Balanitis xerotica obliterans

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Balanitis xerotica obliterans

Balanitis Xerotica Obliterans (BXO) is also known as Lichen Sclerosus et Atrophicus (LSA).[1][2][3][4] First described in Germany by Stühmer in 1928,[5] it is a skin disease of unknown etiology[1] and occurs in both males and females. BXO is the name traditionally used when the disease afflicts the male sexual organs, while LSA is the name applied when the disease appears in a female or a male in other than the genital organs. An older name for BXO is kraurosis glandii et praeputii penis.[1][6]

This page is limited to information about the disease in males when it affects the genital organs. For information on the disease in females see Lichen Sclerosus.

Affecting only 6 in 1000 males (0.6%), BXO is a rare disease which can affect males at any age.[3] As rare as it may be, BXO is a relatively serious disease. It can cause urethral stricture and retention of urine.[1] Malignant tumors have been reported to develop from BXO, albeit very rarely.[1][7] Meffert et al. (1995) provide a recent review of the literature.[8] A person with BXO or suspected BXO should be under the care of a medical doctor.


Freeman & Laymon (1941) provide a detailed classic description of the disease:[1] BXO is usually distinguished by a ring of hardened tissue with a whitish color at the tip of the foreskin. The hardening of the tissue prevents retraction of the foreskin.[7] Immunophenotyping may be useful in differential diagnosis.[9] Histologic examination of cutaneous biopsy gives a definite diagnosis.[10][11][7][12] The presence of BXO must be confirmed in order to consider the choice of treatment modality. If the biopsy rules out BXO as a cause of non-retractile foreskin, then conservative treatment is most likely possible. If, on the other hand, a biopsy confirms the presence of BXO, the choice of treatment modality is more difficult.


In the past, the traditional treatment of BXO has been radical circumcision.[13] However, many conservative treatment options are now available.

Conventional vs. conservative treatment

Conventional medical wisdom has stated that BXO is an absolute indication for circumcision,[13] however, this treatment modality dates from a time when the prepuce was considered to have no value for the individual. In more recent times, this is no longer the case, as the function and value of the prepuce are now being recognized, and males may wish for treatment that preserves the integrity of their organs; protection of the individual from unnecessarily radical surgery is always a doctor's prerogative. Fortunately, thanks to advances in modern medicine, researchers have reported some success with conservative therapies for BXO that spare the patient from surgery and preserve the prepuce.

Non-surgical treatment

Corticosteroids have been used with varying degrees of success.[14][15] Pasieczny (1977) reports successful treatment with topical testosterone propionate ointment.[10][16] Several authorities report success with clobetasol propionate.[17][18][19][20] Shelley and colleagues (1999) report successful treatment with antibiotics.[21] While Depasquale and colleagues (2000) recommend radical circumcision, they also suggest mometasone or clobetasol cream as a non-surgical alternative.[12] Dewan (2001) reports that BXO is successfully treated with topical steroid ointment during the early stages.[22][23] Finkbeiner (2003) reports that tacrolimus ointment is effective for treatment of LSA in women.[24] Clinical experience has shown it to be effective against BXO in boys. Ebert et al. (2007) report safety and good results with the use with Tacrolimus ointment.[25]

Surgical treatment

Rosemberg et al. (1982) Carbon dioxide (CO2) laser surgery has been used with reported good results.[26][27][28][29][30] A carbon dioxide laser is used to vaporize the lesions. Circumcision is the conventional radical surgical treatment but sacrifices the prepuce.[11][7][20][16][12]


There still seems to a wide range of opinion on the best treatment modalities for BXO. The cause is still unknown, although Shelley et al. (1999) hypothesize spirochete infection.[20] More research is needed. Now, however, there is a good possibility of successful treatment without radical circumcision.[31] The trend today seems to be for greater use of medical treatment and less use of radical surgery in the treatment of BXO.


  1. a b c d e f REFjournal Freeman C, Laymon CW. Balanitis xerotica obliterans. Arch Dermat Syph (Chicago). 1941; 44(4): 547-59.
  2. REFjournal Laymon CW, Freeman C. Relationship of Balanitis xerotica obliterans to lichen sclerosus et atrophicus. Arch Derm Syph (Chicago). 1944; 49: 57-9.
  3. a b REFjournal Parsad D, Saini R. Oral Stanozolol in Lichen Sclerosus et Atrophicus (archive URL). J Am Acad Dermatol. February 1998; 38(2 pt. 1): 278-9.
  4. REFjournal Finkbeiner AE. Balanitis xerotica obliterans: a form of lichen sclerosus. South Med J. 2003; 96(1): 7-8.
  5. Stühmer A. Balanitis xerotica obiterans und ihre Beziehungen zur 'Kraurosis glandi et praeputii penis'. Arch Dermatol Syph (Berlin) 1928;156:613. DOI: 10.1007/BF01828558 (Abstract)
  6. McKay DL Jr, Fuqua F, Weinberg AG. Balanitis xerotica obliterans in children. J Urol 1975;114(5):773-5.
  7. a b c d Shankar KR, Rickwood AM. The incidence of phimosis in boys. BJU Int 1999;84(1):101-2.
  8. Meffert JJ, Davis BM, Grimwood RE. Lichen Sclerosus. J Am Acad Dermatol 1995;32(3):393-416.
  9. Hinchliffe SA, Ciftci AO, Khine MM, et al. Composition of the inflammatory infiltrate in pediatric penile lichen sclerosus et atrophicus (balanitis xerotica obliterans): a prospective, comparative immunophenotyping study. Pediatr Pathol 1994;14(2):223-33.
  10. a b Pasieczny TAH. The treatment of balanitis xerotica obliterans with testosterone propionate ointment. Acta Derm Venerol (Stockholm) 1977;57:275-7.
  11. a b Rickwood AMK, Hemalatha V, Batcup G, Spitz L. Phimosis in Boys. Brit J Urol 1980; 52:147-150.
  12. a b c Depasquale I, Park AJ, Bracka A. The treatment of balanitis xerotica obliterans. BJU Int 2000;86(4):459-65.
  13. a b Meuli M, Briner J, Hanimann B, Sacher P. Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year followup after complete circumcision. J Urol 1994:152(3):987-9.
  14. Catterall RD, Oakes JK. Treatment of balanitis xerotica obiterans with hydrocortisone injections. Br J Ven Dis 1962;38:75.
  15. Poynter JH. Levy J. Balanitis xerotica obliterans: effective treatment with topical and sublesional corticosteroids. Br J Urol 1967;39(4):420-5.
  16. a b Rickwood AMK. Medical indications for circumcision. BJU Int 1999: 83 Suppl 1, 45-51.
  17. Jørgensen ET, Svensson Å. The treatment of phimosis in boys, with a potent topical steroid (clobetasol propionate 0,05%) cream. Acta Dermato-Venereologica (Stockholm) 1993;73(1):55-56.
  18. Jorgensen ET, Svensson A. Problems with the penis and prepuce in children: Lichen sclerosus should be treated with corticosteroids to reduce need for surgery. BMJ 1996;313:692. (link to
  19. Dahlman-Ghozlan K, Hedblad MA, von Krogh G. Penile lichen sclerosus et atrophicus treated with clobetasol dipropionate 0.05% cream: a retrospective clinical and histopathological study. J Am Acad Dermatol 1999;40(3):451-7.
  20. a b c Neuhaus IM, Skidmore RA. Balanitis xerotica obliterans and its differential diagnosis. J Am Board Fam Pract 1999; 12(6):473-476.
  21. Shelley, WB, Shelley ED, Gruenwald MA, et al. Long-term antibiotic therapy for balanitis xerotica obliterans. J Am Acad Dermatol 1999;40:69-72.
  22. Kiss A, Csontai A, Pirot L, et al. The response of balanitis xerotica obliterans to local steroid application compared with placebo in children. J Urol 2001;165(1):219-20.
  23. Neill SM, Tatnall FM, Cox NH. Guidelines for the management of lichen sclerosus. Br J Dermatol 2002;147:640-9.
  24. Finkbeiner AE. Balanitis xerotica obliterans: a form of lichen sclerosus. South Med J 2003;96(1):7-8.
  25. Ebert AK, Vogt T, Rösch WH. (Topical therapy of balanitis xerotica obliterans in childhood: Long-term clinical results and an overview.) Urologe A. 2007;46(12):1682-6.
  26. Rosemberg SK, Jacobs H. Continuous wave carbon dioxide treatment of balanitis xerotica obliterans. Urology 1982;19(5):539-41.
  27. Ratz JL. Carbon dioxide laser treatment of balanitis xerotica obliterans. J Am Acad Dermatol 1984;10:925-28.
  28. Rosemberg SK. Carbon dioxide laser treatment of external genital lesions. Urology 1985;25(6):555-8.
  29. Windahl T, Hellsten S. Carbon dioxide laser treatment of lichen sclerosus et atrophicus. J Urol 1993;150:868-70.
  30. Kartamaa M, Reitamo S. Treatment of lichen sclerosus with carbon dioxide laser vaporization. Br J Dermatol 1997;136:356-9.
  31. REFjournal Dalton JD. BXO does not require treatment by circumcision (letter). BMJ. 2000; rapid response pages.