Reply to letter: Erosive balanitis caused by Staphylococcus haemolyticus in a healthy, circumcised adult male

1 OPEN DATA Reply to letter: Erosive balanitis caused by Staphylococcus haemolyticus in a healthy, circumcised adultmale JoséMazuecos- Blanca1,*, José RafaelMazuecos- Gutiérrez2 and AnaJiménez- Gil2 REPLY Mazuecos- Blanca etal., Access Microbiology 2024;6:000831 DOI 10.1099/acmi.0.000831 Received 21 February 2024; Accepted 17 April 2024; Published 4 June 2024 Author affiliations: 1Dermatology Area, Department of Medicine, Faculty of Medicine, University of Seville, Sevilla, Spain; 2Amate Health Centre, Seville District, Andalusian Health Service, Seville, Spain. *Correspondence: José Mazuecos- Blanca, mazuecos@ us. es Keywords: balanitis; balanoposthitis; circumcision; diabetes; lichen sclerosus. Abbreviation: LS, lichen sclerosus. 000831 © 2024 The Authors This is an openaccess article distributed under the terms of the Creative Commons Attribution License. The Microbiology Society waived the open access fees for this article. Sir, The etiopathogenesis of lichen sclerosus (LS) is unknown and several factors are implicated. Chronic inflammation is one of the most reported [1]. The occlusive and moist environment under the foreskin may facilitate the development of male genital LS [2]. Chronic and intermittent exposure to urine, through urinary microincontinence, has been implicated [3], but also poor hygiene and retention of smegma [4]. A significant relationship has also been seen between patients with LS and diabetes [5], in addition to obesity and smoking [6]. Clinically, the typical involvement of male genital LS occurs on the glans and foreskin. Erythematous, shiny, and welldefined plaques evolving to whitish, indurated, and atrophic are observed. It is accompanied by pruritus, soreness, and tenderness, sometimes with dysuria [1]. When the sclerotic tissue formation progresses, the thickened foreskin cannot be retracted causing phimosis, with impairment of sexual intercourse with dyspareunia. The formation of painful, longitudinal fissures in the whitish sclerotic ring will hinder retraction of the foreskin and erection [2]. The treatment of choice for patients with LS and nonretractile foreskin is circumcision, which also allows to confirm the histological diagnosis. On the other hand, circumcision is also indicated in recurrent balanoposthitis, so balanitis is rare in circumcised patients and severe balanitis much more so [7]. Our patient did not report erythematous or whitish plaques on the glans penis, nor pruritus, pain, difficulty retracting the foreskin or dyspareunia in the years prior to genital surgery, suspicious for genital LS. No clinical manifestation of LS was also not observed after antimicrobial treatment, so this clinical image was not published as irrelevant. On the advice of his urologist, the patient underwent circumcision alone to prevent recurrent balanoposthitis [8]. However, we have also observed extensive balanitis with involvement of the glans and shaft of the penis caused by Enterococcus faecalis in a diabetic male two months after undergoing a postectomy for severe phimosis that prevented him from retracting the foreskin. The pathological study was diagnosed as lichen sclerosus. The patient reported not having sexual intercourse with his wife since the development of phimosis, so we thought that there was a previous genital colonization by this species of enterococcus [7]. In conclusion, although exploration of all possible diagnoses is beneficial and consideration of LS is reasonable, it does not appear that the patient with erosive S. haemophilus balanitis had a male genital LS, unlike the second patient with extensive E. faecalis balanitis, in whom both the sclerotic clinical manifestations and the pathologic study indicated a genital LS. Funding information This work received no specific grant from any funding agency. Conflicts of interest The authors declare that there are no conflicts of interest. References 1. Monsálvez V, Rivera R, Vanaclocha F. Lichen sclerosus. Actas Dermosifilogr. (English Edition) 2010;101:31–38. 2. De Luca DA, Papara C, Vorobyev A, Staiger H, Bieber K, etal. Lichen sclerosus: The 2023 update. Front Med (Lausanne) 2023;10:1106318. 3. Kravvas G, Muneer A, Watchorn RE, Castiglione F, Haider A, etal. Male genital lichen sclerosus, microincontinence and occlusion: mapping the disease across the prepuce. Clin Exp Dermatol 2022;47:1124–1130. OPEN ACCESS 2 Mazuecos- Blanca etal., Access Microbiology 2024;6:000831 4. Morris BJ, Krieger JN. Penile inflammatory skin disorders and the preventive role of circumcision. Int J Prev Med 2017;8:32. 5. García- Bravo B, Sánchez- Pedreño P, Rodríguez- Pichardo A, Camacho F. Lichen sclerosus et atrophicus. A study of 76 cases and their relation to diabetes. J Am Acad Dermatol 1988;19:482–485. 6. Hofer MD, Meeks JJ, Mehdiratta N, Granieri MA, Cashy J, etal. Lichen sclerosus in men is associated with elevated body mass index, diabetes mellitus, coronary artery disease and smoking. World J Urol 2014;32:105–108. 7. Mazuecos- Blanca J, Mazuecos- Gutiérrez JR, Jiménez- Gil A. Severe bacterial balanitis in circumcised adult males. Cross Current Int J Med Biosci 2024;6:12–15. 8. Mazuecos- Blanca J, Mazuecos- Gutiérrez JR, Jiménez- Gil A. Erosive balanitis caused by Staphylococcus haemolyticus in a healthy, circumcised adult male. Access Microbiol 2023;5:000582.v4. The Microbiology Society is a membership charity and not-for-profit publisher. Your submissions to our titles support the community – ensuring that we continue to provide events, grants and professional development for microbiologists at all career stages. Find out more and submit your article at microbiologyresearch.org