Balanitis Xerotica Obliterans



Lichen sclerosus is a chronic, progressive, sclerosing inflammatory dermatosis of unclear etiology. Most reported lichen sclerosus cases (83%) involve the genitalia. In men, this genital involvement has traditionally been known as balanitis xerotica obliterans (BXO). A more accurate term is male genital or penile lichen sclerosus. The image below shows the condition.

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Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.

Yardley et al[1] believe that the prevalence of BXO is greater than previous series have shown and that it may manifest in children at an earlier age than previous series have shown. This belief is based on a study of 422 boys at a median age of 6 years 2 months (range, 3 mo to 16 y), of whom 186 (44.1%) received treatment involving surgery (148 circumcision, 33 preputial adhesiolysis, 5 frenuloplasty). Of the 186 boys, 110 had histological tissue examination; 84.8% of skin samples were pathologic. Specifically, tissue showed chronic inflammation (n = 69; 46.6%), BXO (n = 51; 34.5%), and fibrosis (n = 4; 2.7%).

Related Medscape Reference articles include Lichen Sclerosus et Atrophicus, Balanitis Circumscripta Plasmacellularis, and Balanitis in Emergency Medicine.


The etiology of male genital lichen sclerosus is unknown, but it is thought to be multifactorial. Balanitis xerotica obliterans (BXO) has occurred in monozygotic twins, which suggests a genetic basis for the disease in some cases. Human papillomavirus type 6 or type 16 has not been detected in patients with BXO, which strongly suggests that genital papillomaviruses do not have a strong association with BXO.



United States

Kizer et al[2] noted that of 153,432 male patients discharged from Brooke Army Medical Center, 108 (0.070%) had a diagnosis of balanitis xerotica obliterans (BXO). The age distribution was similar over a range of 2-90 years, with the exception of the third decade, when the incidence almost doubled. Black and Hispanic patients had twice the rate found in white patients (10.59 cases, 10.67 cases, and 5.07 cases per 10,000 patients, respectively).


The prevalence of male genital lichen sclerosus (balanitis xerotica obliterans [BXO]) has traditionally been estimated at 1 case per 300-1000 males. No recent studies confirm this estimate, but male genital lichen sclerosus is not considered a rare condition. Huntley et al[3] reported on 100 consecutive patients seen in pediatric urology clinics who were followed to discharge. Eighteen referrals for circumcision were for religious reasons. Of the other 82 patients, the main reason for referral was retractability or phimosis. Six patients were identified as having BXO, a condition that had not been suggested on referral. Epidemiological data continue to show that BXO can effect boys.[4, 5] Some in Italy claim that the incidence of BXO has been understated.[6]

In Austria, 75 boys younger than 10 years were treated for phimosis; phimosis grade 2 or 3 (schema by Kikiros) was suspected of being BXO. Boys were given either circumcision or conservative therapy with circumcision secondarily (only if therapy did not yield good results in the conservative group). A pathologist examined every circumcision specimen. Doctor performed circumcision primarily in 29 boys and secondarily in 17 boys (mean age, 3.7 y; range, 1-10 y). The pathologist found BXO, chronic inflammation, and normal histological results in 8 (17.4%), 26 (56.5%), and 12 (26.1%) of patients, respectively. The average follow up was approximately 8 months. Doctors did not report recurrences. BXO appeared to be more common than previously reported. The clinical appearance can be confusing in boys, and preoperative BXO suspicion failed to correlate with the final biopsy results.[7]


Male genital lichen sclerosus (balanitis xerotica obliterans [BXO]) has no known predilection for any racial or ethnic group.


Male genital lichen sclerosus (balanitis xerotica obliterans [BXO]) occurs most frequently in persons who are uncircumcised and who are of middle age. One study[8] revealed that 51 (98%) of 52 patients clinically diagnosed with penile lichen sclerosus were uncircumcised.


Although males with genital lichen sclerosus (balanitis xerotica obliterans [BXO]) are most frequently of middle age, the condition also may appear in children, ranging from young boys to adolescents. The incidence of BXO in pediatric patients is higher than most physicians realize. Additionally, the incidence of BXO is high in boys with phimosis.[9, 10, 11]


Early in its course, penile lichen sclerosus (balanitis xerotica obliterans [BXO]) is relatively asymptomatic with only mild visually observable changes of the penis and glans. Physical changes occur over months or years and may include color or textural changes. Early symptoms are more prevalent in uncircumcised patients.

Symptoms occurring with time and progression of penile lichen sclerosus are as follows:

Symptoms occurring in late penile lichen sclerosus (in uncircumcised patients) are as follows:

The development of multifocal squamous cell carcinoma (SCC) in persons with lichen sclerosus et atrophicus of the penis and hepatitis C virus infection has been reported. SCC of the penis arising from BXO alone has also been noted.

A urethral stone manifesting as a stop valve, a rare complication of BXO, has been reported.

In older patients, BXO with phimosis can be a cause of difficulty with urination; thus, older patients should be examined to see if they have BXO in they have symptoms of difficulty with urination.[12]


Early penile lichen sclerosus (balanitis xerotica obliterans [BXO]) demonstrates only subtle physical findings (eg, mild, nonspecific erythema; mild hypopigmentation).

As the condition progresses, single or multiple discrete erythematous papules or macules progress and coalesce into atrophic ivory, white, or purple-white patches or plaques. Lesions most commonly affect the glans and prepuce. The frenulum, urethral meatus, fossa navicularis, penile shaft, and perianal areas may become involved. A sclerotic white ring at the tip of the prepuce is diagnostic at this stage. Erosions, fissures, petechiae, serous and hemorrhagic bullae, and telangiectasias of the glans have been reported, albeit uncommonly.

With further disease progression, the glans may become adherent to the prepuce. The coronal sulcus and frenulum may be sclerotically destroyed. The urethral meatus may narrow to the point of urinary retention. Urinary retention may be severe enough to cause retrograde damage to the posterior urethra and to the bladder and kidneys. Significant urethral meatal narrowing has led to sloughing of the distal half centimeter of the urethra. Phimosis and paraphimosis of uncircumcised patients may occur at this late stage.

Seventeen percent of lichen sclerosus cases are extragenital, beginning as mild, nonspecific erythema with mild hypopigmentation.

In one case report[13] , BXO in a middle-aged man involved the entire anterior urethra and the scrotum. It manifested as a palpable nodular scrotal mass and caused obstructive voiding symptoms. He was treated with a staged urethroplasty.


The etiology of male genital lichen sclerosus (balanitis xerotica obliterans [BXO]) is unknown but is thought to be multifactorial. Several contributing factors are possible, as described below.

Circumcision after age 13 years/uncircumcised state

This may very well be due to the effect known as the isomorphic, or Koebner, phenomenon. The large majority of inflammatory dermatoses of the male genitalia, including lichen sclerosus, occur in uncircumcised or late-circumcised men.

The presence of a foreskin may promote chronic irritation or serve to maintain a friendly environment for an as-yet unidentified infectious agent. Such chronic irritation and subsequent inflammation may initiate the changes noted in lichen sclerosus.

Hormonal factors

Hormonal influences in the development of lichen sclerosus have long been postulated, mainly in female vulvar lichen sclerosus.

Most studies have concentrated on the role of testosterone in the pathogenesis of vulvar lichen sclerosus. Childhood vulvar lichen sclerosus frequently resolves with the onset of menarche and the related pubertal increase in testosterone production in genital skin; additionally, adults with lichen sclerosus have been found to have decreased serum levels of free testosterone, androstenedione, and dihydrotestosterone compared with control subjects.

The underlying defect may be a problem with the function of the enzyme 5-alpha reductase.

Autoimmune disease

Various autoantibodies (including antinuclear, thyroid antimicrosomal, antigastric parietal cell, anti-adrenal cortex, antismooth muscle, and antimitochondrial antibodies) have been detected in patients with lichen sclerosus.

Vitiligo, thyroid disease, diabetes, and alopecia areata have also been commonly reported in association with lichen sclerosus.

Genetic factors [14]

Lichen sclerosus (not necessarily genital lichen sclerosus) has been reported in families, including twins (identical and nonidentical), sisters, mothers and daughters, and a brother and sister. Note, however, that no consistent pattern of genetic inheritance has been identified.

Presence of human papillomaviruses

The presence of human papillomaviruses (HPV) has been reported in some cases of childhood penile lichen sclerosus. Whether the lichen sclerosus is directly attributable to HPV infection, or if lichen sclerosus merely promotes HPV infection is unclear.

Patients with penile lichen sclerosus alone have not been demonstrated to have a higher incidence of HPV infection.


In a study of 18 patients[15] with combined buccal mucosa grafting and genital skin flap reconstruction of extensive anterior urethral strictures, 16.7% of stricture cases were caused by BXO.

Laboratory Studies

A rapid protein reagin test helps exclude syphilis.


Skin biopsy aids in the diagnosis of male genital lichen sclerosus (balanitis xerotica obliterans [BXO]).

Histologic Findings

Histopathologic changes of genital lichen sclerosus are similar to those of nongenital lichen sclerosus.

Epidermal findings include orthokeratosis, hyperkeratosis with follicular plugging, hyperkeratosis without follicular plugging, stratum malpighii atrophy, basal layer hydropic degeneration, and dermoepidermal clefting (in some cases).

Follicular plugging is not apparent in mucosal BXO. Significant dermal edema and homogenization of the collagen in the upper dermis occurs, with dilatation of blood and lymph vessels and a loss of elastic fibers.

The immune cells moving into areas of BXO include lymphocytes, plasma cells, and histiocytes in the mid dermis. The inflammatory infiltrate is less pronounced in long-standing lesions.

Lester and Swick in 2014 studied 66 biopsies of BXO,[17] 30 from females and 36 from males. Nine were extragenital and 57 were genital. Spongiosis was noted in 14, epidermal hyperplasia in 28, and squamous cell carcinoma in 7. Early/transitional lichen sclerosis was noted in 35, with epidermal basement membrane thickening (97%), hyperplasia (57%), and epidermotropism of lymphocytes (97%). Eosinophils occurred in 35 specimens (53%) contained eosinophils (23 early/transitional lichen sclerosis). Increased eosinophils were in men (P  = .074), and squamous cell carcinoma (P  =0.014) was predictive of eosinophil number. The researchers concluded that epidermotropism of lymphocytes, epidermal hyperplasia, and basement membrane thickening were useful features in pointing out early lichen sclerosis. Eosinophils commonly occurred in lichen sclerosis and were most common in genital male eruptions and in lichensclerosis associated with squamous cell carcinoma.

Medical Care

No consistently effective treatment has been developed for penile lichen sclerosus (balanitis xerotica obliterans [BXO]); however, the therapies described below have varying degrees of reported success.

Topical and intralesional steroids have been used. Topical steroids can offer a reliable option only in the management of mild BXO limited to the prepuce in boys with minimal scar formation. Patients and their families must have realistic expectations with regard to the success of such treatments. Steroid-based creams are ineffective in persons with established scarring. Studies have shown that applying a potent topical steroid improves BXO in the histologically early and intermediate stages of disease and may inhibit further worsening in the late stages. Kiss[18] questioned the utility of topical steroid-based creams for the treatment of clinical BXO. Differences in success rates may relate to an unwillingness to use superpotent corticosteroids.

Ghysel et al reported on successful therapy with topical steroid application and skin stretching on prepubertal boys with unretractable foreskin and phimosis.[19]

Successful treatment of BXO with topical tacrolimus has been reported.

Etretinate therapy has been used, but it is no longer available; acitretin is the current equivalent.

Carbon dioxide laser treatment has been used.[20]

An interesting report notes the successful use of intralesional adalimumab, a medication for psoriasis among other things, for BXO.[21]

Ebert et al,[22] in a retrospective analysis of 13 children with BXO published in 2007, reported that the relapse rate was lower after topical tacrolimus therapy than with betamethasone therapy.

In a case series of 3 patients, 2 had softening of the skin and pruritus, tenderness, and inflammatory change resolution within 3 weeks of receiving oral and intramuscular penicillin. Dirithromycin at 500 mg/d abated BXO in a third patient; the BXO returned when dirithromycin was discontinued but it improved again upon resumption of therapy.

Further treatment, or treatment of circumcised patients, is more challenging.

Intraurethral steroids provide efficacious therapy for stricture disease in patients with biopsy-proven BXO before invasive surgery.[23]

Surgical Care

A variety of surgical techniques can be used to treat more severe penile lichen sclerosus (balanitis xerotica obliterans [BXO]).

Uncircumcised patients usually benefit from therapeutic circumcision. Provide regular follow-up care to observe any changes in involved areas suggestive of malignancy.

Foreskin preputioplasty combined with intralesional triamcinolone might be a tenable alternative as against circumcision to treat BXO.[24]

Consider surgical intervention for symptoms or signs of urethral meatal stenosis. Buccal mucosal graft (BMG) for BXO-induced urethral stricture can work.[25]

Dubey et al[26] report that in BXO-related strictures with a viable urethral plate, 1-stage dorsal onlay buccal mucosal urethroplasty achieves superb medium-term results. They also state that the intervention created a normal, wide-caliber, slitlike glans, and a 2-stage procedure provides effective treatment but is associated with a higher revision rate.

Full-thickness skin grafts from eyelids to penis, plus split-thickness grafts in chronic BXO have been reported.

Buccal mucosa appears to be a durable source of nongenital tissue for urethral replacement. Attention to detail in terms of graft harvest, graft preparation, and graft fixation helps to avoid major postoperative complications. Onlay grafts appear to be preferable to tube grafts, and patients with a diagnosis of BXO do not appear to be candidates for the 1-stage urethral reconstruction using buccal mucosa.

Circumferential laser vaporization for severe meatal stenosis secondary to BXO reportedly is effective.

In 2007, Levine et al[27] reported on buccal mucosa graft urethroplasty for anterior urethral stricture repair. They evaluated the impact of stricture location and lichen sclerosus on surgical outcome. When lichen sclerosus affects the penis, complete excision of the diseased urethra with multistage repair decreases the rate of stricture recurrence associated with a 1-stage repair.

Palminteri et al[28] treated 17 patients, performing y resurfacing or reconstruction of the glans penis for benign, premalignant, and malignant penile lesions (5 glans skinning and resurfacing; 5 glans amputation and reconstruction of the neoglans, and 7 partial penile amputation and reconstruction of the neoglans). Four patients had lichen sclerosus. Glans resurfacing and reconstruction were performed with the use of a skin graft harvested from the thigh. Patients who received glans resurfacing reported glandular sensory restoration and complete sexual ability. Patients receiving glansectomy or partial penectomy with neoglans reconstruction maintained sexual function and activity, albeit with reduced sensitivity secondary to glans/penile amputation. Palminteri et al concluded that glans resurfacing or reconstruction can ensure a normal-appearing and functional penis, without jeopardizing cancer control.

A review published in 2013 found that BXO likely is more common than believed, and, while circumcision is its primary treatment, topical or intralesional treatments can be co-adjuvants of treatment.[29]

Simsek et al in 2014 performed circular buccal mucosal urethroplasty in 15 males for BXO related to anterior urethral strictures.[30] Urethral catheter removal occurred within 2 weeks, and, during subsequent visits, cosmetic outcome, symptoms assessment, and uroflowmetry over 20.5 months (range, 4-96 mo) were measured. The 15 men manifested no recurrent stricture, a normal meatus, and no chordee or erectile dysfunction. Excellent functional and cosmetic results were achieved in all 15 patients. They concluded that for surgical treatment of meatal strictures, a circular mucosal graft technique restores a functional and cosmetic penis.


Consider consultation with urologists for the following:


In some cases of male genital lichen sclerosus, painful erections may limit sexual function.

Medication Summary

Topical steroids, especially superpotent topical steroids, are the mainstay of medical therapy. Zavras et al reported successful treatment of 1079 (91.1%) of 1185 boys with a diagnosis of phimosis using fluticasone propionate 0.05%, including boys with mild balanitis xerotica obliterans (BXO).[31]

Topical testosterone is mostly ineffective and is not discussed further. Etretinate has been used with limited success but is no longer available for prescription in the United States.

Clobetasol (Temovate)

Clinical Context:  Clobetasol is a class I superpotent topical steroid; it suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction. Clobetasol is used in most studies dealing with treatment of lichen sclerosus.

Class Summary

Topical corticosteroids help reduce inflammatory lesions and may reduce or resolve lesions.

Tacrolimus ointment 0.1% or 0.03% (Protopic)

Clinical Context:  The mechanism of action for tacrolimus ointment in atopic dermatitis is not known. It reduces itching and inflammation by suppressing the release of cytokines from T cells. It also inhibits transcription for genes that encode IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in early stages of T-cell activation. Additionally, tacrolimus ointment may inhibit the release of preformed mediators from skin mast cells and basophils and may down-regulate expression of FCeRI on Langerhans cells. It can be used in patients aged 2 years or older. It is more expensive than topical corticosteroids. It is available as ointment in concentrations of 0.03 and 0.1%. Tacrolimus ointment is indicated only after other treatment options have failed.

Class Summary

Topical calcineurin inhibitors are immune suppressants that block early T-cell activation, degranulation of mast cells, and multiple cytokines.

Further Outpatient Care

Provide regular follow-up care to observe any changes in involved areas suggestive of malignancy.

Consider surgical intervention for symptoms or signs of urethral meatal stenosis.

Patients can be taught to dilate the urethral meatus at home if the penile lichen sclerosus (balanitis xerotica obliterans [BXO]) involves the meatus; this sometimes is useful.


Early circumcision may decrease the risk of developing male genital lichen sclerosus (balanitis xerotica obliterans BXO]); nearly all cases have been reported in uncircumcised patients.


As the disease progresses, urinary retention may be sufficient to lead to retrograde damage to the posterior urethra, bladder, and kidneys.

As previously noted, painful erections in some cases of male genital lichen sclerosus may limit sexual function.

Malignancies have been reported to occur in penile lesions (rare). Common signs and symptoms of penile malignancy include nodule or tumor growth, ulceration, blistering, hematuria, erythema, pain, purulent discharge, bleeding, lymphadenopathy, and failure to respond to treatment for presumptive inflammatory or infectious balanitis. For this reason, close follow-up care is indicated in order to quickly diagnose any malignant changes.

Long-standing penile lichen sclerosus (balanitis xerotica obliterans [BXO]) resulting in renal impairment in a child that lead to a persistent but improved renal impairment after circumcision has been noted.[32]


Male genital lichen sclerosus is chronic and often progressive. Regression or improvement of atrophic areas is unexpected.

Malignancies have been reported to arise in penile lichen sclerosus lesions (rare); most common cancers are squamous cell carcinoma (SCC),[33] adenosquamous carcinoma, and verrucous carcinoma. A study of 86 uncircumcised men with genital lichen sclerosus revealed malignant changes (3 SCC, 1 SCC in situ, and 1 verrucous carcinoma) occurring in 5 (5.8%) subjects. The average time between diagnosis of lichen sclerosus and subsequent diagnosis of penile malignancy was 17 years.[34] Notably, 4 of the 5 patients with malignant changes were found by polymerase chain reaction to have evidence of HPV-16 in their tissue specimens. It has been suggested that lichen sclerosus may promote HPV infection and perhaps the development of SCC.[35]


Noah S Scheinfeld, JD, MD, FAAD, Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.

Specialty Editors

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD, † Former Associate Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

Additional Contributors

Mark W Cobb, MD, Consulting Staff, WNC Dermatological Associates

Disclosure: Nothing to disclose.


George C Keough, MD Chief, Clinical Assistant Professor, Department of Medicine, Dermatology Service, Eisenhower Army Medical Center

George C Keough, MD is a member of the following medical societies: American Academy of Dermatology and American Medical Association

Disclosure: Nothing to disclose.

Daniel S Lehman, MD Fellow in Minimally Invasive Urology/Oncology, Department of Urology, Columbia University Medical Center

Disclosure: Nothing to disclose.


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Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.

Balanitis xerotica obliterans (lichen sclerosus). Courtesy of Wilford Hall Medical Center Slide collection.