Lichen Sclerosus

Definition

• Lichen sclerosus is a chronic inflammatory disorder primarily affecting genital and perianal areas.

• It leads to atrophic, white, thickened patches of skin that can be very pruritic and prone to tearing and scarring.

Clinical Features

• White, thickened patches: Often fragile, easily bruised or torn

• Vulval Involvement:

  • Severe pruritus, possible bleeding or blood blisters

  • Ulcers, fissuring, and scarring

  • Can lead to vaginal narrowing or introital stenosis

• Penile Involvement:

  • Typically the glans; firm, white scarring, phimosis

• Associated with intense itching, soreness, possible dyspareunia in women, painful erections in men

Associated Conditions

• Vulval Cancer: Lichen sclerosus significantly increases the risk; annual surveillance recommended

• Autoimmune Associations: e.g. Hashimoto’s thyroiditis, pernicious anaemia, vitiligo

• Complications:

  • Permanent scarring or deformity (vulval architecture distortion, meatal stenosis in men)

  • Ongoing psychosocial impact (sexual dysfunction, body image issues)

Management

Referral

• Dermatology or gynaecology/urology referral for diagnosis confirmation (biopsy if atypical) and to rule out malignant transformation

Skincare

• Soap-free washes: Gentle, non-irritant cleansers

• Avoid tight clothing: Reduce friction

• Regular Emollients: Soften and protect the skin, alleviate dryness

Medications

• Potent Topical Steroids (e.g. clobetasol propionate, betamethasone dipropionate)

  • Typically first-line, applied daily or on a tapering schedule

  • High relapse rate (~85%), often requiring lifelong intermittent maintenance

• Vaginal Oestrogen Cream/Pessary

  • Useful in postmenopausal women to improve atrophic changes and comfort

• Consider topical calcineurin inhibitors (e.g. tacrolimus) if steroids not tolerated or for rotation therapy

Notes

• Annual surveillance essential to detect early vulval or penile carcinomas.

• Encourage regular follow-up to ensure adequate symptom control and monitor for steroid side effects (e.g., skin atrophy).

• Provide patient education on lifestyle modifications (loose clothing, gentle cleansing) and psychological support if chronic discomfort.