What is the treatment for lichen sclerosis of the penis?

Treatment of Penile Lichen Sclerosus

First-line treatment for penile lichen sclerosus is topical clobetasol propionate 0.05% ointment applied once daily for 2-3 months, with gradual dose reduction; if medical therapy fails or urethral stricture develops, circumcision is curative in 96% of cases when disease is limited to the foreskin and glans. 1, 2

Initial Medical Management

Topical Corticosteroid Therapy

• Apply clobetasol propionate 0.05% ointment once daily for 2-3 months as the gold standard first-line treatment 1, 2
• After the initial 2-3 month period, gradually taper the dose to zero if symptoms resolve 1
• For patients with ongoing disease after initial treatment, maintenance therapy typically requires 30-60g of clobetasol propionate 0.05% ointment annually 1, 2
• Mometasone furoate 0.05% is an alternative potent corticosteroid that has shown efficacy, though clobetasol remains preferred 1, 3

Critical Pre-Treatment Step

• Always obtain a biopsy before initiating treatment to confirm lichen sclerosus and rule out squamous cell carcinoma or penile intraepithelial neoplasia 1, 2
• This is non-negotiable given the malignant transformation risk associated with lichen sclerosus 1, 4

Expected Outcomes with Medical Therapy

• Approximately 50-53% of patients achieve complete symptom resolution with topical corticosteroids alone 4
• Hyperkeratosis, ecchymoses, fissuring, and erosions should resolve, though atrophy and scarring will persist 1
• About 60% of patients experience complete remission of symptoms with appropriate steroid use 1

Surgical Management Algorithm

When to Proceed to Surgery

Circumcision is indicated when:

• No response to ultrapotent topical steroids after 1-3 months of adequate trial 2
• Disease limited to foreskin and glans without urethral involvement 1
• Persistent phimosis despite medical therapy 1
• Preputial adhesions that persist despite adequate medical treatment 1

Circumcision Success Rates and Technique

• 96% success rate when lichen sclerosus is confined to the glans and foreskin 1, 2
• The desiccating effect of circumcision allows mild glans disease to revert to normal within months 1
• Critical pitfall: Recurrence is common when residual moist skin folds are left or unavoidable (such as in obese patients) 1, 2
• All tissue removed at circumcision must be sent for pathological examination to confirm diagnosis and exclude malignancy 1, 2

Management of Urethral Complications

For meatal stenosis:

• Ventral meatotomy or dorsal V-meatoplasty can be performed 1
• Extended meatoplasty with creation of a hypospadiac meatus has 87% success in complex cases 1
• Simple meatotomy can be followed by restenosis, so interposition techniques are preferred 1

For urethral stricture disease:

• Short, distal strictures: Circumcision plus relief of distal obstruction, potentially with staged urethroplasty using nongenital tissue 1
• Long or multifocal strictures: Staged urethroplasty using buccal mucosa or other nongenital tissue grafts 1
• Critical principle: Never use genital skin for reconstruction - genital skin grafts have a 90% stricture recurrence rate, while nongenital tissue (buccal mucosa, bladder mucosa) has near-zero recurrence 1

Two-Stage Urethroplasty Technique

• First stage: Excise urethral plate, open glans fully, graft buccal mucosa to tunica albuginea 1
• Second stage: Urethral tubularization performed 6-12 months later 1
• This approach is necessary because the urethral plate is often unusable in lichen sclerosus 1

Perineal Urethrostomy Option

• Consider for patients with extensive disease who are poor surgical candidates or unwilling to undergo complex reconstruction 1
• Use flap-based technique (not puncture technique) to avoid restenosis in lichen sclerosus patients 1
• In one series, 8 of 19 patients elected to keep functional perineal urethrostomy rather than complete reconstruction and were satisfied 1

Alternative and Adjunctive Therapies

Second-Line Medical Options

• Topical calcineurin inhibitors (pimecrolimus) are less effective than clobetasol propionate but may be used in steroid-refractory cases 3, 5
• Intralesional triamcinolone (10-20mg) for hyperkeratotic areas resistant to topical steroids, only after biopsy excludes neoplasia 2
• Topical testosterone, dihydrotestosterone, and progesterone have no proven efficacy and may worsen symptoms 1, 3

Therapies to Avoid

• Hormonal treatments (testosterone, progesterone) are ineffective and potentially harmful 1, 3
• Genital skin flaps for urethral reconstruction have 100% failure rate 1
• Routine urethral dilation is outdated and not recommended 1

Long-Term Follow-Up Requirements

Malignancy Surveillance

• Lichen sclerosus carries increased risk of squamous cell carcinoma development 1, 6
• Long-term follow-up is mandatory due to malignant transformation risk 1
• Any new lesions, ulcerations, or areas of disease reactivation require immediate biopsy 1

Monitoring for Recurrence

• Restricturing after urethroplasty usually occurs in first 2-3 years but can occur up to 10 years later 1
• Patients require ongoing surveillance even after successful treatment 1, 4
• Most patients with ongoing disease require 30-60g of clobetasol propionate annually for maintenance 1, 2

Common Pitfalls to Avoid

• Do not proceed directly to circumcision without adequate trial of topical steroids - many patients are unnecessarily referred for surgery 2
• Do not use genital skin for any reconstructive procedures - 90% recurrence rate versus near-zero with nongenital tissue 1
• Do not skip pathological examination of circumcision specimens - this is essential for diagnosis confirmation and cancer exclusion 1, 2
• Do not leave residual moist skin folds during circumcision - this leads to recurrence 1, 2
• Do not assume all foreskin fibrosis is simple phimosis - always consider lichen sclerosus, which has different long-term implications 2

Stepwise Treatment Approach

1. Confirm diagnosis with biopsy to exclude malignancy 1, 2
2. Initiate clobetasol propionate 0.05% once daily for 2-3 months 1, 2
3. If symptoms resolve: Gradually taper dose to maintenance or zero 1
4. If no response after 1-3 months: Proceed to circumcision if disease limited to foreskin/glans 2
5. If urethral involvement: Staged reconstruction with nongenital tissue grafts 1
6. Send all surgical specimens for pathology 1, 2
7. Lifelong surveillance for recurrence and malignancy 1, 4