Lichen Sclerosus (LS) is a chronic inflammatory skin disease that can affect any skin surface, but is most commonly seen in the genital and/or anal area.
Lichen sclerosus affects 1 in 70 women; it has been reported in all age groups and it is most often seen in postmenopausal women which is thought to be a result of decline in estrogen production from the ovaries. The exact cause of LS is not known, but it appears to have a genetic and autoimmune association such as thyroid disorders, pernicious anemia, vitiligo, or alopecia areata. LS is not an infection and it is not contagious. You do not have to worry about passing it to a sexual partner. A biopsy specimen should always be obtained to confirm the diagnosis of lichen sclerosus. In addition, it is essential to obtain the biopsy prior to starting treatment as the characteristic pathological changes can be altered with treatment.
Symptoms of Lichen Sclerosus
Itching is the most common symptom and that is why many women think they have recurrent vaginal infections. This vulvar itching may become worse at night. Some women complain of small “paper cut tears” around the vaginal opening or rectal area. Additional symptoms may include pain around the vaignal opening or pain with intercourse. 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 thin/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. Also, prompt diagnosis and compliance with the prescribed treatments is important because chronic inflammation can lead to fusing/destruction of the labia minora and/or phimosis of the clitoris which may affect sexual response and the ability to orgasm.
How is Lichen Sclerosus Diagnosed?
A patient can be diagnosed based on physical examination and symptoms. However, a small biopsy or two is necessary to confirm the diagnosis and rule out any malignancy. A biopsy is done in the office using a local, injected anesthetic and is generally tolerated very well. Patients with lichen sclerosus have an increased risk for developing skin cancer known as squamous cell carcinoma. 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 lesions or non-healing ulcerations will be re-biopsied.
There is no cure for lichen sclerosus, but it can be controlled with medications. The goal is to alleviate the symptoms and prevent any anatomical changes (such as loss of labia or clitoral architecture). Current treatment recommendations include a high potency steroid such as clobetasol ointment, or macrolide immunosuppressant ointment known as tacrolimus. Ointments are preferred because they absorb better than creams, and they are better absorbed after a warm bath or shower. It is recommended that you use a fingertip amount of the prescribed ointment and apply it directly to the affected area which may be 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 and exam are stable, the frequency will be tapered to 2-3 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 you sleep because many women experience itching at night. Hydroxyzine can be sedating, so it is best to take it in the early evening or close to bedtime. You can also take another dose during the day If your symptoms are severe, but remember, this medication is sedating, so you should not drive or operate heavy equipment. Note: Patients are sometimes 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 prescribed treatment because your symptoms will most likely return. Also, failure to properly treat the vaginal tissues may increase the risk of developing vulvar skin cancer, or squamous cell carcinoma.