Lichen Sclerosus Causes, Symptoms, Diagnosis, Treatment, Prevention

Lichen Sclerosus Causes, Symptoms, Diagnosis, Treatment, Prevention


What Is Lichen Sclerosus?


Lichen sclerosus (LIKE-in skler-O-sus) is a skin disorder that can affect men, women, or children, but is most common in women. It usually occurs on the vulva (the outer genitalia or sex organ) in women, but sometimes develops on the head of the penis in men. Occasionally, lichen sclerosus is seen on other parts of the body, especially the upper body, breasts, and upper arms.

The symptoms are the same in children and adults. Early in the disease, small, subtle white spots appear. These areas are usually slightly shiny and smooth. As time goes on, the spots develop into bigger patches, and the skin surface becomes thinned and crinkled. As a result, the skin tears easily, and bright red or purple discoloration from bleeding inside the skin is common. More severe cases of lichen sclerosus produce scarring that may cause the inner lips of the vulva to shrink and disappear, the clitoris to become covered with scar tissue, and the opening of the vagina to narrow.

Lichen sclerosus of the penis occurs almost exclusively in uncircumcised men (those who have not had the foreskin removed). The foreskin can scar, tighten, and shrink over the head of the penis. Skin on other areas of the body affected by lichen sclerosus usually does not experience scarring.

How Common Is It?


Although definitive data are not available, lichen sclerosus is considered a rare disorder that can develop in people of all ages. It primarily affects the vulva. Fewer than 1 in 20 women who have vulvar lichen sclerosus have the disease on other skin surfaces. The disease is much less common in childhood. In boys, it is a major cause of tightening of the foreskin, which requires circumcision. Otherwise, it is very uncommon in men.

What is lichen sclerosus and whom does it affect?


Lichen sclerosus is an uncommon skin condition. It used to be called lichen sclerosus et atrophicus, but it is often now just called lichen sclerosus. It most commonly affects the vulva (genital skin) of women. Less commonly it affects other areas of the skin. It can occur at any age but most commonly develops in middle-aged women. It is estimated that lichen sclerosus affects about 1 in 1,000 women. However, it may be more common than this, as some mild cases may go undiagnosed.

In males, lichen sclerosus affects the foreskin and end of the penis. It is uncommon but can occur at any age, including in young boys. Lichen sclerosus in males used to be called balanitis xerotica obliterans.

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What causes lichen sclerosus?


The cause is not known. There is a type of inflammation within affected skin which causes changes to the structure of the affected skin. It is not clear why this happens.

The cause is possibly an autoimmune disease. This is when the body's immune system attacks a part of the body. This causes inflammation and damage to the affected part of the body. In people with lichen sclerosus the genital area of skin may be attacked by some parts of the immune system which then causes inflammation. However, this has not been proved and it is not known what triggers lichen sclerosus to develop.

About 1 in 4 people with lichen sclerosus has another autoimmune disease such as thyroid disease, vitiligo, or pernicious anaemia. This is why it is thought that lichen sclerosus is also an autoimmune disease.

What Are the Symptoms of Lichen Sclerosus?


Symptoms vary depending on the area affected. Patients experience very different degrees of discomfort. When lichen sclerosus occurs on parts of the body other than the genital area, most often there are no symptoms, other than itching. If the disease is severe, bleeding, tearing, and blistering caused by rubbing or bumping the skin can cause pain.

Very mild lichen sclerosus of the genital area may cause itching, but often causes no symptoms at all. If the disease worsens, itching is the most common symptom. Rarely, lichen sclerosus of the vulva may cause extreme itching that interferes with sleep and daily activities. Rubbing or scratching to relieve the itching can create painful sores and bruising, so that many women must avoid sexual intercourse, tight clothing, tampons, riding bicycles, and other common activities that involve pressure or friction. Urination can be accompanied by burning or pain, and bleeding can occur, especially during intercourse. When lichen sclerosus develops around the anus, the discomfort can lead to constipation. This is particularly common in children.

Most men with genital lichen sclerosus have not been circumcised. They sometimes experience difficulty pulling back the foreskin and have decreased sensation in the tip of the penis. Occasionally, erections are painful, and the urethra (the tube through which urine flows) can become narrow or obstructed.

How is lichen sclerosus diagnosed?


The appearance is often fairly typical in which case no further tests are needed. If the diagnosis is in doubt, a small sample (biopsy) of affected skin may be taken under local anaesthetic. The sample of skin is put under the microscope to look at the structure of the skin cells and tissues. This can confirm the diagnosis and rule out other disorders which can sometimes mimic this condition.

If lichen sclerosus is diagnosed it is usual also to do a routine blood test to check for an underactive thyroid gland. This is because of the association between lichen sclerosus and autoimmune diseases and, in particular, autoimmune thyroid disease. Up to 3 in 10 people with lichen sclerosus also have an underactive thyroid gland.

What is the treatment for lichen sclerosus?


Patients with lichen sclerosus of nongenital skin often do not need treatment because the symptoms are very mild and usually go away over time. (The amount of time involved varies from patient to patient.)

However, lichen sclerosus of the genital skin should be treated, even when it is not causing itching or pain, because it can lead to scarring that may narrow openings in the genital area and interfere with either urination or sexual intercourse or both. There is also a very small chance that cancer may develop.

Topical steroid


A strong steroid ointment or cream (topical steroid) is the main treatment. Steroids reduce inflammation. It is usual to use the ointment or cream regularly for three months. A common plan is to use a single application at night for four weeks followed by alternate nights for four weeks and then twice a week for four weeks. But, use the steroid as directed by your doctor. Keep on with treatment for as long as advised. Irritation tends to ease after two weeks or so, but the skin may take about three months of treatment to look and feel better. 

The skin may return to normal if lichen sclerosus is diagnosed and treated with a topical steroid at an early stage. However, if the appearance of the skin has already changed a lot, the changes may not reverse much with topical steroid treatment, even though symptoms of itch and soreness are often relieved. 

After the initial regular treatment for about three months, you may then only need to use the ointment or cream once or twice every 1-2 weeks to keep symptoms away.

Some general measures


Use an emollient (moisturiser) cream or ointment instead of soap to clean the genital area. This is also soothing. Avoid bubble baths, scented soap, detergents, perfumes, etc, to the vulva. These may irritate the skin and make symptoms worse. Lubricants are useful during sex if having sex is painful.

Other treatments that are sometimes used


  • Other medicines. In the small number of cases where topical steroids do not help, a skin specialist may advise other medicines to reduce inflammation.
  • A vaginal dilator may be advised if you have any narrowing of the vaginal opening. A vaginal dilator is a cylinder-shaped piece of plastic that you insert into the vagina to gently stretch the vagina and vaginal opening. You use it each day for a time as directed by your doctor.
  • Surgery. An operation to widen the opening of the vagina is occasionally needed in women with severe lichen sclerosus which has caused narrowing of the vaginal entrance. (But note: regular use of a dilator as described above may prevent the need for surgery.)
  • Circumcision (removal of the foreskin) may be needed in some affected men or boys.

Young girls may not require lifelong treatment, since lichen sclerosus can sometimes, but not always, disappear permanently at puberty. Scarring and changes in skin color, however, may remain even after the symptoms have disappeared.

For women and girls, surgery to remove the affected skin is not an acceptable option. Surgery may be useful for scarring, but only after lichen sclerosus is controlled with medication.

Sometimes, people do not respond to the ultrapotent topical corticosteroid. Other factors, such as low estrogen levels that cause vaginal dryness and soreness, a skin infection, or irritation or allergy to the medication, can keep symptoms from clearing up. Your doctor may need to treat these factors as well. If you feel that you are not improving as you would expect, talk to your doctor.

If you need medicine, ask your doctor:


  • How does the medicine work?
  • What are its side effects?
  • Why is it the best treatment for my lichen sclerosus?

Lichen Sclerosus Prevention


The following measures help to prevent the risk of lichen sclerosus. They include:

  • Use moisturizer rather than a soap for washing and cleaning the genital areas.
  • Do not go for bubble baths and don’t use perfumes, detergents or scented soaps to the genital areas as they cause irritation and worsen the symptoms.
  • Nutritional vitamins C and E, and Zinc, so the diet program need being plentiful in these.
  • Circumcision (removal previous your foreskin) may well be necessary in some afflicted men or boys.

Can People With Lichen Sclerosus Have Sexual Intercourse?


Women with severe lichen sclerosus may not be able to have sexual intercourse because of pain or scarring that narrows the entrance to the vagina. However, proper treatment with an ultrapotent topical corticosteroid should restore normal sexual ability, unless severe scarring has already narrowed the vaginal opening. In this case, surgery may be needed to correct the problem, but only after the disease has been controlled.

Will Lichen Sclerosus go away?


There is no permanent cure for lichen sclerosus. However, treatment with a topical steroid usually controls the symptoms of itch and soreness, and often prevents the condition from getting worse. Occasionally, the condition clears away for good for no apparent reason. This is more common in young girls when the condition often goes during puberty.

Is Lichen Sclerosus Related to Cancer?


Lichen sclerosus does not cause skin cancer. However, skin that is scarred by lichen sclerosus is more likely to develop skin cancer. About 1 in 20 women with untreated vulvar lichen sclerosus develops skin cancer. The frequency of skin cancer in men with lichen sclerosus is not known. It is important for people who have the disease to receive proper treatment and to see their doctor every 6 to 12 months, so that he or she can monitor and treat any changes that might signal skin cancer.