Lichen Sclerosus Diagnosis and Management

Introduction to Lichen Sclerosus

The British Journal of Dermatology recommends that lichen sclerosus be considered as a primary differential diagnosis for patients presenting with porcelain-white papules or plaques on the labia minora and interlabial sulci, causing dyspareunia when erosions or fissures develop 1, 2, 3
Lichen sclerosus presents as porcelain-white papules and plaques with areas of ecchymosis affecting the interlabial sulci, labia minora, clitoral hood, and perineal body, with the main symptom being itch (worse at night), but pain and dyspareunia occur specifically when erosions or fissures are present 1, 2, 3, 4
Lichen sclerosus has a bimodal age distribution with peaks in prepubertal girls and postmenopausal women 3, 4, 5

The British Journal of Dermatology suggests that biopsy of the affected area is the first-line diagnostic test to confirm lichen sclerosus and rule out squamous cell carcinoma 5
Documenting the duration, pattern of symptoms, and any periods of remission is crucial in diagnosing lichen sclerosus 5
Distinguishing between pruritus versus pain with erosions/fissures is essential in diagnosing lichen sclerosus 5
STI testing, including gonorrhea and chlamydia nucleic acid amplification tests, is necessary, particularly if gland involvement is suspected 5
Viral culture for HSV and serologic testing for syphilis should be performed when ulcerations or papules are present 5

The British Journal of Dermatology recommends ultrapotent topical corticosteroid clobetasol propionate ointment as the accepted first-line treatment for confirmed lichen sclerosus 1, 2
Applying clobetasol propionate once nightly for 4 weeks, then alternate nights for 4 weeks, and finally twice weekly for the final month is the recommended treatment regimen 1
Surgery may be necessary for introital narrowing causing dyspareunia, and topical steroids with vaginal dilators must be used postoperatively to prevent readhesion 1, 2

The British Journal of Dermatology suggests that neuropathic pain (vulvodynia) represents neuropathic pain that does not respond to topical corticosteroids, and xylocaine 5% ointment or amitriptyline may be tried 1, 2
Long-term surveillance is mandatory due to the malignancy risk associated with lichen sclerosus 5
Pregnancy improves symptoms and signs, and normal vaginal delivery is usually possible 3