(pronounced ‘lie-ken scler-roe-suss’)
Lichen Sclerosus is a dermatology condition, looked after by Dr Dimalee Herath, Consultant Dermatologist at Clinica London. Dr Herath is a highly experienced general, skin cancer and woman´s dermatologist.
Lichen sclerosus is an uncommon skin condition and can occur at any age. The two peak ages are in young children and middle aged adults. It affects women more than men. It is an uncomfortable chronic skin condition which very often the patients are reluctant to talk about or to seek health care for. Seeking health care can help diagnose lichen sclerosus and get treatment started early before more pain from affected areas occurs.
The skin condition of lichen sclerosus is an inflammatory disorder which is not a skin cancer. Lichen sclerosus can affect any part of the body. The commonly affected skin areas include the genital and anal area, but it can also affect many extragenital areas, such as the face.
Lichen sclerosus can be classified as an autoimmune disease and occurs with other autoimmune diseases, such as Hashimoto’s thyroiditis, Graves’ disease, vitiligo, alopecia areata, and pernicious anemia. Lichen sclerosus also has a genetic element and is seen among family members. Lichen sclerosus often goes unrecognised or misdiagnosed for several years, but over time it can lead to scarring, sexual dysfunction, and rarely to skin cancer.
In women, lichen sclerosus most commonly affects the genital skin (vulva) and presents symptoms of itchiness, vulvar discomfort, an awareness that something is not right, and pain during intercourse. It is difficult for women to see this area; hence, they often do not seek help until their symptoms persist and worsen. In men, it affects the penis and can lead to symptoms, including painful erections. The skin lesions of lichen sclerosus look like porcelain white plaques and papules resembling “cigarette paper.” If not treated lichen sclerosus can lead to local scarring with symptoms of increased pain and ulceration. In women, fusion of vulva lips, clitoris burying, disruption of vulvar opening, and vulval and peri-anal ulceration can occur.
In a typical case, small pearly or porcelain white plaques and spots develop on the genital skin (vulva and perianal). The spots are usually itchy. However, in some people there is no itch or other discomfort and lichen sclerosus is sometimes diagnosed by chance when the genitals are examined by a doctor for another reason. In about 3 in 10 cases, the skin around the back passage (anus) is also affected. Sometimes only the perianal skin is affected.
Typically, the itch and irritation become persistent and distressing. The itch tends to be worse at night, which can disturb sleep. The areas feel sore. Lichen sclerosus is a skin condition only and does not extend into the vagina or inside the anus.
Over time, the white spots may become larger and join together. The whole vulva and/or anal skin may then become white and be more fragile than normal. The fragile skin may become damaged, inflamed, raw and prone to painful splitting and cracking. It may become painful to have sex. If the anal skin is affected, passing poo (faeces) may cause pain.
If left untreated, over months or years, the vulva may shrink (doctors call this ‘atrophy’). In some cases the changes of the vulval skin may make the entrance to the vagina narrower. This can also make it difficult or painful to have sex. Also, thrush and other infections tend to be more common if the vulva is sore or cracked, adding to the disconcerting symptoms.
Symptoms may slowly worsen, but not all the above symptoms may occur. It can take months or years from the first small spots to progress to more severe symptoms. At first, the symptoms may be mistaken for thrush or other problems: often women have tried lots of creams from the chemist before being examined and having lichen sclerosus diagnosed.
At Clinica London Dr Herath does Woman´s Dermatology and sees many adult women patients with lichen sclerosus. She does not look after adult men with suspected or established lichen sclerosus.
Lichen sclerosus occur on other parts of the body in both women and men as small pearly white areas on the skin. Sometimes they occur in people who also have genital lichen sclerosus, but equally can occur without genital problems. Away from the genital area, patches of lichen sclerosus usually do not cause itch or other symptoms.
The aetiology is probably autoimmune. There affected skin is inflamed, which in turn causes structural changes.
In autoimmune disease, the body’s immune system accidentally attacks your own 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 really known what triggers lichen sclerosus to develop.
About 1 in 4 people with lichen sclerosus have another autoimmune disease, such as thyroid disease, vitiligo, or pernicious anaemia. This is why it is thought that lichen sclerosus might be an autoimmune disease.
The itch and discomfort may cause a lot of distress. The changes to the genital skin may cause sexual difficulties or problems in passing urine. There is also a small increased risk of developing skin cancer of the vulva. The exact risk is not known, but it is thought that about 4 in 100 women with lichen sclerosus develop this skin cancer. In men, there is a small increased risk of developing cancer of the penis. Again, the exact risk is unknown, but it is thought that around 8 in 100 men with lichen sclerosus develop this skin cancer.
A thorough history is taken, and a gentle examination is carried out with a chaperone present. If the appearance of the affected skin is typical, no further tests or biopsies are needed. If required to help the diagnosis, a small sample (biopsy) of affected skin may be taken under local anaesthetic by Dr Herath. The sample of skin is put under a microscope to look at the structure of the skin cells and tissues. This will confirm the diagnosis and rule out other disorders, including a skin cancer which can sometimes copy (mimic) this condition.
When 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.
Lichen sclerosus can be treated. The treatment consists mainly of a strong steroid ointment or cream (topical steroid). Steroids reduce inflammation and help improve uncomfortable symptoms. 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. You must use the steroid cream as directed by your dermatologist. 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. 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.
Treat lichen sclerosus by using a moisturising (emollient) cream or ointment instead of soap to clean the genital area. Avoid bubble baths, scented soap, detergents, perfumes, etc, to the genital skin (vulva) since these may irritate the skin and make symptoms worse. Lubricant gel is useful during sex to reduce or abolish pain.
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.
If you think you may have Lichen Sclerosus and require further information and advice, you should make an appointment to see Woman´s Dermatologist Dr Dimalee Herath at Clinica London.
Dr Herath also sees all adult patients, men and women, with suspected skin cancers, skin lumps and tags, and for mole checks.