Lichen Sclerosus

Lichen sclerosus is a chronic inflammatory skin condition that can affect any part of the skin, but it most often affects the genital skin (vulva) and the skin around the anus. It can start in childhood – or adulthood (usually after menopause) and affect girls or women of any age.

What causes lichen sclerosus? 

The cause of lichen sclerosus is not fully understood. It can be associated with other diseases in which the body’s immune system attacks normal tissues such as the thyroid gland (causing an overactive – or underactive thyroid gland) or the insulin-producing cells in the pancreas (causing diabetes), but it has not been proven that it is an auto-immune condition in itself.

Lichen sclerosus is not due to an infection – the disease is not contagious and cannot be spread through contact, including sexual intercourse. Friction or damage to the skin triggers lichen sclerosus and make it worse. This reaction is called a ‘Koebner response.’ Irritation from urine leakage or wearing incontinence pads or panty liners can make the problem worse. 

It is not known if lichen sclerosus is hereditary, but it rarely occurs in relatives.

The most common symptom of vulval lichen sclerosus is itching, which may be severe and be very sore if the skin breaks down or cracks.

In the genital area, the scar-like process can tighten the skin, which can interfere with urination and sexual intercourse. 

Tightening of the skin around the anus may cause discomfort when passing bowel motions and aggravate any tendency to constipation, especially in children. The patches on the non-genital skin rarely cause any symptoms at all.

The skin has a shiny white appearance, usually thinned but can sometimes become raised and thickened. When the anus is affected, it is described as ‘a figure of eight patterns.’

Skin fragility may lead to the breaking of some small blood vessels in the skin, which appear as tiny blood blisters. Occasionally, blisters and small cracks called fissures can be seen. 

If not treated, there may be a change in the normal appearance of the vulva. There is a small risk (less than 5%) of developing skin cancer in affected areas on the vulva.

This condition can look like lumps, ulcers, or crusted areas. In areas away from the genital skin, lichen sclerosus looks like small ivory-colored, slightly raised areas, which can join up to form white patches. After a while, the surface of the spots can look like white wrinkled tissue paper. The most common sites are the bends of the wrists, the upper trunk, around the breasts, the neck, and armpits.

The diagnosis can usually be made from the typical appearance of the condition. If there is any doubt, a small skin sample may be taken and examined under a microscope to confirm the diagnosis, especially if there is an open sore or a thickened area of skin. This procedure is known as a skin biopsy and requires a local anesthetic injection and possibly stitches to close the wound, leading to a small scar.

There is no permanent cure for lichen sclerosus, but the symptoms and signs of the disease can be well controlled by applying creams to the affected skin. If it starts in childhood, it usually goes away around the time of puberty. 

A variety of treatments are available for lichen sclerosus :

• Strong steroid ointments (most commonly clobetasol propionate 0.05%) is used to stop the inflammation and also soften the affected skin. Please do not worry about the warning inside the pack, where it might say ‘not to use these ointments on genital skin’ as these are very safe for this condition, and your dermatologist will advise you how and when to apply the steroid ointments safely. 
• Moisturizers help to soften and protect the skin.
• It is possible to develop thrush or another infection is the skin cracks, and your doctor will treat these problems if they arise.
• Rarely, a small operation may be needed to divide adhesions if the skin sticks together.

• Avoid washing with soap and instead use an emollient soap substitute/cream.
• Carefully dry yourself after passing urine to reduce the contact of urine with your skin.
• Using a moisturizer or soft yellow paraffin (such as Vaseline) as a barrier cream can protect your skin from exposure to urine.
• If sexual intercourse is painful because of the tightening of the skin at the entrance to the vagina, the use of lubricants and, on occasions, vaginal dilators will help.
• Keep an eye on your skin. There is a small risk of developing vulval cancer in lichen sclerosus, but with proper control of the symptoms and signs, this risk is reduced further. Lifelong regular self-examination is very important for all females who have had genital lichen sclerosus. If any skin changes develop which do not respond to steroid creams, in particular any skin thickening, soreness, or ulceration lasting more than two weeks, you need to tell your doctor without delay. You may need a biopsy to test for skin cancer.
• If you are a smoker, stop smoking to reduce the risk of cancer.