Lichen Sclerosus (LS)

Lichen Sclerosus is a chronic autoimmune inflammatory condition causing thinning, hypopigmentation, and scarring, predominantly of the genital and perianal skin. It is associated with intense intolerable itch, often worse at night.

Symptoms:

• • Itch and Pain: Intense vulvar/perianal itching; burning, soreness, or pain with urination.

  • Trauma: Recurrent cracking, fissures, purpura, or bruising after minor friction (e.g., tight clothes, wiping).

  • Functional Issues: Painful intercourse (dyspareunia) or skin tearing; difficulty retracting the foreskin (phimosis) in men; constipation due to fissuring in children.

  • Associations: Possible co-existing autoimmune conditions (e.g., thyroid disease, vitiligo).

Crucial Note for Darker Skin Tones:

• The classic hypopigmented or porcelain-white patches may contrast very sharply with the surrounding skin.

• Early inflammation (erythema) may be subtle, appearing instead as violaceous, grey, or brown discoloration.

• Post-inflammatory pigment changes (dark brown/ashen areas) are more prominent and persistent after the inflammation settles.

General Pattern: Lesions start as ill-defined red/brown patches and evolve into:

• • • Thin, white, ivory-coloured plaques ("porcelain-like").

    • Sclerosis (skin tightening) and atrophy (thinning) with a wrinkled appearance (“cigarette paper” texture).

Genital Findings:

• • • Women: Involvement of the labia minora, clitoral hood, perineum, and perianus in a characteristic “keyhole” or “figure-of-eight” shape. The vagina and cervix are typically spared. Scarring can cause resorption of the labia minora and narrowing of the vaginal opening (introital stenosis).

    • Men: Affects the foreskin, glans, and coronal sulcus, leading to phimosis and potential meatal narrowing.

Key Examination Nuances in Darker Skin Tones:

• • • Hypopigmentation is highly visible.

    • Early inflammatory colour is often brown-red, violaceous, or slate grey.

    • Purpura/bruising may appear very dark purple or black.

    • Post-inflammatory hyperpigmentation (PIH) is a prominent, long-lasting sequel.

When to Biopsy: Any atypical lesion, non-healing ulcer, or nodule must be biopsied immediately to rule out squamous cell carcinoma (SCC), as chronic, uncontrolled LS carries up to a 5% cancer risk.

Treatment is lifelong, primarily medical, and aims to stop disease progression, prevent scarring, and minimize cancer risk.

1. General Care:

• Avoid Irritants: Counsel patients to avoid harsh soaps, fragrances, and tight clothing.

• Barrier Protection: Use bland emollients generously (e.g., petrolatum) as barrier protection.

• Itch Cycle: Use sedating antihistamines at night to break the itch–scratch cycle.

2. First-Line Treatment (Gold Standard):

• High-potency topical steroid: Clobetasol propionate 0.05% ointment (ointment is preferred as it stings less).

  • Dosing: Daily application for 3 months, then reduced to a maintenance schedule (1–2 times per week) lifelong.

• Goal: This therapy stops disease progression, reduces scarring, controls itch, and reduces cancer risk.

3. Second-Line and Refractory Disease:

• Steroid-Sparing: Topical Calcineurin Inhibitors (Tacrolimus 0.1% ointment) can be used for long-term maintenance or if steroids cause irritation.

• Systemic Agents: Used for severe/refractory cases and require specialist supervision (e.g., Methotrexate, systemic retinoids).

4. Surgical Options:

• Men: Early circumcision for foreskin involvement is often curative.

• Women: Surgery to release adhesions or correct introital stenosis if scarring causes functional limitations.

Monitoring & Long-Term Care:

• Lifelong follow-up is mandatory (every 6–12 months) to check for disease activity, functional issues, and signs of SCC.

NCBI Bookshelf (StatPearls) – Lichen Sclerosus: https://www.ncbi.nlm.nih.gov/books/NBK538246/

DermNet NZ – Lichen sclerosus: https://dermnetnz.org/topics/lichen-sclerosus