Lichen Sclerosus

Question 1

What is lichen sclerosus?

Answer 1

Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.

Question 2

What causes lichen sclerosus?

Answer 2

Lichen sclerosus is thought to be an autoimmune condition. It is associated with other autoimmune diseases, such as type 1 diabetes, alopecia, hypothyroid and vitiligo.

Question 3

How is lichen slcerosus diagnosed?

Answer 3

The diagnosis of lichen sclerosus is usually made clinically, based on the history and examination findings. Where there is doubt, a vulval biopsy can confirm the diagnosis

Question 4

What may lichen sclerosus be confused with?

Answer 4

Lichen sclerosis may be confused with other conditions that include “lichen” in the name. Lichen refers to a flat eruption that spreads. It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.

Lichen simplex is chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.

Lichen planus is an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

Question 5

Typical presentation of lichen sclerosus?

Answer 5

The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms:

Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures

The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.

Question 6

Appearance of lichen sclerosus?

Answer 6

Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears:

“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques

Question 7

Management of lichen sclerosus?

Answer 7

Lichen sclerosis cannot be cured, but the symptoms can be effectively controlled. Lichen sclerosus is usually managed and followed up every 3 – 6 months by an experienced gynaecologist or dermatologist.

Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy.

Steroids are initially used once a day for four weeks, then gradually reduced in frequency every four weeks to alternate days, then twice weekly. When the condition flares patients can go back to using topical steroids daily until they achieve good control. A 30g tube should last at least three months.

Emollients should be used regularly, both with steroids initially and then as part of maintenance.

Question 8

Complications lichen sclerosus?

Answer 8

The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva.

Other complications include:

Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of the vaginal or urethral openings