The Onset of Puberty Presents Unique Management Issues in Penile Chronic Graft-versus-Host Disease Requiring Circumcision in Male Pediatric Patients.

Chronic GvHD of the penile tract in male pediatric patients has not been described well in the literature and is often under-diagnosed. We report three cases of penile chronic GvHD in adolescent male patients who received HSCT before the onset of puberty. Their penile cGvHD became symptomatic upon the onset of penile growth associated with puberty in combination with the fibrotic changes in the foreskin. Symptoms did not respond to systemic chronic GvHD medication but require circumcision for alleviation of symptoms. This case series highlights the need for frequent monitoring of the prepubertal pediatric HSCT patient who has the presence of sclerotic cGvHD and enters puberty. This population is particularly reluctant to allow a thorough examination of the genitalia. In addition, optimization of systemic and topical immunosuppression treatment for patients with chronic GvHD of the penile tract potentially with the introduction of novel agents that target the tissue repair and fibrosis pathway is needed to prevent circumcision as the only option in the future.