Vulva Lichen sclerosus

Lichen sclerosus

It is the commonest chronic vulvar condition Prevalence ranges from one in 300 to one in 1000. The usual age of onset is middle age but children can be affected.

Symptoms are variable. Pruritus is the most common complaint. It can be severe and intolerable but the condition can be asymptomatic. Children itch and scratch and then complain of burning and irritation and the clinical features are often mistaken for sexual abuse. Most women, however, present with irritation, itch and pruritus. Scratching causes secondary changes in open areas resulting in complaints of dysuria, burning and dyspareunia. Children with perianal involvement may present with constipation. Scarring can lead to complaints of dyspareunia and apareunia.

Clinically there are scattered papules or confluent ivory white papules forming plaques with a cellophane-like sheen to the surface. The lesions are found anywhere on the perineum from the clitoris and periclitorally to the gluteal cleft. The involvement may be patchy or generalized. It can involve anywhere on the cutaneous surface but most commonly is found on the vulva in women. Extragenital disease occurs in 10-20%. Lichen sclerosus does not involve the vagina.

Secondary changes can be seen, with excoriations, purpura, erosions, thickening (known as lichenification) and crusting. Scarring ranges from loss of labia or burying of the clitoris to loss of the whole vulva.

Differential diagnosis includes sexual abuse in children, vitiligo, lichen simplex chronicus, lichen planus and cicatricial pemphigoid. There is a cancer risk of about 4%.

Treatment involves a thorough assessment with biopsy to confirm the diagnosis. Education is very important. All irritants must be stopped. Superpotent steroid ointment ?halobetasol or clobetasol 0.05% ointment daily in a thin invisible film for 12 weeks and then used as maintenance 1-3 times a week indefinitely. Protopic may be effective. Treat all secondary infection, particularly yeast. Stop scratching with sedatives as needed. If very thick consider intralesional triamcinolone. Set up long term followup. If not responding: reassess, re-biopsy to r/o SCC, R/O contact dermatitis.