Case of Male Genital Lichen Sclerosus Treated Successfully

A middle-aged male patient [Patient ID- 55094] presented with persistent white scaly spots and blotchy wrinkled skin on the penis, accompanied by severe itching and mild pain for the past six months. The condition gets aggravated in the morning, and small blisters with redness were noted during January and February 2024. The symptoms showed slight improvement with conventional medicines, which included a steroid ointment. The patient has been using clotrimazole cream once every 2–3 days for the past week.

The onset of the primary skin complaint was six months ago, with moderate intensity and partial relief with previous conventional treatment. The itching was severe, and white scaling with blotchy, wrinkled skin on the penis was characteristic. Symptoms were aggravated in the morning and were associated with painful coition due to the lesions.

Past medical history -Intermittent use of conventional medicines, including a mild steroid ointment, from January to June 2024. There was no record of the exact dosage or regimen. 

Associated complaints -1] Hypothyroidism diagnosed 10 years ago, was taking Tab. Thyroxine 50 mcg once daily.

2] Osteoarthritis -Joint pains affecting knees, ankles, toes, fingers, and elbows for the past three years. The joint pain occurred once every 20 days, lasted for a few hours to 1–2 days, had mild to moderate intensity, and showed no progression

Physical generals:

Average vegetarian diet with occasional egg intake, a craving for vanilla ice cream, and an aversion to oily and spicy foods. The patient consumed around 2 liters of water daily, experienced profuse generalized perspiration, had satisfactory bowel movements, and reported painful coition due to local lesions. On examination, the tongue was pinkish with a white coating.

Personal history - The patient worked at BARC, his wife was a homemaker, and he had two children — a daughter in 12th standard and a son in 2nd standard. 

Family history - Hypothyroidism in his mother and sister.

Life profile and mental generals- The patient is highly introverted, fearful, polite, sober, and helpful in nature. His father was short-tempered, and his wife reportedly had bipolar disorder, which contributed to a long-standing feeling of fear since childhood.

Follow-ups:

30/11/2024 – His condition was the same. White scaly spots, itching, and mild pain persisted. No further improvement due to a busy schedule; the patient had not taken the last prescribed medicines and had stopped conventional treatment. There was a gap of three months without medication.

09/01/2025 – Improvement noted. Patient had 25–30% relief. Redness had reduced, pain was much better, itching had decreased, and blotchy wrinkled patches were slightly improved.

08/02/2025 – Mild improvement, about 40% better overall, mild itching persisted, white scaly spots remained, but there was no pain.

30/03/2025 – Significant improvement, approximately 70% relief in primary complaints. Pain much better, skin redness and itching significantly reduced, blotchy wrinkled patches greatly improved, and white patches decreased in size.

19/05/2025 –  No new lesions; old lesions continued to improve. Redness reduced, but pain was still present, particularly aggravated after eating bread/pav. Itching was further reduced. The patient was not on any treatment during this time.

29/06/2025—Overall 70–75% better. No new eruptions, old lesions were healing well, redness and itching were significantly reduced, and the patient remained off medication.

Conclusion:

The patient with lichen sclerosus showed marked improvement in local and associated complaints with homeopathic treatment in Life Force. The progress was sustained even without continuous medication, indicating a positive long-term prognosis.

• Case study written by Dr. Shreya Hedaoo, an associate doctor to Dr. Rajesh Shah, MD [Homo]