Lichen sclerosus

Lichen sclerosus is a chronic inflammatory skin disease that mainly affects the genital and perianal region, although it can sometimes also appear in other areas of the body. It produces a progressive thinning of the skin, which acquires a whitish, shiny and fragile appearance. Without adequate treatment it can cause permanent scars and anatomical alterations.

Although it can appear at any age and in both sexes, it is more frequent in women after menopause, girls before puberty and uncircumcised men. It is not a contagious disease or a sexually transmitted infection.

The exact cause is still not known. It is considered a disease of multifactorial origin, in which the following are involved:

• Alterations of the immune system.
• Genetic predisposition.
• Hormonal factors.
• Repeated trauma or chronic friction (Koebner phenomenon).
• Association with other autoimmune diseases, such as autoimmune thyroiditis, vitiligo, alopecia areata and type 1 diabetes mellitus.

It is not related to poor hygiene or to an infection.

In the initial phases, intense itching (the most frequent symptom), burning, stinging, pain and a feeling of tight skin may appear.

With evolution, the following may be observed:

• Pearly white plaques.
• Thin and shiny skin.
• Small fissures.
• Bruises or small bleeding after minimal trauma.
• Pain during sexual intercourse (dyspareunia).
• Pain when urinating when it affects the vulva or penis.
• Narrowing of the foreskin (phimosis) in men.

In advanced cases, scars and changes in the genital anatomy may occur.

The diagnosis is usually made through the clinical history and the clinical skin or gynaecological/urological examination. In many patients the appearance of the lesions is very characteristic.

Is a biopsy necessary? Not always. A biopsy may be recommended when the diagnosis is not clear, when the lesions are atypical, when there is a suspicion of skin cancer or when the lesions do not respond to the usual treatment.

If it is not treated correctly, lichen sclerosus can cause:

• Permanent scars.
• Narrowing of the vaginal entrance.
• Pain during sexual intercourse.
• Phimosis.
• Difficulty retracting the foreskin.
• Urination disorders.

In addition, there is a small increase in the risk of squamous cell carcinoma in the affected area, especially in long-standing cases without treatment. For this reason it is important to carry out periodic check-ups.

High-potency topical corticosteroids. They are the first-choice treatment. The most used is clobetasol propionate 0.05%, applied following the regimen indicated by the specialist. A correct treatment manages to control the symptoms and reduce the risk of scars and complications.

Calcineurin inhibitors. In some patients tacrolimus and pimecrolimus can be used. They are generally reserved for selected cases or as maintenance treatment when indicated.

Surgical treatment. In men with involvement of the foreskin and persistent phimosis, circumcision may be recommended. Surgery is not usually necessary in women, except in very specific situations arising from significant scars.

Follow exactly the prescribed treatment, do not stop the corticosteroids on your own initiative, use gentle soaps or soap substitutes and moisturise the area with emollients if your doctor recommends it. Avoid very tight clothing and scratching, use lubricants during sexual intercourse if there is dryness or discomfort and attend the periodic check-ups even if the symptoms disappear.

You should consult if persistent genital itching appears, if you observe white spots in the genital area, if you present pain during sexual intercourse, if you have fissures or repeated bleeding, if the treatment stops being effective or if an ulcer, a lump or a lesion that does not heal appears. These last situations require a rapid medical evaluation.

• Myth: Lichen sclerosus is a sexually transmitted infection. Fact: No. It is not caused by viruses, bacteria or fungi and is not transmitted during sexual intercourse.
• Myth: It is the consequence of poor hygiene. Fact: There is no relationship with personal hygiene.
• Myth: Corticosteroids always dangerously thin the skin. Fact: When used correctly and under medical supervision, topical corticosteroids are the most effective and safe treatment to control the disease.
• Myth: It only affects women. Fact: It can also appear in men and children.
• Myth: If the itching disappears, the disease is cured. Fact: Lichen sclerosus is a chronic disease that requires follow-up, even when the symptoms are controlled.

• Lichen sclerosus is a chronic inflammatory disease that mainly affects the genital area.
• Intense itching is usually the most frequent symptom.
• Early treatment prevents scars and deformities.
• Clobetasol propionate is the first-choice treatment.
• It is not a contagious disease or a sexually transmitted infection.
• It is important to maintain periodic check-ups due to the small increase in the risk of squamous cell carcinoma.
• Most patients achieve an excellent quality of life with adequate treatment.