Vulval Lichen Planus

VULVAR LICHEN PLANUS

 

Introduction

Lichen planus is an inflammatory skin disorder that probably affects about 1 – 2% of all women.  It can affect any areas of skin and also can affect mucosal surfaces such as the nasal cavity, the mouth and the vagina.  About 50% of women who have oral lichen planus will also have vulvar lichen planus.  Oral lichen planus often presents as white plaques or ulcers in the mouth.

The most common age bracket to develop lichen planus is women in their 50 – 60 year old age range; however it can affect women of any age.  The most common symptoms of vulvar lichen planus are pain, burning, and less commonly, an itch.  Occasionally the disease is totally asymptomatic and is found on a routine examination. 

What Is The Cause?

The exact cause of lichen planus is unknown but it is thought to be due to an abnormality in the woman’s immune system and it is often found in association with other autoimmune diseases such as thyroid disease.  A form of lichen planus can be caused as a complication of the use of some medications.

What Are The Symptoms and What Do I See?

The majority of people who have symptoms of lichen planus complain of soreness of the vulva or vagina, a burning feeling or less commonly, an itch.  The disease can affect the vulva alone, or in about 50% of cases affects the vulva and the vaginal skin.  You may notice that the skin of the vulva has a glaze, or even eroded appearance and it often looks moist and red in association with this glazed look.  It is almost as if the skin of the vulva is covered by glass.  Because the commonest form of lichen planus on the vulva which is called erosive lichen planus can be associated with loss of architecture, or fusion of skin, you may also notice loss of skin of the labia minora or some scar tissue, especially scar tissue which may bury the clitoris.

Intercourse may be painful, especially if there are erosions at the vaginal opening or within the vagina.  These erosions can be associated with bleeding after intercourse.

Less commonly the skin may have a thickened appearance or areas of plaque formation and it is sometimes difficult to differentiate these plaques from an early form of skin cancer and in this case, a biopsy may be necessary under local anaesthetic.  If you have lichen planus on the skin of other parts of your body the rash often has a purple colour and may be quite fine with some white streakiness.  The white streaky areas almost have a lacy appearance.

How Is Lichen Planus Diagnosed?

Lichen planus may be diagnosed because it has as a typical appearance, and then there is very little doubt about the diagnosis.  Sometimes if the lichen planus has a rarer appearance such as plaque or even ulceration, a biopsy under anaesthetic may be necessary.  Dr Kliman will always look at your skin with a special digital microscope which helps make the diagnosis and will always make your skin completely numb before a biopsy is taken.

Treatment of Lichen Planus

Treatment needs to be individualised for each particular patient depending on their signs and symptoms and degree and site of disease.  Lichen planus is a disease which is difficult to completely cure but rather treatment aims at controlling the condition and watching for any signs of skin cancer.  Firstly skin involved by lichen planus is more easily irritated and it is important to use bland soaps and avoid skin irritants such as perfumed soaps and deodorants.  It is however, an unusual condition and often settles down itself with minimal treatment and so the severity of the disease can come and go by itself.  The primary initial treatment is the use of a super-potent steroid cream such as Clobetasol applied locally to the vulva.  If the vaginal skin is involved then similar steroid containing medications can be used in the vagina.

As lichen planus is primarily a disease involving a deficiency in the immune system, especially the body’s T-cells, often if the disease is not responding to local treatment, such as steroid creams or ointments, then medications to modify your immune system may be necessary.  There are a number of options and these are used on an individual case basis and will be discussed with you.  It is important in all women with lichen planus to watch for skin cancer changes which are known to occur in 3 – 5% of all women with lichen planus.  You will be followed regularly to ensure that this is not occurring as the skin cancers often develop particularly slowly.  However, if at any time you notice a new raised or bleeding area, or an area which is not healing, or that seems to have changed in any way, it is important that you ring the rooms so you can be seen quickly.

With over three decades of experience, Dr Len Kliman has treated tens of thousands of gynaecological patients and delivered over 20,000 babies.

He is a member of the International Society for the Study of Vulval and Vaginal Skin Disorders (ISSVD) and the Australian and New Zealand Vulvovaginal Society (ANZVS).

In 2017, Dr Kliman was awarded an Order of Australia for his services to obstetrics and gynaecology.