Lichen sclerosis

Question 1

What is lichen sclerosis?

Answer 1

• relatively common, chronic, autoimmune skin disorder involving ANOGENITAL region
• particularly women
• combination of genetic and environment factors
• Rx is emollients and topical steroids, rarely immunomodulators
• increased risk of SSC
• scarring can require surgery

Question 2

What antibodies might be found in lichen sclerosis?

Answer 2

• up to 80% have extra cellular metric protein-1 (ECM-1) antibodies
• not clear if ECM-1 antibodies are a cause or a result of LS

Question 3

Aetiology and epidemiology of LS?

Answer 3

• cause unknown
• 15% have FHx
• associated with (obesity, coronary artery disease, smoking, preceding trauma and infections)
• TEN times more common in women
• 3% women and 0.5% men
• less common in circumcised men
• can be seen in prepubescent children
• associated with other autoimmune conditions eg psoriasis, lichen planus, vitiligo
• 20% have another autoimmune condition eg thyroid disease or pernicious anaemia

Question 4

Presenation of lichen sclerosis?

Answer 4

• white papules plaques
• itch, main symptom, worse at night

NEVER affects vaginal mucosa

• affect non-hair bearing areas of vulva and perineum (Labia minora and clitoral hood)
• figure 8 area around genitals and anus
• dysuria, dyspareunia
• scarring can affect function
• reduce / restrict anogenital openings
• in men it affects the glans (balanitis xerotic obliterans BXO)
• painful erections and peeing

Extragenital:

• only in 10% of cases (but 95% of extragenital have genital)
• typically inner thigh, buttocks, maybe torso / axillae

Question 5

Complication of lichen sclerosis

Answer 5

SQUAMOUS CELL CARCINOMA 5%

• more likely if LS is poorly controlled
• presents as enlarging lump that does not resolve
• surgical excision or cryotherapy

Question 6

Diagnosis of lichen sclerosis

Answer 6

Often clinical, but can confirm with skin biopsy.

Documenting lesions with photography can help with follow-up (if patient consents)

Question 7

Differential diagnoses when considering lichen sclerosis?

Answer 7

• vitiligo
• lichen planus
• SSC / Bowen’s disease
• candida

Question 8

Management of lichen sclerosis?

Answer 8

SUPPORTIVE:

• wash gently once or twice a day
• use emollient or non soap or water
• avoid tight clothing, avoid synthetics
• avoid cycling and horse riding

TOPICAL:

• emollients
• ULTRAPOTENT STEROIDS eg clobetasol proprionate 0.05%
• controlled; potent steroids, mometasone fumorate 0.1%
• steroids should be once daily for 1-3months and then reduce
• topical OESTROGEN can be tried

ORAL:

• only in resistant cases
• options: steroids, retinoids, methotrexate, ciclosporin

SURGERY:

• excision of SCC
• circumcision may help in men
• release adhesions or excise scar tissue from vaginal orifice

Question 9

Prognosis of lichen sclerosis?

Answer 9

Most cases are well controlled with topical agents:

• symptomatic remission in 98% women
• 75% men cured by circumcision
• 60% men respond to ultrapotent steroids

It is chronic and incurable though.

• resistant cases are often associated with lichen planus.