Video
Lichen sclerosis: My approach to treatment
Dr. Michael Baggish elaborates on his therapeutic approach to lichen sclerosis
Diagnosis: Lichen simplex chronicus.
Treatment: Ultra-potent corticosteroid ointment applied very sparingly twice daily and covered with petroleum jelly. You also order nighttime sedation with amitriptyline to break the itch-scratch cycle. When the patient’s itching resolves and her skin clears, you taper her off the corticosteroid, warning her that recurrence is likely, and instruct her to restart the medication immediately should itching recur.
Lichen simplex chronicus (formerly called squamous hyperplasia or hyperplastic dystrophy, and also known as eczema, neurodermatitis, or localized atopic dermatitis) occurs when irritation from any cause produces itching in a predisposed person. The subsequent scratching and rubbing both produce the rash and exacerbate the irritation that drives the itching, even after the original cause is gone. The rubbing and scratching perpetuate the irritation and itching, producing the “itch-scratch” cycle.
The appearance of lichen simplex chronicus is produced by rubbing (where the skin thickens and lichenifies) or scratching (where the skin becomes red with linear erosions, called excoriations, caused by fingernails).
The initial trigger for lichen simplex chronicus often is an infection—often yeast—but overwashing, stress, sweat, heat, urine, irritating lubricants, and use of panty liners also may precipitate the itching. At the office visit, the original infection or other cause of irritation often is no longer present, and only lichen simplex chronicus can be identified.
How to treat lichen simplex chronicus
Management of lichen simplex chronicus requires very sparing application of an ultra-potent topical corticosteroid (clobetasol, halobetasol, or betamethasone dipropionate in an augmented vehicle ointment) twice daily, with the ointment covered with petroleum jelly. Care also must be taken to avoid irritants.
In addition, nighttime sedation helps to interrupt the itch-scratch cycle by preventing rubbing during sleep.
When the skin appears normal and itching has resolved, taper the medication down or off, warning the patient that recurrence is common with any future irritation.
Restart therapy immediately upon recurrence to prevent lichenification and chronic problems.
Second-line medications include calcineurin inhibitors (tacrolimus or pimecrolimus). Although these agents do not contribute to atrophy, they are less effective than topical corticosteroids, 9 cost more, and can cause burning upon application.
Unlike lichen sclerosus, lichen simplex chronicus does not always recur upon cessation of treatment, and there is no need for concern about an increased risk of malignancy or significant scarring.
Related article: New treatment option for vulvar and vaginal atrophy Andrew M. Kaunitz, MD (News for your Practice; May 2013)
CASE 4. ORAL AND VULVAR INVOLVEMENT
A 73-year-old patient seeks your help in alleviating longstanding introital itching and rawness, with dyspareunia. She has tried topical estradiol cream intravaginally three times weekly in combination with weekly fluconazole, to no avail.
Physical examination reveals deep red patches and erosions of the vestibule, with complete resorption of the labia minora ( FIGURE 4 ). Patchy redness of the vagina is apparent as well, so you examine the patient’s mouth and find deep redness of the gingivae and erosions of the buccal mucosae, with surrounding white, lacy papules. A wet mount shows a marked increase in lymphocytes and parabasal cells, with a pH of more than 7.