Gynaecology - Lichen Sclerosus

What is Lichen Sclerosus?

Lichen sclerosus is a common, itchy skin condition that affects the genital skin and the skin around the anus. It may also occasionally affect the non-genital skin, such as the breast and torso. It can occur in men and women, at any age. It causes white or red changes on the skin of the vulva which can become sore and itchy.

We are not sure what causes Lichen Sclerosus, there may be an autoimmune (over-active immune system attacking healthy skin cells) element to it. It is not confirmed but it does likely run in families. It is not contagious and is not caused by poor personal hygiene.

Lichen Sclerosus increases your risk of getting cancer of the vulva, penis or anus. The risk is low but it’s a good idea to check yourself regularly and see your GP if you have any concerns.  Symptoms to look for include a lump, a change in skin texture, such as thickening, or an ulcer that does not go away.

How is Lichen Sclerosus treated?

There are 3 main components to the management of Lichen Sclerosus (British Association of Dermatologists).

• Patient Education
• Corticosteroid creams
• Emollients

Topical corticosteroids include an initial three month course of ultrapotent topical corticosteroids (e.g. clobetasol, proprionate (Dermovate ointment)). The treatment is one finger-tip unit (from the tip of the finger to the first crease) nightly for 4 weeks and then twice a week for 4 weeks.

When you get the packet of steroid cream from your pharmacist you will notice that the information leaflet inside says that it should not be applied to genital skin. This information is for people who do not have Lichen Sclerosus. It is quite safe to use it for this condition.

Many people are worried about steroids thinning the skin. Steroids actually reverse the thinning caused by Lichen Sclerosus. This is why it is important to be shown where you need to apply the cream. Make sure you use a mirror when applying the cream. A maintenance dose will not cause the skin to thin as the small amount isn’t enough or used frequently enough to cause thinning.

Regular use of emollients (e.g. Cetraban). These are used to moisturise and smooth the skin. They can be used to provide a barrier to potential irritants (e.g. urine) and keep the skin hydrated.
 
It is also important to perform monthly self-examinations of your vulva to ensure there is no abnormal changes to your vulva. A leaflet on how to perform self-examination can be found on The British Society for the Study of Vulval Disease website (bssvd.org).

What else can I do?

• Avoid all scented products (including wet wipes)
• Use lubricants during sexual intercourse
• Wash with an emollient soap substitute instead of regular soap
• Gently dab your genitals dry after weeing
• Wear cotton or silk underwear

Anything I shouldn’t do?

• Do not scratch or rub the affected skin
• Do not wear tight or restrictive clothes
• Do not wash your underwear with detergent - just use water
• Do not do activities like cycling or horse riding until your symptoms have improved

Long-term treatment and follow-up

Long term topical corticosteroids can be used as maintenance once or twice a week. If symptoms recur (a flare-up) the treatment can be increased to daily until the symptoms settle and then reduced again, this should be within a week. If your symptoms are very well controlled you may find you don’t need the steroid treatment at all for some time. Regular (daily) use of emollients should also continue.

You should be seen at the hospital 3 months after starting treatment to assess the response to treatment and ensure appropriate use of topical corticosteroids.

Further follow-up in the hospital should be arranged for:

• Lichen Sclerosus associated with troublesome symptoms
• Localised skin thickening
• Previous cancer or any new concern about cancer

GP follow-up is appropriate for those who have good symptom control, good function and are happy to self-manage.

It is suggested that those who continue to use a topical steroid see their GP once or twice a year.

Referral back to the hospital should occur if you develop:

• Persistent well defined area of redness
• Ulceration
• New lumps on the vulva
• Persistent itchiness or soreness, splitting or pain during intercourse in spite of using the steroid ointment regularly (more than 3 times per week)
• If you are needing to use the steroid ointment more than three times a week or 30g of ointment in 6 months
• Problems passing urine such as poor stream
• Sexual problems