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'''Balanitis Xerotica Obliterans''' (BXO) is also known as Lichen Sclerosus et Atrophicus (LSA).<ref name="freeman">Freeman C, Laymon CW. [http://www.cirp.org/library/treatment/BXO/freeman1/ Balanitis xerotica obliterans]. ''Arch Dermat Syph'' (Chicago) 1941;44;(4):547-55959.</ref><ref name="laymon">Laymon CW, Freeman C. [http://www.cirp.org/library/treatment/BXO/laymon1/ Relationship of Balanitis xerotica obliterans to lichen sclerosus et atrophicus]. ''Arch Derm Syph'' (Chicago) 1944: 49; 57-599.</ref><ref name="parsad">Parsad D, R. Saini R. [http://www.vulvarpain.icomm.ca/parsad.html Oral Stanozolol in Lichen Sclerosus et Atrophicus]. ''J Am Acad Dermatol'' 1998; 38( 2) part 1: 278-9. (link to www.vulvarpain.icom.ca)</ref><ref name="finkbeiner">Finkbeiner AE. [http://www.cirp.org/library/treatment/BXO/finkbeiner2003/ Balanitis xerotica obliterans: a form of lichen sclerosus]. ''South Med J'' 2003;96(1):7-8.</ref> First described in Germany by Stühmer in 1928,<ref name="stühmer"> 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 ([http://www.springerlink.com/content/k2895227m2410756/ Abstract])</ref> it is a skin disease of unknown etiology<ref>Freeman C, Laymon CW. [http://www.cirp.org/library/treatment/BXO/freeman1/ Balanitis xerotica obliterans]. ''Arch Dermat Syph'' (Chicago) 1941;44;(4):547-559.<name="freeman" /ref> 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.<ref>Freeman C, Laymon CW. [http://www.cirp.org/library/treatment/BXO/freeman1/ Balanitis xerotica obliterans]. ''Arch Dermat Syph'' (Chicago) 1941;44;(4):547-559.<ref name="freeman" /ref><ref name="McKay">McKay DL Jr, Fuqua F, Weinberg AG. [http://www.cirp.org/library/treatment/BXO/mckay1/ Balanitis xerotica obliterans in children]. ''J Urol'' 1975;114(5):773-5.</ref>

Affecting only 6 in 1000 males (0.6%), BXO is a rare disease which can affect males at any age.<ref>Parsad D, R. Saini R. [http://www.vulvarpain.icomm.ca/name="parsad.html Oral Stanozolol in Lichen Sclerosus et Atrophicus]. ''J Am Acad Dermatol'' 1998; 38( 2) part 1: 278-9. (link to www.vulvarpain.icom.ca)<" /ref> As rare as it may be, BXO is a relatively serious disease. It can cause urethral stricture and retention of urine.<ref>Freeman C, Laymon CW. [http://www.cirp.orgname="freeman" /library/treatment/BXO/freeman1/ Balanitis xerotica obliterans]. ''Arch Dermat Syph'' (Chicago) 1941;44;(4):547-559.</ref> Malignant tumors have been reported to develop from BXO, albeit very rarely.<ref>Freeman C, Laymon CW. [http://www.cirp.orgname="freeman" /library/treatment/BXO/freeman1/ Balanitis xerotica obliterans]. ''Arch Dermat Syph'' (Chicago) 1941;44;(4):547-559.</ref><refname="shankar">Shankar KR, Rickwood AM. [http://www.cirp.org/library/treatment/phimosis/shankar1/ The incidence of phimosis in boys]. ''BJU Int'' 1999;84(1):101-2.</ref> Meffert ''et al''. (1995) provide a recent review of the literature.<ref>Meffert JJ, Davis BM, Grimwood RE. [http://www.cirp.org/library/treatment/BXO/meffert1/ Lichen Sclerosus]. ''J Am Acad Dermatol'' 1995;32(3):393-416.</ref> A person with BXO or suspected BXO should be under the care of a medical doctor.

Freeman and Laymon (1941) provide a detailed classic description of the disease:<ref name="freeman" /> 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]].<ref name="shankar">Shankar KR, Rickwood AM. [http://www.cirp.org/library/treatment/phimosis/shankar1/ The incidence of phimosis in boys]. ''BJU Int'' 1999;84(1):101-2.</ref> Immunophenotyping may be useful in differential diagnosis.<ref>Hinchliffe SA, Ciftci AO, Khine MM, ''et al.'' [http://www.cirp.org/library/treatment/BXO/hinchliffe1/ 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.</ref> Histologic examination of cutaneous biopsy gives a definite diagnosis.<refname="pasieczny">Pasieczny TAH. [http://www.cirp.org/library/treatment/BXO/pasieczny1/ The treatment of balanitis xerotica obliterans with testosterone propionate ointment]. ''Acta Derm Venerol'' (Stockholm) 1977;57:275-2777.</ref><refname="rickwood-boys">Rickwood AMK, Hemalatha V, Batcup G, Spitz L. [http://www.cirp.org/library/treatment/phimosis/rickwood/ Phimosis in Boys]. ''Brit J Urol'' 1980; 52:147-150.</ref><ref>Shankar KR, Rickwood AM. [http:/name="shankar" /www.cirp.org/library/treatment/phimosis/shankar1/ The incidence of phimosis in boys]. ''BJU Int'' 1999;84(1):101-2.</ref><refname="depasquale">Depasquale I, Park AJ, Bracka A. [http://www.cirp.org/library/treatment/BXO/depasquale1/ The treatment of balanitis xerotica obliterans]. ''BJU Int'' 2000;86(4):459-46565.</ref> 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]].<refname="meuli">Meuli M, Briner J, Hanimann B, Sacher P. [http://www.cirp.org/library/treatment/phimosis/meuli/ 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.</ref> However, many conservative treatment options are now available.

Conventional medical wisdom has stated that BXO is an absolute indication for circumcision,<ref>Meuli M, Briner J, Hanimann B, Sacher P. [http://www.cirp.org/library/treatment/phimosis/name="meuli" / 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.</ref> 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.

Corticosteroids have been used with varying degrees of success.<ref>Catterall RD, Oakes JK. Treatment of balanitis xerotica obiterans with hydrocortisone injections. ''Br J Ven Dis'' 1962;38:75.</ref><ref>Poynter JH. Levy J. Balanitis xerotica obliterans: effective treatment with topical and sublesional corticosteroids. ''Br J Urol'' 1967;39(4):420-5.</ref> Pasieczny reports successful treatment with topical testosterone propionate ointment.<ref>Pasieczny TAH. [http://www.cirp.org/library/treatment/BXO/pasieczny1/ The treatment of balanitis xerotica obliterans with testosterone propionate ointment]. ''Acta Derm Venerol'' (Stockholm) 1977;57:275-277.<name="pasieczny" /ref><refname="rickwood-medical">Rickwood AMK. Medical indications for circumcision. ''BJU Int'' 1999: 83 Suppl 1, 45-51.</ref> Several authorities report success with clobetasol propionate.<ref>Jørgensen ET, Svensson Å. [http://www.cirp.org/library/treatment/phimosis/jorgensen/ 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.</ref><ref>Jorgensen ET, Svensson A. [http://www.bmj.com/cgi/content/full/313/7058/692 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 www.bmj.com)</ref><ref>Dahlman-Ghozlan K, Hedblad MA, von Krogh G. [http://www.cirp.org/library/treatment/BXO/dahlman-ghozlan1/ 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.</ref><refname="neuhaus">Neuhaus IM, Skidmore RA. [http://www.familypractice.com/references/referencesframe.htm?main=/journal/1999/v12.n06/1206.06/art-1206.06.htm Balanitis xerotica obliterans and its differential diagnosis]. ''J Am Board Fam Pract'' 1999; 12(6):473-476.</ref> Shelley and colleagues report successful treatment with antibiotics.<ref>Shelley, WB, Shelley ED, Gruenwald MA, ''et al.'' [http://www.cirp.org/library/treatment/BXO/shelley1/ Long-term antibiotic therapy for balanitis xerotica obliterans]. ''J Am Acad Dermatol'' 1999;40:69-72.</ref> While Depasquale and colleagues recommend radical circumcision, they also suggest mometasone or clobetasol cream as a non-surgical alternative.<ref>Depasquale I, Park AJ, Bracka A. [http://www.cirp.org/libraryname="depasquale" /treatment/BXO/depasquale1/ The treatment of balanitis xerotica obliterans]. ''BJU Int'' 2000;86(4):459-465.</ref> Dewan reports that BXO is successfully treated with topical steroid ointment during the early stages.<ref>Kiss A, Csontai A, Pirot L, ''et al.'' [http://www.cirp.org/library/treatment/BXO/kiss1/ The response of balanitis xerotica obliterans to local steroid application compared with placebo in children]. ''J Urol'' 2001;165(1):219-20.</ref><ref>Neill SM, Tatnall FM, Cox NH. [http://www.cirp.org/library/treatment/BXO/neill2002/ Guidelines for the management of lichen sclerosus]. ''Br J Dermatol'' 2002;147:640-9.</ref> Assmann et al. report that tacrolimus ointment is effective for treatment of LSA in women.<ref>Finkbeiner AE. [http://www.cirp.org/library/treatment/BXO/finkbeiner2003/ Balanitis xerotica obliterans: a form of lichen sclerosus]. ''South Med J'' 2003;96(1):7-8.</ref> 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.<refname="ebert">Ebert AK, Vogt T, Rösch WH. ([http://www.cirp.org/library/treatment/BXO/ebert2007/ Topical therapy of balanitis xerotica obliterans in childhood: Long-term clinical results and an overview.]) ''Urologe A.'' 2007;46(12):1682-6.</ref>

Carbon dioxide (CO2) laser surgery has been used with reported good results.<ref>Rosemberg SK, Jacobs H. Continuous wave carbon dioxide treatment of balanitis xerotica obliterans. ''Urology '' 1982;19(5):539-41.</ref><ref>Ratz JL. [http://www.cirp.org/library/treatment/BXO/ratz1/ Carbon dioxide laser treatment of balanitis xerotica obliterans]. ''J Am Acad Dermatol'' 1984;10:925-28.</ref><ref>Rosemberg SK. [http://www.cirp.org/library/treatment/BXO/rosemberg1/ Carbon dioxide laser treatment of external genital lesions]. ''Urology'' 1985;25(6):555-8.</ref><ref>Windahl T, Hellsten S. [http://www.cirp.org/library/treatment/BXO/windahl1/ Carbon dioxide laser treatment of lichen sclerosus et atrophicus]. ''J Urol'' 1993;150:868-70.</ref><ref>Kartamaa M, Reitamo S. [http://www.cirp.org/library/treatment/BXO/kartamaa1/ Treatment of lichen sclerosus with carbon dioxide laser vaporization]. ''Br J Dermatol'' 1997;136:356-9.</ref> A carbon dioxide laser is used to vaporize the lesions. [[Circumcision]] is the conventional radical surgical treatment but sacrifices the [[foreskin|prepuce]].<ref>Rickwood AMK, Hemalatha V, Batcup G, Spitz L. [http://www.cirp.org/library/treatment/phimosis/name="rickwood/ Phimosis in Boys]. ''Brit J Urol'' 1980; 52:147-150.<boys" /ref><refname="shankar">Shankar KR, Rickwood AM. [http://www.cirp.org/library/treatment/phimosis/shankar1/ The incidence of phimosis in boys]. ''BJU Int'' 1999;84(1):101-2.</ref><ref>Neuhaus IM, Skidmore RA. [http://www.familypractice.com/references/referencesframe.htm?mainname="neuhaus" /journal/1999/v12.n06/1206.06/art-1206.06.htm Balanitis xerotica obliterans and its differential diagnosis]. ''J Am Board Fam Pract'' 1999; 12(6):473-476.</ref><ref>Rickwood AMK. Medical indications for circumcision. ''BJU Int'' 1999: 83 Suppl 1, 45name="rickwood-51.<medical" /ref><ref>Depasquale I, Park AJ, Bracka A. [http://www.cirp.org/library/treatment/BXO/depasquale1name="depasquale" / The treatment of balanitis xerotica obliterans]. ''BJU Int'' 2000;86(4):459-465.</ref>

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.<ref>Neuhaus IM, Skidmore RA. [http://www.familypractice.com/references/referencesframe.htm?mainname="neuhaus" /journal/1999/v12.n06/1206.06/art-1206.06.htm Balanitis xerotica obliterans and its differential diagnosis]. ''J Am Board Fam Pract'' 1999; 12(6):473-476.</ref> More research is needed. Now, however, there is a good possibility of successful treatment without radical circumcision.<ref>Dalton JD. [http://bmj.com/cgi/eletters/321/7264/792#10014 BXO does not require treatment by circumcision]. (letter) ''BMJ'' 2000; rapid response pages.</ref> The trend today seems to be for greater use of medical treatment and less use of radical surgery in the treatment of BXO.