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Clinical Summary

Lichen sclerosus (LS) is a benign, chronic, inflammatory condition of unclear etiology that results in epithelial atrophy or hyperplasia, and scarring. The condition typically occurs in the anogenital region (85%-98%), but can develop on any skin surface. Female-to-male ratio is 10:1 with onset often perimenopausal. It occurs more frequently in women in low-estrogen states with autoimmune conditions such as diabetes mellitus type 1, vitiligo, and thyroid disorders.

Patients may be asymptomatic or may have intense pruritis and pain in the affected areas, bleeding, dyspareunia, or dysuria. Lesions are white, atrophic papules and patches and most often affect the labia. Excoriations may be present and may lead to secondary lichenification (thickening of the epidermis with exaggeration of normal skin lines). The disease is often progressive, and scarring may lead to loss of the vulvar architecture with fusion of the labia. Extragenital lesions may occur on the thighs, breasts, wrists, shoulders, neck, and, rarely, the oral cavity. They are usually not as pruritic as genital lesions.

Management and Disposition

No emergent treatment is necessary. Advise patients on good vulvar hygiene and cessation of scratching to prevent secondary infections. Consider oral antihistamines for pruritis. Refer patients for outpatient gynecologic evaluation, which may include biopsy for definitive diagnosis. Potential treatments include topical steroids, hormonal treatments, and/or immunosuppressants.

FIGURE 10.20

Lichen Sclerosus. Early lichen sclerosus appearing as white, atrophic papules and patches of the labia minora and labia majora. (Photo contributor: Hope Haefner, MD.)

FIGURE 10.21

Lichen Sclerosus—Chronic. Atrophy and scarring of chronic lichen sclerosus with early fusion of the anterior labia. (Photo contributor: Hope Haefner, MD.)

Pearls

  1. Lichen sclerosis is associated with an increased risk of vulvar squamous cell cancer. Refer all patients for biopsy and histologic evaluation.

  2. Advise patients that although LS is not an infectious condition, the presence of open excoriations and fissures can increase risk of acquiring STIs.

  3. The vagina and cervix are not involved in lichen sclerosis.

FIGURE 10.22

Lichen Sclerosus—Advanced. Extensive fusion of the labia minora in advanced lichen sclerosus over the vaginal opening. (Photo contributor: Hope Haefner, MD.)

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