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Extragenital lichen sclerosus arising in tattooed skin
  1. Aarthy Kanmany Uthayakumar,
  2. Georgios Kravvas and
  3. Christopher Barry Bunker
  1. University College London Hospitals NHS Foundation Trust, London, London, UK
  1. Correspondence to Dr Aarthy Kanmany Uthayakumar; aarthy1903{at}gmail.com

Abstract

Lichen sclerosus (LSc) is a chronic inflammatory condition commonly affecting the anogenital area, with extragenital involvement seen in less than 1%–20% of cases. Concomitant extragenital and genital LSc is extremely rare in male patients. The Koebner phenomenon is a recognised feature of LSc; here we present a rare case of extragenital LSc occurring in tattooed skin.

  • dermatology
  • sexual health

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Description

A 43-year-old man presented with a 9-year history of an eruption which started on the chest and spread to involve the upper back, arms and scrotum. The first few patches originated at the site of existing tattoos that had been professionally executed over 10 years previously. All the affected areas were mildly pruritic, but otherwise asymptomatic. The patient had no significant medical history and took no regular medications. On examination, he had white, shiny, sclerotic papules and small, superficial plaques on the upper back, both extensor arms (figure 1) and anterior scrotum (figure 2). The glans and penile shaft were unaffected. Punch biopsies from affected areas on both the scrotum and chest displayed hyperkeratosis, thinning of the surface epithelium, dense fibrosis and patchy lichenoid chronic inflammation in the upper dermis; these features are classical histological features of lichen sclerosus (LSc). The patient was treated with daily applications of clobetasol propionate ointment and pimecrolimus cream with some initial improvement but without resolution. Despite ongoing topical treatment the condition persisted, and the patient even developed further areas of extragenital, perianal and scrotal LSc. In response to this he was treated with a reducing course of oral prednisolone which was successful, with clearance of extragenital lesions and an improvement in scrotal lesions. He required a second course of oral prednisolone after a recurrence of both extragenital and genital lesions, not responsive to a further trial of topical treatment.

Figure 1

Superficial white shiny plaques within tattooed skin on the forearm, consistent with extragenital lichen sclerosus.

Figure 2

White shiny plaques of genital lichen sclerosus affecting the anterior scrotal skin.

LSc is a chronic inflammatory condition commonly affecting the anogenital area, with extragenital involvement seen in <1%–20% of cases.1–3 The Koebner phenomenon is a recognised feature of LSc, as the condition has been noted to occur at sites of scars, vaccines, radiotherapy and even jellyfish stings.4 Two case reports in the literature report the occurrence of generalised (both genital and extragenital) LSc in tattooed skin.4 5

Extragenital LSc is thought to occur in approximately 20% of LSc-affected females, but is only seen rarely in men.1 3 Extragenital lesions are seen more commonly on the neck, shoulders and upper trunk, often in a guttate form, and are rarely symptomatic. Concomitant extragenital and genital LSc are exceedingly rare in male patients3 6 (reported as less than 1% of cases in one study7). Even though genital LSc is a recognised risk factor for developing squamous cell carcinoma, no such associations have been made with extragenital LSc.1 Ultrapotent topical steroids are the mainstay of treatment in genital LSc; however, extragenital lesions are often less responsive to this treatment. As highlighted in the 2018 British Association of Dermatologists guidelines on the treatment of LSc, evidence for the treatment of extragenital LSc is limited.8 Our treatment choice of oral prednisolone was based on personal clinician experience through our specialist male genital dermatology service. Other potential oral treatments include acitretin and methotrexate.8 Phototherapy (primarily UVA9 and narrowband UVB in a few reported cases10 11) has also been shown to be an effective treatment for both extragenital and genital LSc. However, the risk of inducing carcinogenesis in the genitals following phototherapy must be considered, and therefore in the UK guidelines phototherapy is recommended only in extragenital LSc.8 We are considering these potential therapeutic options in future, if required for disease recurrence.

Learning points

  • Concomitant extragenital and genital lichen sclerosus (LSc) is extremely rare in male patients, and extragenital LSc can be resistant to treatment.

  • The Koebner phenomenon is a recognised feature of LSc, and rarely can occur in tattooed skin.

  • Ultrapotent topical steroids are the treatment of choice in LSc. Other treatment options include phototherapy.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors All authors reviewed and approved the final manuscript prior to submitting. AKU wrote the first draft of the case report and carried out a literature review.GK assisted with literature review and editing of the case report. CBB oversaw the overall conception, drafting and editing of the case report.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.