Lichen Sclerosus

Question 1

Define

Answer 1

Destructive inflammatory skin condition that affects mainly the anogenital area of women

This can occur in the foreskin of men, leading to phimosis

• Not contagious
• Occurs at extremes of age: <10yo, >60yo
• 0.1% children
• 3% women >80yo

· Aetiology unknown but associated with autoimmunity and genetics

• Autoimmune – hypothyroidism, Graves’ Disease, T1DM
• Genetic

Question 2

Aetiology

Answer 2

• Chronic inflammation in the subdermal layers of the skin results in hyalinisation of the skin – inflammatory dermatosis of unknown aetiology
• This leads to a fragility and white ‘parchment paper’ appearance of the skin and loss of vulval anatomy
• Lichen sclerosus is evident elsewhere on the body in 15% of patients

NOT CONTAGIOUS

Question 3

Risk factors

Answer 3

Personal or family history of atopy- hayfever, asthma, eczema

AI disease - hypothyroidism, Graves, T1DM

Genetic

Question 4

Signs/ Symptoms

Answer 4

o Pruritis

o White/shiny vulva (“Figure of 8 pattern”)

o May be raised or thickened

o Dyspareunia (due to tightened skin)

o Dysuria (due to tightened skin)

o Can be on wrists, upper trunks, around breasts, neck, armpits

Loss of vulval anatomy- loss of labia minora and/or midline fusion

Question 5

Investigation

Answer 5

EXAMINATION OF THE AREA

• Characteristic clinical appearance
• Biopsy can confirm diagnosis
• Histology- thinned epidermis with subepidermal hyalinisation and deeper inflammatory infiltrate

Skin swab only useful if co-existing infection or symptoms/ signs to suggest this

Question 6

Management

Answer 6

Ultra-potent topical steroids e.g. Clobetasol Proprionate

• Applying pea-sized amount daily for 1 month
• Alternate days for the 2nd month
• Twice a week for 3rd month
• Review at 3 months
• Then can be used as needed depending on symptoms

NOTE: 30g of ultra-potent steroid ointment should last 3 months

Ultra-potent topical steroid with antibacterial and antifungal e.g. Dermovate

• May be used to combat secondary infection
• Should be used for short period of time to clear infection

2nd line: tacrolimus(topical calcineurin inhibitor) + biopsy (as steroid-resistant)

• If not complete resolution of symptoms, biopsy is indicated
• Seek medical advice if lesions become raised or resistant to treatment – refer to Vulval clinic

Question 7

Complications

Answer 7

Complications

• Can never be completely cured
• Development of squamous cell carcinoma (vulval cancer) – < 5%
• Development of clitoral pseudocyst
• Sexual dysfunction
• Dysaesthesia

Prognosis

• If recurs, seek medical advice