Lichen Sclerosus

Lichen Sclerosus (LS) is a chronic inflammatory skin disease that can affect any skin surface, but is most commonly seen in the genital area.

LS has been reported in all age groups, but it is most commonly seen in postmenopausal women. The exact cause of LS is not known, but it appears to have a genetic and autoimmune association such as thyroid disorders or vitiligo. LS in not an infection and it is not contagious. You do not have to worry about passing it to a sexual partner.

Symptoms of LS.  Itching is the most common symptom and may become worse at night. Some women complain of small “paper cut tears” around the vaginal opening or rectal area. Women often complain of painful intercourse due to atrophy (thinning) of the vaginal tissues and some women complain of small “paper cut tears” around the vaginal opening or rectum.

Physical changes from LS vary among patients from minor to severe. Hypopigmentation (lighter skin) is common and some women have fusing of the vaginal tissues and clitoral hood. Severe fusing can result in loss of architecture or cause entrapment of the clitoris.

The vulvar skin may look white, shiny, brittle, thickened, or take on the appearance of cigarette paper. The skin may also look fragile, crinkled, or shiny like cellophane. When the skin is fragile, it will often split which can cause burning and pain. The affected area often extends to the perianal region and forms a “figure 8” appearance.

How is LS diagnosed?  A patient can be diagnosed based on physical examination and symptoms. However, a small biopsy is necessary to confirm the diagnosis and rule out any malignancy. A biopsy is done in the office and is generally tolerated very well.

Patients with LS are at an increased risk for developing skin cancer. The chances of a treated LS becoming malignant ranges from 4 to 6%. Although the risk is fairly small, you will be followed and monitored throughout your lifetime. Once your symptoms have stabilized, you will be examined every 6-12 months. Any suspicious areas such as new raised lesions or non-healing sores will be re-biopsied.

Treatment.  There is no cure for LS, but it can be controlled through medications. The goal for LS treatment is to alleviate the symptoms and to prevent any anatomical changes (such as loss of labia or clitoral architecture). Current treatment recommendations include high potency steroids such as Clobetasol ointment. Ointments are preferred because they absorb better than creams.

It is recommended that you use a fingertip amount of the steroid ointment and apply it directly to the vaginal opening, clitoris, perianal area, or other areas of itching and irritation. After a month or two of daily use, you will be re-examined. If your symptoms are under control, you may try applying the ointment 3-4 days a week for maintenance. In the event you should have a flare, you can increase the frequency to every day until the symptoms resolve.

You may be prescribed an antihistamine (such as hydroxyzine) to help control the itching. Hydroxyzine can be sedating, so it is best to take it near bedtime. If your symptoms are severe throughout the day, you can also take an additional dose of hydroxyzine during the daytime.

Note: Patients are sometime told they should not apply a steroid ointment to the vaginal tissues because it will “thin the skin”. This is only true for healthy skin. However, if your tissues are thin because of a lack of estrogen, a vaginal estrogen cream will also be prescribed to help heal the vaginal tissues.

Do not abruptly stop steroid treatment because your symptoms will return. Failure to properly treat the vaginal tissue with a topical steroid may increase the risk of developing vulvar skin cancer.