Lichen sclerosus is a chronic inflammatory skin condition which can affect men and children as well as women. However it is most common in the anogenital region in women with bimodal peaks during prepuberty and post-menopausally. The true incidence is difficult to determine as the condition is often not recognized but is estimated at 1 in 70 to 1 in 1000.
The cause is not known but is suspected to be auto-immune. Up to 20% of women with LS have other auto-immune conditions such as thyroid disease, vitiligo and alopecia areata. A genetic element is likely.
Vulvar itch is the commonest symptom; however it can be mild and intermittent or severe and constant. Some women are asymptomatic but present with concerns about skin colouration.
LS causes classical skin changes, often in a figure of 8 or keyhole pattern over the vulva and perineum. The skin is blanched, shiny and tissue paper-like. Changes occur only externally and not in the vagina. Fissures are common and the skin is easily traumatized. It may become infected especially if there is vigorous scratching. Structural changes if untreated include loss of labia, burying of the clitoris and vaginal narrowing causing dyspareunia.
Vulval biopsy will confirm diagnosis however in classical disease it is not always necessary. If there is any doubt about the diagnosis, or suspicion of dysplastic changes (VIN) or cancer it is mandatory to biopsy.
Swabs may be of assistance to rule out concurrent infectious conditions. Additional testing for autoimmune disease such as thyroid can be useful.
Pre-cancer (VIN) and Squamous cell carcinoma (SCC) do occur with increased frequency in LS due to the chronic inflammation. The lifetime risk is 3-5 % of developing SCC. Regular monitoring by vulvoscopy is recommended to promote early diagnosis.
Treatment is with potent steroids, initially twice daily for 3-4 weeks then weaning. Ointment is preferred as it contains less additives and so is less likely to irritate the skin. Review after 4-6 weeks is useful to refine treatment. Treatment will not reverse existing scarring but hopefully will prevent progression.
Once control of symptoms is achieved the aim is maintenance with a milder formulation 1-2 x per week if possible. Education on general skin care and avoidance of irritants is important.
Regular annual review is recommended to assess for pre-cancerous change. Patients should seek review if there is a persistent lesion or change in symptoms.
1.“ A colour Handbook of Dermatology” R. Rycroft and S Robertson.
2. Vulvar Lichen Sclerosus: Diagnosis and management. N Wendel and L Johnson www.medscape.com