I am very grateful to Prof. Mirastschijski and her colleagues for pointing out the specific problems and risk of recurrence of lichen sclerosus despite total circumcision in patients with buried penis. They attribute these complications to an unfavorable microenvironment. The moist milieu under the foreskin, together with obesity and any penile anomalies such as hypospadias, seems to promote lichen sclerosus in the presence of a genetic predisposition (1).
Lichen sclerosus is an inflammatory dermatosis of uncertain etiology that can lead to scar formation and local carcinomas. The evidence on treatment of men is sparse: one randomized study demonstrated the successful treatment with potent topical corticosteroids in boys (2). No prospective randomized trials including circumcision have been carried out. Factors triggering lichen sclerosus in the presence of a genetic predisposition include high body mass index, mechanical stimuli such as frequent retraction of the foreskin, and local infections (3). Good epidemiological studies on this topic are lacking. In women, thorough anti-inflammatory treatment minimizes scar formation and vulval cancer risk (4). It can therefore be assumed that also in men, progression of lichen sclerosus can be avoided by early, thorough, and persistent anti-inflammatory treatment with potent topical corticosteroids, possibly preventing urethral involvement requiring highly complex urological interventions. We need well-controlled studies on treatment, long-term effects, and possible triggers of lichen sclerosus. It needs to be investigated whether anti-inflammatory treatment with potent topical corticosteroids for 3 months can achieve sustained remission in boys and men. Treatment with topical corticosteroids to suppress inflammation may also reduce the risk of recurrences after surgical interventions. In case the attempt of treatment with steroids is not successful, total circumcision may be an option; long-term follow-up is recommended and should be documented. As mentioned in my article, an interdisciplinary approach involving dermatologists, gynecologists, and experienced surgeons or urologists familiar with the disease is desirable (5).
Dr. Gudula Kirtschig
Institute for General Medicine and Interprofessional Care
Faculty of Medicine, University of Tübingen, firstname.lastname@example.org
Conflict of interest statement
Dr. Kirtschig has received payment from Dr. August Wolff GmbH & Co for giving a lecture on lichen sclerosus, together with reimbursement of the associated congress attendance fees and travel costs.
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|3.||Kirtschig G, Cooper S, Aberer W et al.: Evidence-based (S3) guideline on |
(anogenital) Lichen sclerosus. J Eur Acad Dermatol Venereol 2015; 29: e1–43 CrossRef MEDLINE
|4.||Lee A, Bradford J, Fischer G: Long-term management of adult vulvar Lichen sclerosus: A prospective cohort study of 507 women. JAMA Dermatol 2015; 151: 1061–7 CrossRef MEDLINE|
|5.||Kirtschig G: Lichen sclerosus—presentation, diagnosis and management. Dtsch Arztebl Int 2016; 113: 337–4 VOLLTEXT|