Lichen simplex of the scrotum

Authors: Nicole S. Kim, Medical Student, University of Toronto, Canada; Dr Yuliya Velykoredko, Dermatology Resident, University of Toronto, Canada. DermNet NZ Editor-in-Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. September 2018.


What is lichen simplex of the scrotum?

Lichen simplex of the scrotum is a pruritic form of dermatitis in which excessive scratching or rubbing leads to lichenification. Characteristically, there are well-demarcated, erythematous or hyperpigmented plaques with marked skin thickening on one or both sides of the scrotum. Lichen simplex is typically secondary to an underlying skin condition or neuropathy causing extreme itch.

Lichen simplex is also known as lichen simplex chronicus and neurodermatitis. Lichen simplex of the scrotum is also known as lichen simplex of the male genitalia and wash leather scrotum [1,2,3,5].

Lichen simplex of the scrotum

Who gets lichen simplex of the scrotum?

Lichen simplex of the scrotum is most often diagnosed in males between the ages of 35 and 50 years [5].

What causes lichen simplex of the scrotum?

Lichen simplex of the scrotum is attributed to a persistent itch-scratch cycle. Underlying pruritus, a cutaneous or systemic condition, or a neuropathy or psychiatric disorder can induce intractable scratching that leads to hypertrophy of the scrotal skin. Contributing factors to scrotal lichen simplex may include [1,2,3,5]:

What are the clinical features of lichen simplex of the scrotum?

Lichen simplex of the scrotum manifests with clearly demarcated thickening of the scrotal skin with hypo- and/or hyperpigmentation and variable scale. It is often unilateral but it may also be bilateral. Coalescing papules form solitary or multiple plaques. Other features may include:

  • Excoriations and fissures
  • Exaggerated skin lines
  • Varying degrees of erythema
  • Scarcity of hair; or short, broken-off hair shafts [3,4,5].

Signs of an underlying skin disorder may also be noted adjacent to lichen simplex of the scrotum and/or on another body site.

More areas of lichen simplex may also be found, commonly the neck, the scalp, the extensor surfaces of extremities, or the lower legs/ankles [1,2].

What are the complications of lichen simplex of the scrotum?

Complications of lichen simplex of the scrotum may include:

Lichen simplex of the scrotum has also been suspected of contributing to reduced fertility [6].

Adverse effects from treatment can also arise, particularly atrophy due to extended use of a potent topical corticosteroid on the normally thin scrotal skin. Topical steroids can also cause pigmentation abnormalities [2,5].

How is lichen simplex of the scrotum diagnosed?

The clinical features of scrotal lichen simplex are generally sufficient to establish the diagnosis. When findings are atypical, further tests can be considered to make a definitive diagnosis or to exclude other similar dermatoses.

If the scrotal lichen simplex is associated with generalised pruritus, a work-up for systemic causes can be undertaken as outlined on our pruritus page.

What is the differential diagnosis for lichen simplex of the scrotum?

Other disorders that should be considered in a patient with lichen simplex of the scrotum include [1,2,3]:

What is the treatment for lichen simplex of the scrotum?

The main goals of treatment for scrotal lichen simplex are:

  • Avoiding exacerbating factors
  • Breaking the itch-scratch cycle
  • Treating any underlying dermatosis or predisposing condition
  • Re-establishment of the normal skin barrier.

Short-term use of topical corticosteroids are used first line to break the itch-scratch cycle. Treatment principles include using a medium potency topical steroid such as triamcinolone ointment until there is resolution of active lesions. If the disease is refractory after 2–3 weeks of intermediate-strength corticosteroid, more potent topical steroids can be used on a short-term basis. As the condition improves, application frequency and potency of the corticosteroid should be decreased to minimise their adverse effects [3,4].

Aim to repair the barrier function of skin with frequent application of emollient creams and moisturisers. Minimise environmental triggers such as:

  • Dryness
  • Sweating or excessive moisture
  • Skin friction from tight-fitting or rough materials.

Identify and treat underlying disorders that cause or worsen scrotal lichen simplex [2,3,4,5].

  • Reduce or discontinue using soap, non-prescribed topical medications, and moist wipes.
  • Add a barrier cream to protect the skin.
  • Treat any underlying inflammatory dermatosis, infection, or systemic cause of itch.
  • Treat psychiatric conditions, such as depression, anxiety, or obsessive-compulsive disorder, with appropriate pharmacotherapy (eg, tricyclic antidepressants or selective serotonin reuptake inhibitors) and psychological therapy
  • Radiculopathy may be managed with tricyclic antidepressants or antiepileptic medications.

What is the outcome for lichen simplex of the scrotum?

The clinical course of scrotal lichen simplex is chronic and protracted, and patients may suffer indefinitely without appropriate treatment. As recurrences occur during psychological stresses or flareup of underlying dermatoses, long-term management may be required in some patients [3].

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References

  1. Bolognia JL, Schaffer JV, Cerroni L. Dermatology, 4th edn. Philadelphia: Elsevier, 2018.
  2. Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Fitzpatrick's Dermatology in General Medicine, 8th edn. New York: McGraw-Hill, 2012.
  3. Lynch PJ. Lichen simplex chronicus (atopic/neurodermatitis) of the anogenital region. Dermatol Ther. 2004; 17(1): 8–19. DOI: 10.1111/j.1396-0296.2004.04002.x. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1396-0296.2004.04002.x (accessed 15 March 2018)
  4. Krishnan A, Kar S. Scrotal dermatitis – can we consider it as a separate entity? Oman Med J. 2013; 28(5): 302–305. DOI: 10.5001/omj.2013.91. PubMed Central
  5. BMJ Best Practice. Lichen simplex chronicus. December 2017. Available at: http://bestpractice.bmj.com/topics/en-gb/625 (accessed 18 September 2018)
  6. Hendry WF, Munro DD. "Wash leather scrotum" (scrotal dermatitis): a treatable
    cause of male infertility. Fertil Steril. 1990 Feb;53(2):379-81. PubMed PMID:
    2137101.

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