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Lichen Sclerosus

by Peter C. Schalock, MD

Lichen sclerosus is an inflammatory dermatosis of unknown cause, possibly autoimmune, that usually affects the anogenital area.

The earliest signs are skin fragility, bruising, and sometimes blistering. Lesions typically cause mild to severe itching. When lichen sclerosus manifests in children, the appearance may be confused with sexual abuse. With time, the involved tissue becomes atrophic, thinned, hypopigmented (there may be flecks of postinflammatory hyperpigmentation), fissured, and scaly. Hyperkeratotic and fibrotic forms exist.

Severe and longstanding cases cause scarring and distortion or absorption of normal anogenital architecture. In women, this distortion can even lead to total destruction of the labia minora and clitoris. In men, phimosis or fusion of the foreskin to the coronal sulcus can occur.

Diagnosis

  • Clinical evaluation

  • Sometimes biopsy

Diagnosis can usually be based on appearance, especially in advanced cases; however, biopsy should be done on any anogenital dermatosis that does not resolve with mild conventional therapy (eg, topical hydrocortisone, antifungal drug). It is especially important to biopsy any area that becomes thickened or ulcerated, because lichen sclerosus is a precursor of squamous cell carcinoma.

Treatment

  • Topical corticosteroids

Treatment consists of potent topical corticosteroids (drugs that otherwise should be used with extreme caution in this area). The disease is generally intractable, so long-term treatment and follow-up are necessary. Monitoring for squamous cell carcinoma and sexual dysfunction and providing psychologic support are indicated.

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