Lichen sclerosus is chronic skin disorder that most often affects the genital and perianal areas. It usually persists for years, and can cause permanent scarring. There is no known cure, although most people are substantially improved and quite comfortable with treatment.
The vulval skin appears white and there may be some cracks. The resulting scarring leads to destruction of the normal vulval anatomy with a tendency for the labia minorae to shrink and the clitoris may become hidden. The diameter of the introitus (vaginal entrance) may be reduced so that intercourse becomes painful or impossible.
Lichen sclerosus is ten times more common in women than in men. It can start at any age, although it is most often seen in women over 50. Prepubertal girls can also be affected. It may cause no symptoms but it can be itchy, sometimes severely so. It can develop after an injury to the affected area. It may follow or co-exist with another skin condition such as lichen simplex or candidiasis.
It is characterized by small white patches that are thin and have a crinkled appearance, looking like cigarette paper at times. It may involve the entire vulvar area (from the clitoris to the anus). Often, swelling of the clitoral foreskin hides the clitoris. The labia minora almost completely disappears at times. Not uncommonly, splitting of the skin in the midline is seen. Tears may also develop in the natural folds of the vulva. The vaginal opening may become smaller, interfering with intercourse. Occasionally the tissue breaks down, forming an ulcerative lesion. It may be a chronic process which at times is not curable. The disease does not spread into the vagina. Itching is the primary symptom.
The exact cause of this condition is not known. There have been many names applied to chronic vulval skin conditions. These have included leucoplakia, kraurosis vulvae, Bowen’s disease and Paget’s disease. At one time they were all grouped as vulval dystrophies. With lichen sclerosus, there are inflammatory cells below the skin. Biopsy of the affected vulval skin is sometimes undertaken to confirm the diagnosis although it is now considered reasonable to confine biopsy to patients who do not respond to local medication.
The goal of treatment is to eliminate itching and protect the skin from damage. Various medications are used to improve the skin condition. Strong topical steroid creams or ointments (especially clobetasol propionate) are very helpful for lichen sclerosus, especially when it affects genital areas. They should be applied very accurately to the affected areas for a few weeks or months. Over-use of steroid creams can result in skin thinning; it is most important to follow instructions carefully and to attend follow-up appointments regularly.
Most patients will be told to apply the steroid cream once a day initially. The doctor should reassess the treated area after a few weeks as the response to treatment is quite variable. The itch often settles within a few days but it takes weeks to months for the appearance to return to normal. Once the lichen sclerosus has resolved or skin thinning due to the cream has arisen, the cream should be used less often. Generally it will need to be continued on a regular basis (perhaps once a week) to prevent the lichen sclerosus recurring.
Wash gently in a shower or bath with plain water alone or with a non-soap cleanser. Try to avoid rubbing and scratching. Some patients find it helpful to apply an emollient cream or petrolatum several times a day to relieve dryness or itching.
There are a variety of other treatments occasionally prescribed as well or instead of steroid creams. These include calcipotriol cream, topical and systemic retinoids (acitretin), and systemic steroids. The new immune modulating creams tacrolimus and pimecrolimus look promising for treating lichen sclerosus, but may be difficult to use because they tend to cause burning. Topical oestrogen creams are not effective for lichen sclerosus but may be prescribed for postmenopausal atrophy (dry, thinned and sensitive vulval and vaginal tissues due to hormonal deficiency). Surgery (vulvectomy) is reserved for the most severe cases or if there is vulvar cancer or pre-cancer (vulvar intraepithelial neoplasia or VIN).