Lichen Sclerosus: A black hole in current knowledge and management

Dear Editor, We read with interest the study by Neville et al. [1], “Clinical and Histological Predictors of Disease Severity in Boys with Lichen Sclerosus”. The authors describe an intraoperative clinical grading system for lichen sclerosus (LS) and assess its correlation with histopathology and one-year outcomes. The finding that neither clinical appearance nor histological severity predicted the need for reintervention highlights the difficulty of anticipating LS progression based only on morphology. We particularly agree that meatal involvement is the strongest predictor of persistent symptoms and further treatment. In this setting, adding uroflowmetry to follow-up may help identify children at risk of clinically relevant stenosis [2]. Therapeutically, in Neville et al. study, over half of patients had received topical corticosteroids before surgery, with no clear protective effect in preventing further surgery. We agree that, while steroids remain central in management, recent histopathological studies warned that genital pediatric LS shares features with adult disease, including CD8+/CD57+ infiltrates and increased Ki-67 and p53 expression, raising the possibility of early dysplastic changes [3]. These findings further support the need for careful, individualized management strategies and the need of follow-up. Moreover, long-term steroid local therapy carries risks of skin atrophy, striae formation, rebound reactions, fungal infections, relapse of human papilloma and herpes simplex virus infections [4], so that alternative topic adjuvant treatments aimed at reducing inflammatory and proliferative markers have been proposed [5]. We want to acknowledge the authors once more for their thorough research comprehend pediatric LS and emphasizes the importance of multimodal, individualized management that combines clinical and functional monitoring.