In Reply

Petersen assumes a prevalence of 1% in women; this underlines the importance of the disease. We have nothing to add to his additional remarks from a gynecologist’s perspective. In all patients, early diagnosis means a wider therapeutic scope and improves the prognosis.

The treatment of LS in boys usually falls under the remit of a pediatric surgeon or pediatric urologist since phimosis—the lead symptom—is usually the reason for the referral, rather than the skin disease that would be referred to a dermatologist. Attempts have been made to show that genital LS in children, masked by phimosis, is notably more common that is widely assumed. There is no reliable proof as to whether it is more common in boys or in adult men.

Kemmler qualifies the recommendation for surgery to apply to only cases with non-retractable phimosis. Among the 225 cases we examined, we found only one boy whose lichenoid changes had not yet resulted in irretractable phimosis. This patient represented one of the few cases that we managed to cure successfully by means of conservative treatment.

The question whether circumcision is curative in boys with LS has been the subject of discussion for a long time. Presumably it depends on the duration and dynamics of the process before treatment is started. Ebert cites the study reported by Meuli, who observed only 10 cases of lichen (1). Authors with larger patient cohorts have reported much higher cure rates. Kiss, for example, found in 471 circumcised LS patients 231 with glandular lesions, of which only two did not heal spontaneously (2). Depasquale similarly reported that 276 (92%) of 287 cases of glandular involvement were cured by means of circumcision alone (3).

Our experiences mirror those of Kiss and Depasquale and show that in a scenario of accurate diagnosis and early therapy lesions persisted in only few cases. We treat these topically, similarly to our colleagues in Regensburg, using a combination of highly potent corticoids and calcineurin inhibitors. On the basis of our own data we do not think that general topical aftercare is indicated and do not share the views of Neill et al in this respect (4). We explicitly pointed out that for the selection of protracted cases—in addition to the follow-up examination of boys four months after surgery mentioned earlier—long-term observation is required.

The “buried penis” represents a complex problem that requires a highly individualized therapeutic approach rather than a prescriptive therapeutic plan. The long term result in our patients was positive in every respect.

In sum, we wish to point out once again that an interdisciplinary German guideline for lichen sclerosus is overdue.

DOI: 10.3238/arztebl.2011.0695

Dr. med. Karl Becker

Kinderchirurgische Praxis, Bonn

drkarlbecker@aol.com

Conflict of interest statement
The author declares that no conflict of interest exists.