and better define LS. The identification of the special variants suggests a role of the stromal lymphocytes in the process of carcinogenesis. Confirmation of the observations with more studies is necessary to determine the significance of these findings.

Anogenital lichen sclerosus

Lichen sclerosus (LS) was first described by Hallopeau in 1887. It is a chronic inflammatory condition most commonly involving the anogenital region with a relapsing course and a potential for destruction, functional impairment, atrophy, and malignant changes. LS affects both sexes with a female preponderance of 5:1. The exact prevalence of the disease is difficult to predict as the lesions are asymptomatic in the initial phase and later when the complications arise patients might visit the surgeon, pediatrician, gynecologist, or urologist. The etiology of LS has a complex interplay of genetic factors, autoimmunity, infections, and trauma. Physical examination to assess the extent of the disease and decide the line of management is the most crucial step in the management. Corticosteroids, calcineurin inhibitor, retinoids, phototherapy, and surgery can be helpful. Self-examination and long-term follow-up are necessary.

Long-term topical corticosteroid use and risk of skin cancer: a systematic review

OBJECTIVE

The objective of this systematic review was to synthesize available research evidence to determine the risk of skin cancer in patients with long-term use of topical corticosteroids (TCS).

INTRODUCTION

Topical corticosteroids are one of the most commonly prescribed medicines in dermatology and the mainstay of the treatment of atopic dermatitis and other skin conditions such as psoriasis. They are often required for months or years to control the disease and ultimately restore patients' quality of life. In some patients, TCS may have a local immunosuppressive effect and theoretically increase the risk of skin cancer, whilst on the other hand TCS may decrease the risk of skin cancer in patients where TCS are used to treat inflammatory skin disease. To date, no systematic review has been performed to collate evidence on the effect of long-term TCS use on the risk of skin cancer.

INCLUSION CRITERIA

This review considered studies that included people of all ages, genders and ethnicities, including HIV and transplant participants or participants with genetic diseases (for example, Gorlin-Goltz syndrome) This review considered studies that evaluated long-term use of topical corticosteroids. "Long-term" was defined as using TCS more than once a week for a month or longer. The review included cohort, cross-sectional and case-control observational studies exploring the association between the stated intervention and outcomes. The primary outcome measures of interest were: non-melanoma skin cancer (keratinocyte carcinoma), cutaneous squamous cell carcinoma (cSSC), basal cell carcinoma (BCC) or melanoma skin cancer. Genital and oral skin cancers are considered to be slightly different so we did not include them in this review.

METHODS

We performed a comprehensive search of MEDLINE, Embase and LILACS on November 9, 2017 to identify observational epidemiological studies assessing the association between long-term TCS use and skin cancer. We also searched EThOS at the British Library and three drug safety databases to identify unpublished work. The titles, abstracts and full text identified from the search were assessed independently by two authors against pre-specified inclusion/exclusion criteria. Methodological quality was not assessed as no articles were found which met the inclusion criteria. Data extraction was not possible as no articles were found which met the inclusion criteria. It was not possible to complete data synthesis as no articles were found which met the inclusion criteria.

RESULTS

A total of 1703 potentially relevant studies were identified following a comprehensive electronic search. After abstract and title screening, 51 full texts were assessed for eligibility criteria. Of these, no study met the inclusion criteria. No additional records were identified from searching unpublished literature.

CONCLUSIONS

We did not find any studies that could help us establish if long-term TCS use is associated with skin cancer. Future research using primary care databases might give a better understanding regarding long-term use of TCS and skin cancer.