What is lichen sclerosus?
Lichen sclerosus is a long-term inflammatory skin disease. In boys it most often affects the foreskin and the head of the penis (glans). This form is called balanitis xerotica obliterans, or BXO for short. It is not painful, but over time it leaves scars in the skin.
The scar narrows the tip of the foreskin, and the foreskin can no longer be pulled back. This is called scarred or pathological phimosis. In young children a foreskin that does not retract is usually normal (phimosis), whereas lichen sclerosus is a separate disease that needs treatment.
In children it usually shows up at school age, on average around 8 years.
Signs
- a white, firm, scarred ring at the tip of the foreskin,
- a foreskin that used to retract stops retracting,
- the skin loses its stretch and is sometimes itchy,
- white patches on the glans or around the urinary opening,
- difficulty peeing, a thin or spraying urine stream.
Why treat it in time?
Lichen sclerosus causes scarring. Without treatment the narrowing gets worse and urine flow can be affected. If the disease spreads to the urinary opening, meatal stenosis can develop.
Never force the foreskin back: this causes new tears and more scarring.
Diagnosis
The doctor often suspects the disease from how it looks. But it is not always possible to tell ordinary scarred phimosis from lichen sclerosus by appearance alone. The definite diagnosis comes from examining the skin removed at circumcision under the microscope (histology). This result guides how follow-up is planned.
Treatment
- Circumcision is the main treatment. The European Association of Urology (EAU) recommends offering circumcision for lichen sclerosus and for phimosis that does not respond to treatment. More: circumcision.
- Corticosteroid cream can help in all types of phimosis, but it works less well in scarred phimosis. It is sometimes used as an extra treatment before or after circumcision, as prescribed by the doctor.
- A dermatologist may also be involved when needed.
What happens after circumcision?
In boys with lichen sclerosus, narrowing of the urinary opening after circumcision is more common: about 1 in 5, compared with about 6 in 100 boys circumcised for phimosis without the disease. So:
- watch his urine stream: if it becomes thin or sprays, or he has to strain, tell the doctor,
- come to follow-up visits even if there are no complaints,
- if a narrowing develops, the urinary opening is widened with a small operation (meatoplasty).
This disease needs long-term follow-up, so stay in touch with the doctor after circumcision too.
When to seek urgent care
If any of the following is present, do not wait for a routine appointment: call the doctor or go to the nearest emergency department.
- He cannot pee or urine only dribbles out, and the lower belly is swollen and painful
- Redness and pus at the tip of the penis with a fever
Call your local emergency number (112 in Europe, 911 in North America)
Note for pediatricians and family doctors
Balanitis xerotica obliterans (BXO) is a non-painful chronic inflammatory disease that can involve the glans, foreskin, meatus and urethra; it is the genital form of lichen sclerosus et atrophicus. Histological analysis of prepuces from children and adolescents undergoing circumcision shows signs of BXO in 35–53%, and in 17% of boys younger than ten years. BXO is a special form of pathological phimosis; it remains a histopathological diagnosis and clinical distinction from simple pathological phimosis may be difficult, so histopathology of the resected foreskin is warranted. Response to corticosteroids may be lower in pathological phimosis. EAU strongly recommends offering circumcision in BXO and in phimosis refractory to treatment, and informing families about the risk of meatal stenosis. Post-circumcision meatal stenosis occurs in 20% of boys with confirmed BXO versus 6% of boys circumcised for phimosis without BXO; prolonged follow-up is warranted and may involve a dermatologist. Mean age at presentation in boys is about 8 years; a later risk of carcinoma has also been described.
What happens at the visit?
- The foreskin, glans and urinary opening are examined carefully, and we ask about the urine stream.
- If scarred phimosis is suspected, treatment options, including circumcision and its timing, are discussed with the parents.
- The removed skin is sent for histology, and follow-up of the urinary opening is planned afterwards.
Frequently asked questions
How is this different from ordinary phimosis?
In young children a foreskin that does not retract is usually normal, and the skin is soft and stretchy. In lichen sclerosus the tip of the skin turns white, firm and scarred. A foreskin that used to retract stops retracting. The doctor tells the difference on examination.
Does circumcision cure it completely?
Circumcision is the main treatment, but the disease can also affect the glans and the urinary opening. In these boys, narrowing of the urinary opening after circumcision is more common, so please come to the follow-up visits your doctor arranges.
Is it contagious?
No. It is not an infection but a chronic inflammatory skin disease, and it does not spread to others.
Related topics
- Phimosis Tight foreskin Condition
- Meatal stenosis Narrowing of the urinary opening after circumcision Condition
- Circumcision Circumcision surgery, cosmetic circumcision Treatment
- Meatoplasty Meatotomy, surgery for meatal stenosis Treatment
- Balanoposthitis Redness and swelling of the tip of the penis Condition
- Paraphimosis Constricting foreskin Condition
Sources
- EAU Guidelines on Paediatric Urology, 2026: Phimosis and other abnormalities of the penile skin.
- Nguyen ATM, Holland AJA. Balanitis xerotica obliterans: an update for clinicians. Eur J Pediatr, 2020.
- Celis S et al. Balanitis xerotica obliterans in children and adolescents: a literature review and clinical series. J Pediatr Urol, 2014.
This information is for educational purposes and does not replace medical advice. Decisions about your child’s treatment are made with the doctor after an examination.
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