BXO (male genital lichen sclerosus): symptoms, treatment and surgery

Balanitis xerotica obliterans, usually shortened to BXO, was the traditional name for lichen sclerosus when it involves the male genitals. The British Association of Dermatologists (BAD) now uses male genital lichen sclerosus and lists balanitis xerotica obliterans as the older term. The condition can occur anywhere on the skin but, in men, is mostly seen on the foreskin and glans.

The cause is not fully understood. The NHS says it might be caused by the immune system mistakenly attacking the skin. The BAD says it almost never occurs in men who were circumcised early in life, that it may be linked in some men to autoimmune disease such as thyroid disease or diabetes and to atopic conditions such as eczema, asthma and hay fever, and that it does not usually run in families.

The BAD says affected skin can feel uncomfortable, itchy, burning or sore, particularly during or after sex. The foreskin often gets tighter and harder to retract, which can make erections painful, and the skin may tear and bleed during intercourse. If the urethral opening at the tip is affected, the urine stream may spray. Some men have no symptoms at all.

Early on the skin can look red with small cracks, sores, bleeding points or blood blisters. After longer inflammation it can turn white and thin, and sometimes thickened. Scarring may change the appearance of the foreskin or glans, and a tightened foreskin may draw in around the shaft like a band, which the BAD calls waisting. The NHS describes white, smooth or crinkled patches that are easily damaged and may bleed if rubbed or scratched.

• White, thin or crinkled patches on the foreskin or glans.

• A foreskin that has become tight, or that cannot be pulled back to clean the tip.

• Painful erections, splitting or bleeding with sex.

• A narrowed urethral opening, a change in urine stream or difficulty passing urine.

The BAD says the diagnosis is often made by a dermatologist looking at the affected skin. A small skin sample (biopsy) may be taken, under local anaesthetic and sometimes with stitches, to confirm the diagnosis, especially if there is an open sore or a thickened area. NICE CKS lists suspected lichen sclerosus as a reason to refer someone with balanitis to a specialist. The NHS says a GP may refer you to a specialist for tests and treatment.

The BAD says strong steroid ointments such as clobetasol propionate and diflucortolone valerate are used to stop inflammation and soften skin. It notes that product packs may carry a warning against genital use, and that these ointments are very safe in this condition when applied as the dermatologist directs. After the first treatment period a maintenance plan may use moisturisers and weaker steroid creams intermittently. Tacrolimus and pimecrolimus ointments are not usually first-line.

The NHS says you may need to use the ointment regularly for a few months to get symptoms under control, and that lichen sclerosus cannot be cured. When the foreskin becomes too tight to function and creams do not soften it, the BAD says referral to a urologist for circumcision or other surgery may be necessary, and that this may cure the condition even on the shaft and tip. If the urethral opening narrows, the urologist may suggest stretching it, steroid ointment and, failing that, surgery.

Rubbing or damage to the skin can trigger or worsen the condition; the BAD calls this the Koebner response and says it is sometimes seen after surgery. That is one reason the skin is reviewed after an operation rather than assumed to be settled.

• Wash with an emollient soap substitute instead of soap; the BAD advises against aqueous cream, which can irritate some men.

• Dab dry carefully after passing urine, and use a barrier such as yellow soft paraffin.

• Keep pubic hair trimmed so it does not get trapped between the foreskin and penis.

• Use lubricant for sex to reduce friction. The NHS also advises avoiding tight underwear and not scratching or rubbing the skin.

• Stop smoking; the BAD says this reduces the risk of penile cancer.

• Take care near naked flames if you use emollients, because they can make fabrics catch fire more easily.

The NHS says lichen sclerosus increases the risk of cancer on the penis, vulva or anus, that the risk is low, and that it is sensible to check yourself regularly. It lists a lump, a change in skin texture such as thickening, and an ulcer that does not go away as things to look for. The BAD says any skin change that does not respond to steroid cream, particularly persistent thickening or soreness, should be reported without delay, as a biopsy may be needed. It also says that although circumcision may reduce the risk, it does not absolutely prevent penile cancer.

See a GP if you have an itchy white patch on the genitals, if treatment is not helping, or if there is pain when passing urine or during sex. A foreskin that cannot be pulled back over the glans after retraction needs emergency care; the NHS says to call 999 or go to A&E.