VULVAR LICHEN SCERLOSUS
What is it?
Lichen sclerosus (LS) is a long-term skin disease that mainly affects the genital skin. It usually starts around the age of menopause but may occur in children. It occurs in 1 in 1000 women and less often in men. The skin outside the genital region is less commonly involved. This condition appears as white, fragile, skin patches and can sometimes looked crinkled but have a shiny and smooth surface.
What causes lichen sclerosus?
The cause of LS is unknown. It can be associated in some patients with autoimmune diseases such as thyroid disorders or vitiligo. Autoimmune diseases occur when the cells and proteins that the body uses to fight off infection start to damage the body’s own tissues and prevent their normal actions. Your doctor will do blood tests to check for these autoimmune diseases. It can be made worse by skin irritation like scratching and any infection on open skin from yeast or bacteria. LS is not an infection and is not contagious. It cannot be passed on to a sexual partner. Sometimes the disease may occur in family members but the risk of this is unknown.
What are the symptoms and what do I see?
- Itching is the most common symptom. This can be severe and may disturb sleep
- Some people experience soreness and burning particularly on intercourse. Small cracks in the skin (fissures) and ulcers can occur as a result of scratching the skin and these can be very sore. If the anal skin is split there can be pain with bowel movements.
- The skin becomes pale and white in appearance. This may be patchy or involve the entire vulva extending down the skin around the anus.
- Small purplish/red areas may be seen on the white background. These are bruises due to tiny areas of bleeding into the skin often because of scratching.
- There may be scarring that causes loss of vulval tissue (eg: the inner lips), or shrinkage at the entrance to the vaginal area which can cause pain and interfere with sexual intercourse, and rarely even causes problems with urination.
- It does not involve the vagina.
Some people have no symptoms and diagnosis may be made when the area is examined for another reason. In about 10% of women with vulva LS white patches may be seen on the skin elsewhere. The common sites for this are on the back, waist area and under the breasts.
How Is It Diagnosed?
Medical specialists familiar with the condition may diagnose this by looking at the skin and seeing the usual characteristic appearance. The diagnosis is usually confirmed by taking a skin biopsy. This involves taking a small piece of skin, first numbing the skin using local anaesthetic. The skin is then looked at under the microscope and a small amount of tissue is taken, this is called a biopsy.
What Is The Treatment?
There is no total cure for LS but the symptoms can be controlled extremely well by the use of strong steroid ointments. The appearance of the vulval skin can usually be improved but if there is a lot of scarring changes may not be reversible. Appropriate treatment is aimed at trying to prevent the development of further inflammation and scarring.
The most effective treatment for LS is a very strong topical steroid ointment such as Clobetasol propionate. These are safe to use in the genital area for this condition. In general a pea sized amount of the ointment is sufficient to treat the vulval skin. Your specialist will tell you how much to use and how often to continue the treatment. Treatment should not be stopped unless advised by your doctor, as LS can recur. Many patients find that simple moisturisers such as plain petroleum jelly can be helpful in addition to the strong cortisone/steroid ointments.
All skin irritation should be avoided as far as possible, as irritation may increase the symptoms of LS. Any infections from yeast to bacteria must be treated. Soaps and shower jells are best avoided in the genital area. The genital skin can be washed in plain warm water or a gentle soap substitute. Is it ideal to clean the vulva using one’s fingertips and warm water over the surface. Some people find that a saline solution is helpful.
You may still feel itchy at times. This may be worse at a particular time of the day, usually at night, and many women wake themselves up scratching. Many women cannot help scratching. The itch-scratch response is normal but treatment with a steroid ointment and the emollient will help.
Scratching the genital area is potentially harmful as it can damage the skin and keep symptoms ongoing for some time. First generation antihistamine such as hydroxyzine taken at bed time, may help control itching. It is best to keep your nails short so that scratching in your sleep will not cause too much damage.
If intercourse is painful this can be helped with natural gentle lubricants. If dryness is a problem and you are approaching the menopause, or are menopausal, your doctor will discuss the use of vaginal oestrogen. Painful sexual penetration should be avoided.
What Should I Watch For?
Patients with LS are a little more likely to develop skin cancer in the genital affected area. However, this only occurs in about 3 – 4% of patients with LS. Early treatment may reduce this risk even further. Any new lumps or non-healing sores, or a major change in your symptoms should be reported to your doctor if they do not respond quickly to the steroid ointment. It is a good idea to get used to examining the genital skin yourself at least monthly, if you are able to. We advise patients with LS to have a gynaecological examination by Dr Kliman at least once a year.
Dr Len Kliman is one of Melbourne’s most experienced Obstetricians and Gynaecologist and has been in private practice for over thirty years. He has a special interest in vulval vaginal skin conditions and is a member of the Australian and International Society of Vulval Skin Disorders.