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Lichen sclerosus (LS) is a rare skin disorder that causes skin to thin, wrinkle and get patchy, whiten and grow itchy. It affects mostly the genital and anal area. Only in about 15% of cases do lesions develop on the thighs, breasts, shoulders, neck and even inside the mouth.

The disease occurs most commonly in postmenopausal women. The cause is unknown, but hormonal, genetic or underlying diseases are important factors. 

LS is not contagious and cannot be transmitted sexually. While there is no cure for it, steroid ointments work well and are able to contain symptoms. There is a chance of the disease recurring, so regular visits to the doctor are recommended to keep it under check. 

In men, LS occurs usually on the head of the penis and is more common in uncircumcised men. Circumcision usually takes care of the disease if topical drugs do not.

While LS is not a deadly disease, it does slightly increase the risk of getting squamous cell skin cancer in the genital region.

  1. Symptoms of Lichen Sclerosus
  2. Causes of Lichen Sclerosus
  3. Diagnosis of Lichen Sclerosus
  4. Treatment of Lichen Sclerosus
  5. Management of Lichen Sclerosus in patients

Symptoms of Lichen Sclerosus

The disease usually manifests around the labia, clitoris and anal regions in women and the head of the penis and on foreskin in men. Symptoms include:

  • Whitened, flaky skin around the labia or penis
  • Dull pain around the vulva
  • Intense itching around the genitals to the point of disrupting sleep 
  • Bleeding, fissures and pain in the anal area. Small cracks (fissures) can develop in the skin in the anal and genital area because of constant itching and thinning of the skin. In some cases this can lead to bleeding as well. Bruising may occur as well. 
  • Painful sex (dyspareunia) can occur because of the flaking of the skin. The walls of the labia can also fuse together, narrowing the entry into the vagina, which also makes sex painful. 
  • Scarring, tightness of the foreskin in men.

Causes of Lichen Sclerosus

The cause of LS is not well understood. But certain factors have been associated with it, including:

  • Genetic factors: Those with blood relatives who have LS are more likely to have the disease.
  • Autoimmune disorders: LS may be caused by a misfiring immune system that attacks and damages the skin. Those with autoimmune diseases such as type I diabetes, autoimmune-related thyroid disease, autoimmune-related anemia, and alopecia areata are more likely to get LS. Similarly, if you have LS, you are more likely to develop the above diseases as well.
  • Hormonal factors: Since the disease occurs most commonly is postmenopausal women, hormonal changes are assumed to play a role. 
  • History of sexual abuse: Past injuries to the genital area including sex-related injuries have been associated with a higher prevalence of LS.
  • Urine: In men, urine can sometimes get trapped between the penis glans and folds of the foreskin. This may increase the likelihood of getting the disease. Getting circumcised greatly reduces the likelihood of developing LS.

LS is not a contagious disease and no links have been drawn with any infections causing the disease. Further, the disease is not caused by poor personal hygiene either.

Diagnosis of Lichen Sclerosus

The presenting symptoms of LS may have an overlap with other dermatological conditions. Therefore, some tests will need to be performed to eliminate differential diagnoses. Diagnostic methods include:

  • Considering family history: A personal history of LS will greatly increase suspicion of the disease.
  • Physical examination: The lesions, scarring (if present) and/or bruises will be examined. A full body exam may be conducted to check for dermatological issues elsewhere as well. The spread and type of lesions will help to narrow the cause of the disease.
  • Biopsy: Samples from the affected areas may be taken. This is primarily done to eliminate other suspicions and to check for infections since they can arise independently as well. Similarly, blood work may be carried out to check for hormonal imbalances as well.

Treatment of Lichen Sclerosus

Treatment objectives include controlling symptoms such as intense itching and painful sex. Steroid ointments are the mainstay of LS treatment. Your doctor will decide the strength of the steroid medication depending on the severity of the disease. At first, you will be required to use the medication twice a day. After several days, a ‘maintenance dose’ may be sufficient which is much less frequent but enough to contain symptoms. Since this is a long-term disease, you will need to check in with your doctor regularly to check the response to the steroid treatment and check for side effects. 

Steroid injections and other types of more aggressive therapy may be needed for more stubborn cases. Circumcision is also effective in men.

So far, hormone replacement therapy has not yielded positive results.

Management of Lichen Sclerosus in patients

You may need to get further checkups for dyspareunia (painful sex) since there are often other reasons for it. In women, estrogen creams that act as vaginal dilators may be useful if LS causes the lips of the labia to fuse together. 

Further, LS does increase the likelihood of squamous cell skin cancer of the genitals. Therefore, it is necessary to get regular checkups even after symptoms subside. If you notice lumps in the area, or there are patches that do not improve even after treatment, inform your doctor. Early detection and proactive treatment of vulvar and other types of cancer have more favourable outcomes. 

Also, while LS is not caused by other infections, skin conditions such as vitiligo can coexist with it. If you notice patches in new areas or changing symptoms, inform your doctor.

References

  1. Up to Date [Internet]. UpToDate, Inc.; Patient education: Lichen sclerosus (Beyond the Basics)
  2. Cooper SM, et al. The association of lichen sclerosus and erosive lichen planus of the vulva with autoimmune disease: a case-control study. 2008 Nov;144(11):1432-5. PMID: 19015417
  3. Kunstfeld R, et al. Successful treatment of vulvar lichen sclerosus with topical tacrolimus.. Arch Dermatol. 2003 Jul;139(7):850-2. PMID: 12873877.
  4. NHS [Internet]. National Health Services; Lichen sclerosus
  5. Mayo Clinic [Internet]. Mayo Foundation for Medical Education and Research (MFMER). Rochester, MN; Lichen sclerosus
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