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Lichen Sclerosus

Lichen sclerosus is a relatively uncommon condition in which thin white crinkly patches appear on the skin. It can appear anywhere, but is most troublesome in the genital areas. It may cause no symptoms but it is often very itchy and sometimes sore. Lichen sclerosus usually persists for years, and can cause permanent scarring.

LS usually occurs in postmenopausal women, although men, children, and premenopausal women may be affected. It can develop on any skin surface, but in women it most commonly occurs near the clitoris, on the labia (the inner and outer genital lips), and in the anal region (figure 1). In 15 to 20 percent of patients, LS lesions develop on other skin surfaces, such as the thighs, breasts, wrists, shoulders, neck, and even inside the mouth. In males, lichen sclerosus affects the foreskin and end of the penis. It is less common than in women, affecting around 1 in 100,000 men. It is more common in young boys and also adult men. Lichen sclerosus in males is sometimes also called balanitis xerotica obliterans.

It is not clear exactly how many people have LS. Estimates for LS involving the female genitals vary from 1 in 30 older adult women seen in general gynecology offices to 1 in 300 to 1000 patients referred to dermatologists.

Patients with lichen sclerosus have a slightly increased risk of vulvar cancer and should have a vulvar exam every six months to look for any skin changes that could be early cancer.

Causes                

The cause of lichen sclerosus (LS) is not clear; healthcare providers suspect that a number of factors may be involved.

Genetic factors — LS seems to be more common in some families. People who are genetically predisposed to LS may develop symptoms after experiencing trauma, injury, or sexual abuse.

Disorders of the immune system — LS in females may be an autoimmune disorder, in which the body’s immune system mistakenly attacks and injures the skin. People with LS are at greater risk of developing other autoimmune disorders, such as some types of thyroid disease, anemia, diabetes, alopecia areata, and vitiligo.

Infections — Researchers have tried to identify an infectious organism as a cause of LS, but no clear data have shown that there is an infectious source. LS is not contagious.

Symptoms

Symptoms include –

  • Chronic itchiness in the vulvar or anal area (which may go away and come back later)
  • Skin that looks pale, thicker or crinkled
  • Pain if the skin has split because of scratching.

Skin affected by lichen sclerosus can also scar and join up with nearby skin. This can change the structure of your vulva – for example, your labia minora may appear flattened, your clitoris can become buried under its hood and/or the opening of your vagina may shrink. This can sometimes affect your ability to have and/or enjoy sex.

Features of genital LS in women — Some women with genital LS feel dull, painful discomfort in the vulva, while other women have no symptoms. The most common symptoms include:

  • Vulvar itching – The most common symptom of LS is itching. It may be so severe that it interferes with sleep.
  • Anal itching, fissures, bleeding, and pain
  • Painful sexual intercourse (dyspareunia) – This can occur as a result of repeated cracking of the skin (fissuring) or from narrowing of the vaginal opening due to scarring.

Typically, women with genital LS have thin, white, wrinkled skin on the labia, often extending down and around the anus. Purple-colored areas of bruising may be seen. Cracks (also known as fissures) may form in the skin in the area around the anus, the labia, and the clitoris. Relatively minor rubbing or sex may lead to bleeding due to the fragility of the involved skin.

Features of genital LS in men — In men, LS may appear on the head of the penis. Men who develop LS are usually uncircumcised (they have not had the foreskin of the penis removed), and the foreskin can become tight, shrunken, and scarred over the head of the penis. Men with LS may also have problems pulling back the foreskin and may experience decreased sensation at the tip of the penis, painful erections, or problems with urination.

Features of LS in other areas — LS may also cause lesions to occur in areas outside the genitals, especially the upper body, breasts, and upper arms. These lesions tend to be white, flat or raised, and are not as itchy as the affected skin of the genitals and anus.

Treatment

Topical steroids – Topical steroids are the most effective treatment for lichen sclerosus and can help restore normal texture to genital tissue and prevent further inflammation and changes in vulvar structures. High-potency steroids, applied once or twice a day, can be used safely in the genital area, with monthly examinations early in treatment to evaluate the patient’s response. As tissue begins to return to a more normal texture, the use of steroids may be decreased to two or three times a week. However, it is important to continue treatment as lichen sclerosus can recur. While treatment can prevent further changes in genital tissue, any scarring that has already occurred is not reversible without surgery.

Comfort measures during treatment – The use of moisturizers such as Vaseline or Crisco in addition to the steroids can be helpful in controlling symptoms, especially itching. Any irritation can cause a flare-up of lichen sclerosus. Bacterial or yeast infections need to be aggressively treated, and only mild, fragrance-free products should be used in the genital area. Many women use only water when bathing the vulva, to prevent irritation from soap products, and pat to dry. In women who are postmenopausal, adding estrogen locally in the vagina helps the skin to heal.

Surgery – This is to remove any cancerous or pre-cancerous skin. Surgery can also remove scarring or adhesions that cover the entrance to your vagina if these are affecting your ability to have or enjoy penetrative sex.