Lichen sclerosus is a chronic inflammatory disorder of the anogenital skin that affects approximately one in seventy women. The word “lichen” mean “thick and scaly” and the word “sclerosus” means “scarring.” The average age at diagnosis is 51 years old, but 15% of females with lichen sclerosus are pre-pubertal girls. Lesions on other areas of skin may occur in 11% of patients. While the cause of lichen sclerosus has not been completely elucidated, it is most likely that lichen sclerosus is an auto-immune disorder as it is highly associated with other auto-immune disorders including auto-immune thyroid disease, alopecia areata, viteligo, pernicious anemia, and lichen planus. In addition, there are high levels of circulating auto-antibodies in patients with lichen sclerosus. Women with lichen sclerosus have a 4 – 6% risk of developing vulvar carcinoma. Lichen sclerosus has been found in greater than 60% of cases of squamous carcinoma of the vulva.
While some patients are without symptoms, most women have itching, vulvar pain, and or pain with intercourse. One study that focused on the impact that lichen sclerosus has on a women’s sexual satisfaction showed that women with lichen sclerosus were found to be less likely to be sexually active (vaginal intercourse, oral intercourse, and masturbation) than control groups. Furthermore, 79% of women with lichen sclerosus reported chronic vulvar pain.
Clinically, on examination there are white, thin areas of skin that may have the appearance of “cigarette paper”. There can be areas of hemorrhage under the skin. Because of the chronic inflammation associated with this condition, there can be significant scarring such as narrowing of the opening of the vagina, complete destruction of the labia minora, and the clitoris can be scarred over (phimosis).
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.
The mainstay of treatment is ultra-potent topical corticosteroid ointment, such as clobetasol propionate ointment applied daily until all active disease has resolved. Patients should be seen two to three month after initiating therapy to confirm improvement. Areas of ulceration that do not resolve after appropriate treatment with corticosteroids must be biopsied to rule out precancerous or cancerous growths. Once improvement has been demonstrated, the frequency may be tapered down to once or twice per week. It is important to remember this is a chronic disease and that treatment only when symptomatic is not sufficient as there can be active disease without symptoms.
Click here to view a photo gallery of photos of lichen sclerosus
( PLEASE NOTE – there are explicit photos of the genitals of women and these images are not appropriate for anyone under the age of 18.)