Lichen Sclerosus et Atrophicus in Males: How to Diagnose, How to Manage...

Lichen sclerosus et atrophicus (LSA) is a disease that frequently involves the genital area of both females and males. Diagnosis is usually made on a clinical basis and confirmed by histology even if the typical histopathological pattern is not always present. LSA has been linked to the development of squamous cell cancer (SCC) in males and females with a risk of about 5%.

Dr. Kantere and colleagues (p. 542–546) publish in this issue of Acta Dermato-Venereologica an interesting retrospective study describing the clinical spectrum of LSA in 771 male patients observed in a 10-year period. They also include the results of a questionnaire sent to all patients.

The very large study provides some interesting insights in the field of LSA.

• • Histology seems to be helpful for the diagnosis of LSA. In 240 out of 273 patients who underwent biopsy, the histological pattern was compatible with the clinical diagnosis (88%). The prevalence of penile cancer in the study was high when compared to the incidence of penile cancer in the general population. In our department we strongly encourage biopsy for diagnosis of LSA in adults; in a series of 20 histology confirmed LSA in 2013 we found moderate or severe dysplasia in 3.
• • Both glans penis and prepuce were involved in about half of the patients with LSA and another 40% had only preputial involvement. LSA in other areas seemed to be rare in males in contrast to the situation in women. There is no mention in the paper about the presence of micro-incontinence that has been suggested as strongly associated to male genital LSA in a recent article pub­lished in Acta Dermato-Venereologica (Bunker CB, et al 2013; 93: 246–247) It would have been of interest to have this information also in the large series of patients studied by Kantere et al. (p. 542–546).
• • An important part of the study deals with the results of a questionnaire sent to the patients asking about e.g. symptoms of LSA, circumcision (yes/no), impact on sexual health and number of medical visits for LSA. It is quite clear that LSA aggravates the sexual health of the patients affecting libido, erectile function or ability to ejaculate.
• • Potent steroidal cream is the first line therapy for LSA. The study confirms the efficacy of the treatment. Surprisingly only 4 patients had experience of treatment with tacrolimus ointment. In our department we use topical tacrolimus as a maintenance therapy after initial clobetasol treatment; my impression is that tacrolimus is effective in maintaining a good clinical response with very few, if any side effects. Despite the alleged onchogenic risk of the product we did not observe at the moment any case of penile cancer in patients treated with the drug.
• • The study also confirms the weak association of male LSA with autoimmune diseases; this may reinforce the hypothesis of micro-incontinence as a possible cause of male LSA.

The possibility to observe large series of patients and the information obtained by the questionnaire makes the paper very interesting with a potential major impact on every day practice for dermatovenereologists treating male patients with LSA.

Marco Cusini

Section Editor