Treatment of Balanitis Xerotica Obliterans with Topical Tacrolimus

Abstract

Circumcision is the usual management of balanitis xerotica obliterans (BXO), with the addition of topical corticosteroids when the glans is also mildly affected. However, corticosteroids can have adverse local and systemic effects. Tacrolimus is a novel immunomodulator with a more acceptable side effect profile. To our knowledge we report the first case of topical tacrolimus for the adjuvant management of BXO. CASE REPORT A 28-year-old man presented with a 2-week history of acute balanitis with severe lower urinary tract symptoms. He had noticed gradual phimosis during the previous 3 to 4 months. Physical examination revealed a nonretractable prepuce with a purulent discharge. At circumcision a provisional diagnosis of balanitis xerotica obliterans affecting the glans and foreskin was made, which was subsequently confirmed by histological analysis of the foreskin. The patient was then referred to dermatology for advice on further treatment. He was placed on a regimen of 0.1% topical tacrolimus ointment applied to the glans twice daily. After 3 months there was marked improvement in the extent and severity of the inflammation, with total resolution of symptoms. A degree of atrophic white changes persisted. The only side effect reported was that of pruritus following application. At 9-month followup, with no further tacrolimus application after 3 months there was no return of symptoms or progression of atrophy. DISCUSSION To our knowledge this is the first reported case of tacrolimus ointment in the successful management of BXO. BXO is classified as the penile variant of lichen sclerosus, involving the prepuce, glans or urethra, singly or in combination. There is an increased incidence of autoimmune diseases and HLA subtypes among affected patients. The condition is characterized by progressive contracture of the preputial aperture, causing phimosis. Histological confirmation is recommended particularly due to its association with penile carcinoma. BXO is mainly managed surgically, with circumcision regarded as minimum definitive treatment. In severe cases glandular resurfacing and skin grafts may be necessary. Topical steroid treatment is used as an adjunct to circumcision where there is mild glandular involvement. Topical steroids work, among other ways, by inhibiting interleukin-1 production, thus, modifying epithelial response to inflammation. Clobetasol propionate has been used in the short term but topical steroids have risks, namely, the triggering of latent infection, most importantly human papillomavirus, systemic absorption and cutaneous atrophy.1 Topically, tacrolimus has similar clinical effects to corticosteroids but with a more acceptable side effect profile. The drug is a macrolide derived immunomodulator currently used systemically in transplant medicine, and has recently been licensed for treating atopic dermatitis. It works by inhibiting production of interleukin-2 and subsequent T cell activation. The drug also has T cell independent effects not yet fully delineated.2 Systemic absorption is minimal (except possibly in patients with Netherton’s syndrome). Major side effects from topical use are transient burning and pruritus as shown by followup studies greater than 1 year.3 The only other potential risk is that of ultraviolet radiation induced carcinogenesis. However, this risk does not seem to be applicable in this case.