Vulva Lichen simplex chronicus

Lichen simplex chronicus

This rash is the end stage of the itch-scratch-itch cycle. Classically this condition is the end result of intense, chronic pruritus that results from repetitive rubbing or scratching. The skin responds by thickening and the increase in skin markings referred to as lichenification. This occurs most commonly in atopics. These are individuals with a background history of allergies, eczema, hay fever or asthma. They have sensitive and easily irritated skin. It can occur as the end stage of several itchy vulvar conditions, listed below.

Dermatoses, Atopic dermatitis, Lichen sclerosus, Lichen planus, Psoriasis, Contact dermatitis, Infection, Candida, Dermatophytosis.

Pathophysiology. In this condition there is an altered skin barrier with varying combinations of allergens, irritants and skin pathogens that result in a changed immunoregulatory process. Stress further alters skin barrier function making all of this worse. This condition is defined by relentless pruritus.

Symptoms: These patients have severe pruritus. They have had years of itching. When they scratch they eventually can damage the skin resulting in open areas with burning pain. They are worse with heat, stress, periods, and tight synthetic clothing. They give a history of waking up at night scratching. They have often seen many physicians and nothing helps.

On physical examination the skin is thick because of constant scratching. This thickened skin has increased skin markings (lichenification). The labia are enlarged, rugose and often edematous. The pattern can be unilateral or bilateral and usually involves the labia majora. It can be localized or generalized. The skin is pink, red, violaceous or even ruddy brown and sometimes somewhat gray when very thickened. Secondary changes are seen with erosion, ulcers, oozing, fissuring and honey-colored serosanguineous crusting.

Diagnosis: This is a clinical diagnosis. Biopsies can be done to rule out underlying and associated conditions. Culture should be done for secondary yeast and bacterial infection and patch testing may be necessary.

Treatment: Stop the itch-scratch-itch cycle. Sitz baths are helpful. No irritant should be used, so no soap. To reduce inflammation, superpotent corticosteroids such as clobetasol or halobetasol .05% ointment should be used twice a day for two weeks, then once a day for two weeks, then Monday-Wednesday-Friday for two weeks. Occasionally intralesional cortisone (triamcinolone acetonide) can be used. Systemic steroids are sometimes needed. To control infection, a cephalosporin such as cefadroxil 500 mg bid for 7 days can be used along with fluconazole 150 mg to prevent yeast and that should be repeated one week later. It is very important to stop the scratching so doxepin or hydroxyzine 25-100 mg is recommended at night and sometimes an SSRI like fluoxetine 20 mg qam is used.

Look for more than one cause or a combination of causes for this condition. It is not uncommon to have lichen sclerosus, contact dermatitis and lichen simplex chronicus all in the same patient.