Dr Steben is correct in that the photograph of the patient with pathologic phimosis has concurrent balanitis xerotica obliterans (BXO) or lichen sclerosis et atrophicus. In the pediatric age group there is an association between the two. This does not represent a “diagnostic error,” however. Although the BXO might respond to high-potency topical steroids, it has been our experience, and that of others, that the scarred phimotic ring rarely does.1 Balanitis xerotica obliter-ans might require treatment with topical steroids for a time after circumcision, but in most cases removing the pathologic foreskin will resolve the problem. The risk of cancer of the penis with BXO is not pertinent to the pediatric age group, as the condition is reversed by timely circumcision with or without topical steroid application. The biggest risk in children is the development of meatal stenosis secondary to BXO, which might require meatotomy.
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