Conservative Management of Penile and Urethral Lichen Sclerosus: A Systematic Review

PURPOSE

We evaluate the efficacy and safety profiles of currently available conservative management options for penile and urethral lichen sclerosus.

MATERIALS AND METHODS

A systematic review of existing literature on lichen sclerosus was conducted utilizing the PubMed, Embase, and Web of Science databases. References were assessed for relevance to nonsurgical management of male genital lichen sclerosus by title and abstract by 3 independent reviewers, then reviewed in full and in duplicate by 5 independent reviewers.

RESULTS

Seventeen studies describing conservative management of histologically confirmed penile and urethral lichen sclerosus in male patients were included in the final review. We present available evidence supporting the use of 4 major treatment modalities represented in the existing literature: topical corticosteroids, tacrolimus, platelet-rich plasma, and CO2 laser. We also briefly discuss the limited studies on the use of oral acitretin and polydeoxyribonucleotide injections. Outcomes assessed include symptoms, clinical appearance, quality of life, sexual satisfaction, adverse effects, and long-term efficacy of treatment.

CONCLUSIONS

Topical corticosteroids remain the mainstay of conservative management of penile and urethral lichen sclerosus, with current literature supporting the use of other therapies such as tacrolimus and platelet-rich plasma as alternatives or adjuvant treatments when escalation of treatment is necessary. Future research should further explore the efficacy and safety of newer therapies through additional controlled clinical trials in the targeted population.

Lichen Sclerosus of the Labial Mucosa: A Case Report and Literature Review

Lichen sclerosus (LS) is an uncommon, chronic, inflammatory mucocutaneous disorder found predominantly in females with unknown etiology. It presents as a white sclerotic plaque commonly located on the anogenital area. Extragenital LS is less prevalent, and LS affecting the oral mucosa is extremely rare, with only 39 biopsy-confirmed cases reported in the literature. Due to its several mimicking conditions, histological examination is usually required for a definitive diagnosis, particularly in patients with oral LS. Current evidence-based treatment recommendations for oral LS are unavailable; however, most cases tend to improve after treatment with topical or intralesional corticosteroids. We report a case of a 58-year-old female referred from the otolaryngology department for evaluating an asymptomatic whitish sclerotic plaque on the lower lip mucosa that had existed for 1 year. Following a punch biopsy, the patient was diagnosed with LS of labial mucosa. The condition improved after 2 months of treatment with topical and intralesional corticosteroids. The present case report raises awareness in recognizing oral LS and contributes to knowledge of this rare disorder.

Coexistence of Lichen Sclerosus Et Atrophicus and Morphea in the Same Lesion: A Case Report

Lichen sclerosus et atrophicus (LSA) is an inflammatory dermatosis of unknown etiology, usually affecting the genital region, with extragenital involvement being uncommon. The coexistence of LSA and morphea in the same lesion is rare. The present study aims to demonstrate that LSA and morphea might share similar pathologic processes. We present a case of a 53-year-old female patient with extragenital lesions with clinical appearance and histopathological features of both LSA and morphea. Finally, the two diseases might lie on the same disease spectrum.

Dermatoses in Postmenopausal Women in a Tertiary Health Care Center of Bihar: A Prospective Cross-Sectional Study

Background Postmenopausal women comprise a very unique population with various dermatological, genital, and oral dermatoses due to the various physiological, age-related, and hormonal changes in this period, which have not yet been studied extensively, especially in India. Aims and objectives The aim of the study was to study the various epidemiological and clinical patterns of postmenopausal dermatosis. Material and methods We conducted a single-center observational cross-sectional study on 223 postmenopausal women attending the dermatology outpatient department (OPD) with various dermatological concerns to understand the various clinical patterns and presentations of postmenopausal dermatoses. Women were interviewed face to face using a pre-designed, pre-tested questionnaire. A detailed history followed by general physical, systemic, and cutaneous examination was done, along with investigations wherever needed. Results A total of 223 postmenopausal women were enrolled in our study, with a mean age group of 58.4 ± 5.1 years. The mean age of menopause in our study was 48.7 ± 3.8 years. In our study, 186 (83.4%) women had cutaneous dermatosis, 65 (29.1%) had genital dermatosis, 23 (10.3%) had oral mucosa involvement, 75 (33.6%) had hair disorders, and 58 (26%) had nail disorders. Limitation The limitation of our study is that it is a single-center study, and women with active HIV or hepatitis infection or known malignancy were excluded from the study. Conclusion A broader understanding of the diverse dermatological concerns of postmenopausal women would enable dermatologists to be better equipped to identify and treat postmenopausal dermatosis as well as provide better support to women going through this phase of life.

Genital and Extragenital Lichen Sclerosus et Atrophicus: A Case Series Written Using ChatGPT

Background Lichen sclerosus et atrophicus (LSEA) is a chronic inflammatory dermatosis of genital and extragenital sites with a prevalence ranging from 9% in prepubertal patients to 50% in postmenopausal patients. Chat generative pre-trained transformer (ChatGPT) is an artificial intelligence tool designed to assist humans based on supervised and reinforcement techniques. In this study, we aimed to evaluate the characteristics of patients with LSEA using ChatGPT. Methods In this retrospective study, we included all patients who presented to the outpatient dermatology department during 2017-2022 at a tertiary care teaching hospital in South India. Information regarding demographic data, characteristics of LSEA, comorbidities, and associated autoimmune disorders was gathered using a medical chart review. Following data analysis and drafting of the manuscript, the utility of ChatGPT-3 and ChatGPT-4 in finalizing the draft was assessed. Results Of 20 patients diagnosed with LSEA, 16 (80%) and four (20%) patients were females and males, respectively. Of them, 50% of female patients had attained menopause. While 65% of patients had genital LSEA, 30% of patients had extragenital LSEA only, and 5% of patients had both genital and extragenital LSEA. Furthermore, four (20%) patients were prepubertal children. Of four male patients, two (50%) were younger than 18 years of age, and one patient was diagnosed with balanitis xerotica obliterans. The commonest associated features in LSEA included joint involvement (30%), hypertension (25%), and anemia (15%). Rare concomitant disorders included psoriasis, asthma, and basal cell carcinoma over the nose. Conclusions LSEA may be confused with other various dermatoses, such as morphea, vitiligo, and lichen planus. A high index of suspicion is required, especially in children, to diagnose it early and intervene to prevent further complications. Its relationship with autoimmune disorders and comorbidities warrants further large-scale studies. ChatGPT was unreliable in the literature search due to the provision of non-existent citations. ChatGPT-4 was better than ChatGPT-3 since it provided few true publications. ChatGPT was used in this study to summarize the articles identified by the authors during the literature search and to correct grammatical errors in the final draft of the manuscript.

Tumor necrosis factor-α inhibitor-induced morphea and psoriasiform dermatitis in a pediatric patient with Crohn's disease

Tumor necrosis factor-alpha inhibitor therapy for inflammatory bowel disease may be associated with paradoxical cutaneous adverse events, most commonly psoriasiform eruptions. We present the case of a pediatric female patient with Crohn's disease who developed multiple concurrent cutaneous eruptions while on infliximab treatment, including morphea, psoriasiform dermatitis, and genital lichen sclerosus. Although refractory to skin-directed treatments, all three conditions resolved upon discontinuation of infliximab, supporting their development as a paradoxical reaction to infliximab therapy.

Extragenital lichen sclerosus: A comprehensive review

Lichen sclerosus (LS) is a chronic inflammatory mucocutaneous disease of unknown aetiology. About 85% of total cases of LS are genital cases, while extragenital form is seen in only 15-20% of cases. Extragenital LS (EGLS) can occur simultaneously with genital form; however, in 6% of the cases, only extragenital form has been described. Genetic, autoimmune, infectious, environmental and hormonal factors are implicated in its aetiology. Extragenital LS presents as asymptomatic white opalescent papules, which cluster in plaques and slowly progress over time resulting in parchment-like skin usually involving upper trunk, neck and shoulders. Lesions are frequently accompanied by purpura/haemorrhagic spots. The relationship with morphoea has been a topic of debate. Association with several autoimmune diseases has been observed. Diagnosis is usually based on clinical and dermoscopic examination and further supported by histopathological findings. LS needs to be differentiated from several other dermatological conditions such as discoid lupus erythematosus, vitiligo, mycosis fungoides (hypopigmented variant), lichen planus, graft-versus-host disease and morphoea depending upon the stage of the disease. Generally, extragenital LS is believed to lack carcinogenic potential. However, case reports with possible malignant transformation have been described. In this article, the authors have described a concise review of the extragenital form of LS.

One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysis

PURPOSE

Performing 1-stage urethroplasty in patients with urethral strictures caused by lichen sclerosus (LS) is hotly debated among reconstructive urologists due to conflicting reports of success. Therefore, the objective of this study was to determine the pooled incidence of stricture recurrence following 1-stage buccal mucosal graft (BMG) urethroplasty in patients with LS, to determine the impact of surgical technique on recurrence and to compare recurrence risk between patients with and without LS after 1-stage repairs.

MATERIALS AND METHODS

A systematic review was conducted in accordance with PRISMA criteria. The primary outcome was pooled incidence of recurrence, which was calculated using a Der-Simonian-Laird binary random effects model with a Freeman-Tukey arcsine transformation. A total of 21 studies were included, of which 15 provided data for comparative analyses.

RESULTS

Pooled data from 625 LS patients revealed a stricture recurrence rate of 10% (95% CI 6-14). Among studies with longer followup (≥24 months), this increased to 18%. Among patients with penile urethral involvement, studies utilizing a penile skin incision had significantly higher pooled recurrence rates than those utilizing penile invagination (p=0.004). Across all studies, there was no evidence to suggest a difference in pooled recurrence rate between patients with and without LS (p=0.36). However, across only long-term studies, recurrence risk was significantly higher for patients with LS (OR 1.83, p=0.05).

CONCLUSIONS

One-stage BMG urethroplasty is likely a viable surgical option for patients with LS-related strictures; however, high-quality data are limited. Future multi-institutional, long-term prospective studies are needed to assess durability of 1-stage repair.

Creation of a pioneering interdisciplinary genital dermatology unit for Hispanic men: First 269 patients

The role of circumcision in partially protecting against sexually transmitted infections (STIs) and other dermatoses has been documented. Neonatal circumcision is not routinely practiced in South America. Although it is logical to assume that male genital dermatoses are more prevalent in Hispanic men, they are underrepresented in the existing literature. Objective: To describe the epidemiological characteristics from our male genital dermatology unit in Montevideo (Uruguay), the diagnoses, and correlate them with circumcision status and comorbidities. Methods: A retrospective observational cohort study was conducted. A dermatologist and urologist evaluated all patients using standard questionnaires. In 3 years and 8 months, 269 patients were seen. Median age was 41, prevalence of neonatal circumcision was 0.7%, HIV was 4.2%, STIs were 24.9%, non-STIs were 63.9%, and both (STI + non-STI) were 11.2%. Most frequent entities: eczema/balanoposthitis (27.1%), condyloma (24.9%), and lichen sclerosus (15.6%). Data correlating circumcision and other diagnoses did not reach statistical significance. HIV was positively associated with other STIs (p < 0.05), and an association with balanoposthitis was seen; however, it did not reach statistical significance (p < 0.1). Main limitation was small sample size. This is the first study of its kind based on Hispanic patients. Collaboration between specialties proved to be fundamental. Further studies are needed in this demographic to find an association between circumcision, comorbidities, and genital dermatoses.

Dermatoscopic Features of Pigmentary Diseases in Ethnic Skin

Dermatoscopy is a non-invasive, handy tool, which is increasingly being used in diagnosis and prognostication of pigmentary dermatoses. Dermatoscopic changes in pigmentary pattern, scaling, and vasculature help us to differentiate among the myriad of hypo and hyper pigmentary diseases. This review gives a brief overview of the dermatoscopic features of pigmentary diseases, which are commonly encountered in clinical practice. We also provide a diagnostic approach based on salient dermatoscopic features.

Medical Management of Penile and Urethral Lichen Sclerosus with Topical Clobetasol Improves Long-Term Voiding Symptoms and Quality of Life

PURPOSE

We evaluated the success of minimally invasive management of lichen sclerosus with topical and intraurethral clobetasol, as defined by improvement in patient reported outcome measures and nonprogression to surgery.

MATERIALS AND METHODS

We conducted a review of our prospective ongoing quality improvement study to determine outcomes of our current standard practice for males with penile and urethral biopsy proven lichen sclerosus. Data were collected between 2011 and 2019, and included patient demographic information, medical and surgical histories, and location and extent of lichen sclerosus related pathology. The primary outcomes for this study were voiding function and voiding related quality of life, and were assessed using the AUASS (American Urological Association Symptom Score) and quality of life bother index, respectively.

RESULTS

We identified 42 patients with biopsy proven lichen sclerosus related urethral stricture disease. Of these patients 85.7% were treated with intraurethral steroids alone and did not require surgical intervention. Median AUASS significantly improved from 12 to 8, and median quality of life bother index improved from 4 ("mostly dissatisfied") to 2 ("mostly satisfied"). Average stricture length of those with penile urethral disease and bulbar urethral disease was 4.8 cm (SD 3.0) and 16.2 cm (SD 6.5), respectively. Median followup was 8.4 months (IQR 2.6-26.4).

CONCLUSIONS

Lichen sclerosus related urethral stricture disease can be effectively managed with intraurethral steroids. This minimally invasive management strategy improves patient reported voiding symptoms and voiding quality of life.

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.

Acrosyringeal variant of extragenital lichen sclerosus et atrophicus

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory dermatosis of the anogenital area, and approximately 15% to 20% of patients with LSA have extragenital lesions. Here, we report the case of an 18-year-old Korean man presenting with multiple asymptomatic punctated hypopigmented atrophic macules on the dorsa of both feet. Dermoscopic examination revealed hypopigmented atrophic macules with several central keratotic plugs. The histopathologic findings indicated LSA but were confined to the acrosyringium. Based on the clinical and histopathological findings, the patient was diagnosed with an acrosyringeal variant of extragenital LSA. The patient in this case showed a unique histopathological finding in which the typical features of LSA were confined to the acrosyringium, as well as an unusual clinical presentation of non-coalescing atrophic punctate macules on the dorsum of the feet.

Lichen sclerosus et atrophicus and allergic contact dermatitis: A significant association

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease of unknown etiology. It mainly affects the anogenital area, while the extragenital involvement is uncommon. It manifests as pale, ivory-colored lesions and partially atrophic skin. We report a case of a woman presenting to our department with LSA lesions at the level of the armpit. Furthermore, the patient was allergic to nickel sulfate and balsam of Peru. We assume the presence of an association between nickel allergy and onset of LSA.

Diagnosis and treatment of oral lichen sclerosus in a pediatric patient

Lichen sclerosus is an uncommon chronic inflammatory disease, which rarely affects the oral mucosa. Here, we describe the occurrence of oral lichen sclerosus with gingival destruction in a 12-year-old female patient. After diagnostic confirmation by histopathology, intralesional injection of corticosteroid was performed, producing satisfactory remission of the lesion.

Protein Expression Profiles among Lichen Sclerosus Urethral Strictures-Can Urethroplasty Success be Predicted?

PURPOSE

Urethroplasty of lichen sclerosus strictures has a significantly higher failure rate than strictures due to other causes. We sought to determine predictors of urethroplasty failure in men with lichen sclerosus urethral stricture disease by evaluating protein expression profiles.

MATERIALS AND METHODS

Urethral tissue was excised from patients with lichen sclerosus who were undergoing urethroplasty of urethral stricture disease at a single institution. A tissue microarray was created with cores from each sample. Immunohistochemistry was performed to compare protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. Stricture recurrence was defined by the need for a subsequent unanticipated procedure for urethral stricture disease.

RESULTS

We evaluated 50 men with lichen sclerosus urethral stricture disease, including 31 with successful reconstruction and 19 with recurrent stricture. Recurrent strictures expressed lower levels of several inflammatory markers and had a lower Ki-67 mitotic index and significantly higher vascular endothelial growth factor levels than nonrecurrent strictures.

CONCLUSIONS

To our knowledge this is the first study to use tissue protein expression to identify risk factors for urethroplasty failure among men with lichen sclerosus urethral stricture disease. Our findings suggest that recurrent lichen sclerosus strictures demonstrate a suppressed inflammatory response, a decreased cell turnover rate, and poor oxygenation and nutrient delivery. Prospective studies are needed to clarify the role of these pathways in the pathophysiology of lichen sclerosus urethral stricture disease, determine whether preoperative biopsy can predict urethroplasty success, help counsel patients and develop future treatments.

Lichen sclerosus of the oral mucosa: clinical and histopathological findings. Review of the literature and a case report

OBJECTIVES

Lichen sclerosus (LS) is a rare, chronic mucocutaneous disease that most frequently affects the female genital area. Oral manifestations are seldom detected; only 36 well-documented and histopathologically verified oral LS cases have been published.

MATERIALS AND METHODS

Here we describe one patient affected by oral (LS) and review of the literature 1957-2017.

RESULTS

Findings in our review suggest a female to male ratio of 1.64:1. It is most commonly diagnosed at the age of 10-29 years (46%). Oral LS can appear as symptomless, irregular-shaped, porcelain-white and flat lesions situated asymmetrically. Lesion is commonly sole, well-demarcated area and its size varies from 2 mm (small macula) to 7 cm (large plaque). The most common sites in the oral cavity include the labial mucosa, lips and gingiva. The histopathological criteria include atrophy and sometimes hyperkeratosis of the epithelium, hydropic degeneration of basal cells, hyalinization of the lamina propria, lymphocyte infiltration beneath the zone of hyalinization and scantiness of elastin. Surgical excision is an effective treatment for small lesions; intralesional triamcinolone or corticosteroid injections are used for larger lesions.

CONCLUSIONS

Oral LS may be under-recognized due to its asymptomatic nature and rarity.

Intermediate-Term Outcomes and Complications of Long Segment Urethroplasty with Lingual Mucosa Grafts

PURPOSE

We evaluated outcomes and donor site complications in male patients with complex urethral strictures who underwent urethroplasty using with long strip oral mucosal grafts. We also analyzed whether a lingual mucosa graft is a good substitute for repairing long segment urethral strictures.

MATERIALS AND METHODS

This retrospective study was done in 81 male patients with complex urethral strictures who underwent oral mucosal graft urethroplasty. Patients with long segment (8 cm or greater) anterior urethral strictures who were considered candidates for long strip lingual mucosa graft urethroplasty were included in study.

RESULTS

Oral mucosal graft urethroplasty was performed in 81 patients with complex urethral strictures between August 2006 and December 2014. Mean urethral stricture length was 12.1 cm (range 8 to 20). A single 9 to 12 cm long strip lingual mucosa graft was used in 52 patients, a lingual mucosa graft greater than 12 cm was placed in 17 and a lingual mucosa graft combined with a buccal mucosal graft was used in 12. Mean followup was 41 months (range 15 to 86) postoperatively. The overall urethroplasty success rate was 82.7%. Urethral complications developed in 14 patients (17.3%), including urethral strictures in 10 and urethrocutaneous fistulas in 4. At 12 months 5 patients (6.2%) reported minimal difficulty with fine motor movement of the tongue.

CONCLUSIONS

Lingual mucosa harvested from the ventrolateral surface of the tongue can provide a wide and long graft that is an excellent urethral substitute. Donor site complications are primarily limited to postoperative year 1. Our study confirms that the lingual mucosa graft is a good substitute for urethral reconstruction and lingual mucosa graft urethroplasty is a valuable procedure to treat long anterior urethral strictures.

Vulvar Lichen Sclerosus et Atrophicus

Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis characterized by ivory-white plaques or patches with glistening surface commonly affecting the vulva and anus. Common symptoms are irritation, soreness, dyspareunia, dysuria, and urinary or fecal incontinence. Anogenital lichen sclerosus (LS) is characterized by porcelain-white atrophic plaques, which may become confluent extending around the vulval and perianal skin in a figure of eight configuration. Thinning and shrinkage of the genital area make coitus, urination, and defecation painful. LS is not uncommon in India and present as an itchy vulvar dermatosis which a gynecologist may mistake for candidal vulvovaginitis. There is often a delay in diagnosis of VLS due to its asymptomatic nature and lack of awareness in patients as well as physicians. Embarrassment of patients due to private nature of the disease and failure to examine the genital skin properly are the other reasons for delay in diagnosis. There is no curative treatment for LS. Various medications available only relieve the symptoms. Chronic nature of the disease affects the quality of life. Proper and regular follow-up is required as there are chances of the development of squamous cell carcinoma.

Urethral Reconstruction with Rectal Mucosa Graft Onlay: A Novel, Minimally Invasive Technique

PURPOSE

Alternative grafts are needed for patients who are not suitable candidates for oral mucosa graft harvest or who have a paucity of oral mucosa graft available for reconstruction. Circumferential colonic mucosal grafts have demonstrated feasibility for urethral reconstruction, although sigmoid resection has been required for graft retrieval. We report the feasibility and short-term outcomes of urethral reconstruction using a rectal mucosa graft harvested by a novel, minimally invasive, transanal endoscopic microsurgical technique.

MATERIALS AND METHODS

We retrospectively reviewed the records of all patients who underwent transanal endoscopic microsurgical rectal mucosa graft harvest and onlay urethroplasty since the technique was first implemented in 2013. Graft failure was defined as inability to pass a 16Fr cystoscope in the grafted urethra.

RESULTS

All 4 strictures were bulbopendulous with a median length of 13.5 cm (range 10 to 21). Median followup was 18 months (range 12 to 28). Stricture etiology was lichen sclerosus in 3 patients and failed hypospadias interventions in 1. Three patients had undergone at least 1 prior urethroplasty. In 1 patient stricture recurred in the graft 10 months following reconstruction. There were no colorectal complications.

CONCLUSIONS

To our knowledge this is the first study demonstrating urethral reconstruction using a rectal mucosa graft harvested by the transanal endoscopic microsurgical technique. Initial data revealed that this technique is feasible and safe, and minimizes graft harvest morbidity. Transanal endoscopic microsurgical harvest of a rectal mucosa graft may provide an alternative graft material for patients with long segment urethral strictures who are not candidates for oral mucosa graft harvest. Further experience and longer followup are needed to validate these findings.

Understanding the Relationship between Chronic Systemic Disease and Lichen Sclerosus Urethral Strictures

PURPOSE

Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral stricture disease. In this study we determine systemic comorbidities associated with lichen sclerosus in men.

MATERIALS AND METHODS

We analyzed data from 1,151 men who were enrolled in a multi-institutional prospective urethroplasty outcomes database. Individuals were grouped by stricture etiology, and baseline demographics, medical histories and patient reported outcome measures were retrospectively compared across groups.

RESULTS

Of the 1,151 men in the database 81 (7.0%) were noted to have lichen sclerosus related urethral stricture disease. Average patient age was 46.06 ± 16.52 years, with those with lichen sclerosus being significantly older than those without lichen sclerosus (51.26 ± 13.84 vs 45.68 ± 16.64, p = 0.0011). Men with lichen sclerosus were more likely to have hypertension, hyperlipidemia and diabetes, and to use tobacco products. Controlling for age, men with lichen sclerosus related urethral stricture disease had a higher body mass index (aOR 1.089, 95% CI 1.050-1.130), and were more likely to have hypertension (aOR 2.028, 1.21-3.41) and be active tobacco users (aOR 2.0, 1.36-3.40). Mean preoperative patient reported outcome measures scores for urinary and sexual function were similar. Controlling for stricture length and location, the adjusted odds of surgical failure were higher for lichen sclerosus related urethral stricture disease (aOR 1.9, 95% CI 0.9-4.2).

CONCLUSIONS

Lichen sclerosus related urethral stricture disease is associated with chronic systemic diseases. This association may implicate a systemic inflammatory and/or autoimmune pathophysiology. A 2-hit mechanism implicating local and systemic factors for lichen sclerosus related urethral stricture disease development and progression is hypothesized.

Intraurethral Steroids are a Safe and Effective Treatment for Stricture Disease in Patients with Biopsy Proven Lichen Sclerosus

PURPOSE

We investigated outcomes of the contemporary practice of administering intraurethral steroids to treat stricture disease in patients with biopsy proven lichen sclerosus.

MATERIALS AND METHODS

We performed an institutional review board approved review of the records of patients with biopsy proven lichen sclerosus stricture disease from October 2010 to September 2015. Study inclusion criteria were age 18 years or greater and male gender. Extracted data included patient demographics, comorbidities, location of lichen sclerosus, previous therapies and need for further interventions. Management was considered successful when there was no need for subsequent escalation of therapy. The intraurethral steroid regimen consisted of applying clobetasol cream to the affected urethra to lubricate a calibration device such as a urinary catheter or meatal dilator. The initial phase of therapy included twice daily application for 2 to 3 months, at which point the frequency was decreased by the clinician, enabling the patient to titrate medication use as needed.

RESULTS

We identified 40 patients with biopsy proven lichen sclerosus who had urethral stricture as part of the disease state. Of these patients 28 received the intraurethral steroid regimen and success was achieved in 25 (89%). Mean followup was 24.8 months. No patient who was started on the intraurethral steroid regimen proceeded to urethroplasty.

CONCLUSIONS

Based on our outcomes we have developed a stepwise treatment algorithm for patients with biopsy proven lichen sclerosus stricture disease that uses intraurethral steroids before initiating plans for invasive surgery.

Lichen Sclerosus Comorbidities and Complications from a National Sample of Patients Treated with Urethroplasty

INTRODUCTION

We characterize comorbidities and inpatient complications of patients with lichen sclerosus who underwent urethroplasty from a large national patient data source.

METHODS

We queried the Nationwide Inpatient Sample for patients who underwent urethroplasty between 2000 and 2010. We compared demographics, comorbidities, complications, length of hospital stay and hospital charges for patients with and without the diagnosis of lichen sclerosus.

RESULTS

An estimated 13,700 urethroplasties were performed in the United States during the study period. Patients with lichen sclerosus comprised an estimated 3.8% of the urethroplasty population. The majority of patients with urethral stricture with lichen sclerosus were Caucasian (84%) and older, with 63% age 45 or older. Chronic hypertension, diabetes mellitus, rheumatoid arthritis/collagen vascular disease and obesity were associated with increased odds of having a lichen sclerosus diagnosis. The central East Coast (7.2%) and the Pacific Northwest (6.3%) had the highest percentage of patients treated with urethroplasty with lichen sclerosus. Patients with lichen sclerosus had longer hospital stays than those without lichen sclerosus (3.5 vs 2.6 days, p <0.0001). Patients with lichen sclerosus had more complications and hospital charges than those without lichen sclerosus but these differences did not reach statistical significance.

CONCLUSIONS

A higher percentage of patients with lichen sclerosus had comorbidities, increased complications and longer hospital stays compared to patients treated with urethroplasty without lichen sclerosus. Our findings demonstrate the increased complexity that providers face when treating men with lichen sclerosus related urethral stricture disease.

Extragenital lichen sclerosus et atrophicus along the lines of Blaschko

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory dermatosis of unknown etiology. Extragenital involvement is uncommon and commonly affects the neck, shoulders, and upper portion of the trunk. It is predominant in women with a male-to-female ratio of 1:6 and occurs at any age. Linear pattern along the lines of Blaschko are seen. There is no cure for LSA. Topical corticosteroids and calcineurin inhibitors, such as tacrolimus, pimecrolimus, PUVA antimalarial agents, and topical retinoids have been tried with varying results. A case of a 33-year-old man with LSA over right lower limb along the lines of Blasckho is reported here.

A Case of Lichen Sclerosus et Atrophicus With Distinct Erythematous Borders

BACKGROUND

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory and fibrosing condition that mostly affects the genital mucosa. Nongenital skin may be affected either in isolation or in association with genital involvement. A distinct, brightly red border may be seen but is poorly documented in major dermatology texts. In the case presented, such a border was noted in all of the patient's very extensive lesions.

OBJECTIVE

To draw attention to this clinical manifestation and to stimulate future observations as to its clinical and prognostic significance.

METHODS AND RESULTS

A 67-year-old woman presented with disseminated LSA with genital involvement. All the lesions had a distinct red border. A review of major textbooks available to the authors revealed that the presence of a marginal erythema is regularly not mentioned.

CONCLUSION

An erythematous border to LSA may be a notable feature. Its frequency and clinical significance remain to be determined.

The co-occurrence of lichen sclerosus et atrophicus and celiac disease

A 53-year-old female patient was admitted to our clinic for generalized hypo/hyper-pigmented, partially firm and sclerotic plaques with undefined borders. As the skin biopsy taken from the lesion was compatible with lichen sclerosus et atrophicus (LSA), the patient was treated with ultraviolet A1 (UVA1) treatment. Upon follow-up, she developed abdominal pain and diarrhea. Further investigation (including endoscopic and laboratory tests) showed signs consistent with celiac disease. After 30 sessions of UVA1 treatment, the skin lesions partially regressed. We present this case because the co-occurrence of LSA and celiac disease is very rare.

Meatal stenosis in boys following circumcision for lichen sclerosus (balanitis xerotica obliterans)

PURPOSE

Of boys circumcised for penile lichen sclerosus, ie balanitis xerotica obliterans, 7% to 19% require late surgery for meatal stenosis. We review the management and outcomes of boys circumcised for lichen sclerosus.

MATERIALS AND METHODS

Medical records of boys with clinical lichen sclerosus were reviewed for the period 2000 to 2010. Patients were excluded from the study if the foreskin was not submitted for histopathological analysis, circumcision was not performed at the center during the study period or medical records were unavailable. Data were compared by Fisher exact test and univariate analysis.

RESULTS

Of 300 circumcised boys lichen sclerosus was confirmed in 250. A total of 50 patients had nonlichen sclerosus histology. Mean age was 9.0 years (range 4 to 16) in patients with lichen sclerosus and 8.3 years (2 to 15) in those with nonlichen sclerosus histology. Boys with lichen sclerosus were more likely to have the meatus described as abnormal (57 vs 4) and to have undergone a meatal procedure at circumcision (55 vs 2) or a meatal operation at a later date (49 vs 3, all p <0.05). Boys with lichen sclerosus requiring later meatal procedures (meatal dilation in 25, meatotomy in 24) rarely underwent a meatal procedure at circumcision (4 of 49) and were less likely to have received preoperative topical steroids than boys not needing a later meatal procedure (2 of 49 vs 49 of 151, p <0.05).

CONCLUSIONS

After circumcision for lichen sclerosus up to 1 in 5 boys requires a subsequent operation for meatal pathology. Pre-circumcision topical steroids may help decrease the rate of later meatal pathology. Submission of the foreskin for histological analysis should always be considered, as prognosis differs for lichen sclerosus vs nonlichen sclerosus histology. We recommend a care pathway for boys with lichen sclerosus.

Lichen sclerosus and isolated bulbar urethral stricture disease

PURPOSE

Lichen sclerosus is a chronic inflammatory genital skin condition that can cause destructive urethral scarring. To our knowledge no prior study has described lichen sclerosus in isolated bulbar urethral stricture segments without progressive disease originating from the penile urethra. We report the incidence of lichen sclerosus in isolated bulbar urethral stricture segments.

MATERIALS AND METHODS

We retrospectively reviewed the records of 70 patients after urethroplasty for isolated bulbar stricture disease was performed from 2007 to 2013. Stricture specimens were re-reviewed by a single uropathologist. Cases were evaluated using common histological features of lichen sclerosus, including hyperkeratosis or epithelial atrophy, basal cell vacuolar degeneration, lichenoid lymphocytic infiltrate and superepithelial sclerosis.

RESULTS

Average patient age was 46.5 years (range 19 to 77) and average stricture length was 3.5 cm (range 1 to 7). Of the patients 51 (73.0%) underwent excision and primary anastomosis, and 19 (27.1%) underwent buccal mucosal onlay. In 6 patients (8.6%) stricture recurred during a median followup of 22 months (IQR 14, 44). Three of those patients had lichen sclerosus. Initial pathology assessment revealed lichen sclerosus in 5 patients (7.1%, 95% CI 1.0-13.3). On re-review of specimens using pathology criteria specific to lichen sclerosus 31 patients (44.3%, 95% CI 32.4-56.2) showed pathology findings highly suggestive of (13) or diagnostic for (18) lichen sclerosus (p = 0.0001). On pathological re-review lichen sclerosus was associated with recurrent stricture.

CONCLUSIONS

On re-review of surgical specimens we noted a significant incidence of lichen sclerosus in isolated bulbar strictures in men undergoing urethroplasty. The incidence of lichen sclerosus may be higher than reported in isolated bulbar urethral segments without evidence of distal to proximal progressive urethral disease.