Lichen Sclerosus

Question 1

Definition of lichen Sclerosus

Answer 1

• Inflammatory dermatosis of unknown aetiology.
• There is evidence to suggest that autoimmune
  factors may be involved in its pathogenesis and recent
  evidence has shown autoantibodies to extracellular
  matrix protein
• There is an increased frequency of other autoimmune disorders in females with LS 40 % women

Question 2

Simptoms of Lichen Sclerosus

Answer 2

• Itch, worse at night
  . Soreness
  . Dyspareunia if introital narrowing
  . Urinary symptoms
  . Other symptoms, e.g. constipation, can occur if there
  is perianal involvement
  . Can be asymptomatic, but this is uncommon
• Any age, but most common in the postmenopause
• Scratching with trauma, bleeding and skin splitting
• Not linked to hormones, COC, HRT

Question 3

Signs of Lichen Sclerosus

Answer 3

• Pale atrophic areas affecting the vulva
  . Purpura (ecchymosis) is common
  . Fissuring
  . Erosions, but blistering is very rare
  . Hyperkeratosis can occur
  . Changes may be localised or in a ‘figure of eight’
  distribution including the perianal area
  . Loss of architecture may be manifest as loss of the
  labia minora and/or midline fusion with introital stenosis. The clitoral hood may be sealed over the
  clitoris so that it is buried.

Question 4

Complications of lichen sclerosus

Answer 4

. Development of squamous cell carcinoma (SCC)

(actual risk

Question 5

Diagnosis of lichen sclerosus

Answer 5

. Characteristic clinical appearance
. Histopathology of vulval biopsy: epidermal atrophy,
hyperkeratosis with sub-epidermal hyalinisation of
collagen and lichenoid infiltrate. In early disease,
histology can be difficult to interpret.

Question 6

Investigations in lichen sclerosus

Answer 6

. Biopsy: is mandatory if the diagnosis is uncertain, and if there are atypical features or coexistent vulval intraepithelial neoplasia (VIN)/SCC is suspected.
. Investigation for autoimmune disease if clinically
indicated, especially thyroid dysfunction as it is often asymptomatic and has been found be associated.
. Skin swab: only useful to exclude co-existing infection
if there are symptoms or signs suggestive of this.
. Patch testing: rarely required and only if secondary
medicament allergy was suspected.

Question 7

Treatment of lichen sclerosus

Answer 7

• Ultra-potent topical steroids, e.g. Clobetasol proprionate, daily use for one month,
  alternate days for one month, twice weekly for one
  month with review at three months.
  . 30 g of an ultra-potent steroid should last at least
  three months.
  . Ointment bases are much better to use on the anogenital skin because of the reduced need for preservatives in an ointment base, and hence less risk of
  irritation or secondary contact allergy
  . An ultra-potent topical steroid with antibacterial
  and antifungal, e.g. Dermovate ( generic Clobetasol with neomycin and nystatin) or an alternative preparation that combats secondary infection (such as Fucibet cream) may be appropriate if secondary infection is a concern.
  These should only be used for a short period of
  time to clear infection (to try and avoid the development
  of contact allergy)