Lichen sclerosus

Can occur at any age and in either sex (although more common in postmenopausal women). It can be a cause of severe constipation in girls.

Synonyms in the past have included vulval dystrophy and balanitis xerotica obliterans.

The cause is unknown, but is likely to be auto-immune as it’s strongly associated with auto-immune disorders. On those lines – check TSH. Almost 30% of patients with lichen sclerosus have thyroid disease.

Presentation:

  • Severe itching
  • If scarring, can be difficulty PUing (esp. in men) and dyspareunia/splitting of the skin on attempting intercourse.
  • Areas of white skin – may be small and numerous, or confluent over larger areas, sometimes in a ‘figure of eight’ pattern over the vulva and perianal region.
  • The white patches often look thin, wrinkled, and fragile and have excoriations and red or purple areas of bleeding into the skin.
  • May be thickened plaques or warty areas.
  • In men, the white areas and purpura appear on the glans and foreskin but may be hidden by a tight phimosis.
  • First presentation may be with SCC – rapidly enlarging plaque, ulcer, or nodule.

Differential diagnosis: contact dermatitis, seborrhoeic eczema, lichen planus (which can look similar).

Diagnosis: Skin biopsy. Treatment with strong topical steroids can cause false negatives, so stick to moderate potency for symptom control until the biopsy has been done. Diagnosis is important due to the risk of cancer – patients will need education and follow-up.

Treatment is with clobetasol ointment. There are no RCTs into the best regime, but guidelines suggest nocte for 4/52 then alt nights for 4/52 then twice weekly for 4/52 then prn. Some patients achieve complete remission while others need ongoing treatment. Surgery can be used to correct effects of scarring, but is not otherwise used as it can scar in itself and the lichen sclerosus resolves rapidly.

A national support group is available at www.lichensclerosus.org.

(Old article – BMJ 2010;340:c731 doi: 10.1136/bmj.c731)

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About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in BMJ, Credits 2013, Dermatology, Gynaecology. Bookmark the permalink.

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