Lichen Sclerosus

What is lichen sclerosus?

Lichen sclerosus is an inflammatory skin condition that persists over the long term. It most often affects the genital skin and the skin around the anus, though it can occasionally appear elsewhere on the body. It is not an infection, and partners cannot catch it through sex.

Who gets it?

Lichen sclerosus can affect women, men and children, but it is much more common in women. In women it is seen most often after the menopause, but it can begin at any age, even in childhood. In men it most commonly affects the foreskin and the head of the penis, and it occurs mainly in men who are not circumcised.

What causes it?

The cause is not fully understood. It is associated with autoimmune conditions in females, in which the immune system attacks the body's own tissues, such as thyroid disease, vitiligo and alopecia areata, but it is not clear whether lichen sclerosus is itself autoimmune. It does not weaken the immune system or affect internal organs.

In men, urine trapped under the foreskin is thought to play a part, and lichen sclerosus is rare in men who were circumcised in early childhood. In men there are also links with diabetes and with atopic conditions, namely eczema, asthma and hay fever. In men and women, symptoms can be aggravated by rubbing, scratching, and irritation from urine, pads or panty liners.

Infection, allergy and hormonal problems do not cause lichen sclerosus, and it has nothing to do with hygiene.

Is it hereditary or contagious?

Lichen sclerosus does not usually run in families, although it occasionally occurs in more than one family member. It is not contagious and cannot be passed on by touch or sexual contact.

What does it look and feel like?

The symptoms and appearance of lichen sclerosus differ slightly between women and men.

In women

The most common symptom is itch, which can be intense and often worse at night. Scratching can break the skin and make it sore. The affected skin becomes pale, white and shiny, and is usually thinner and more fragile than normal, so it can tear easily, including during sex. Small blood blisters and bruising can appear. Sometimes the skin becomes thickened instead.

Without treatment, lichen sclerosus can cause scarring that changes the appearance of the vulva. The inner lips (labia minora) can shrink or fuse, the clitoris can become buried under scarred skin, and the entrance to the vagina can narrow, which can make sex painful. If the skin around the back passage is also affected, the overall shape is often likened to a figure of eight. Constipation can be a symptom, especially in children.

Lichen sclerosus does not affect the inside of the vagina.

In men

In men, lichen sclerosus typically affects the foreskin and the head of the penis. It can cause white, shiny patches, itch, soreness, splitting or bleeding of the foreskin, and pain during erections or sex. Over time the foreskin can become tight and difficult or impossible to pull back (phimosis). In some men, scarring narrows the opening of the urethra, causing a weak or spraying urine stream.

On other areas of skin

Occasionally lichen sclerosus affects non-genital skin, causing small white, slightly raised areas that join to form white patches with a wrinkled, tissue-paper surface. They tend to appear where skin is rubbed or under pressure, for example at the waist, on the shoulders and around the breasts. Lichen sclerosus on non-genital skin does not carry an increased risk of skin cancer.

How is it diagnosed?

Lichen sclerosus can usually be diagnosed from its appearance by a clinician experienced in genital skin conditions. A small skin biopsy under local anaesthetic may be recommended if the diagnosis is uncertain or if there is an area of thickening or an ulcer.

What are the treatment options?

Lichen sclerosus is part of Dr Mounsey's special interest in genital dermatology. He will confirm the diagnosis, which sometimes requires a small biopsy, and examine the affected skin carefully. The mainstay of treatment is a very potent steroid ointment, used in a set pattern to bring the condition under control and then less often to keep it settled. He will advise on gentle skin care with soap substitutes and emollients, and on any problems with intercourse or passing urine. Long-term follow-up is recommended so that any change in the skin can be checked. For men, circumcision may be recommended in some cases.

What is the outlook?

Lichen sclerosus is a long-term condition and cannot be cured, but symptoms and progression can usually be well controlled. Early diagnosis helps to limit scarring and changes in the anatomy. It will not clear by itself, but with good control it can be symptom-free. When it starts in childhood, it often improves around puberty, although it can return later in life.

Is there a risk of cancer?

Affected genital skin carries a slightly raised risk of squamous cell carcinoma, a type of skin cancer, thought to be under 5 in 100 for women with vulval lichen sclerosus. In men, there is a link with cancer of the penis, but this is rare. Good long-term control is thought to reduce the risk. Regular self-examination is important, and any lump, ulcer, thickened area or sore patch that does not heal within a couple of weeks should be checked promptly.

More information

British Association of Dermatologists patient leaflet on women: https://www.bad.org.uk/pils/lichen-sclerosus-in-females

British Association of Dermatologists patient leaflet on men: https://www.bad.org.uk/pils/lichen-sclerosus-in-males

This page gives general information only and is not a substitute for a consultation. Everyone's skin is different, and what is right for you will depend on your own circumstances. If you are worried about a skin problem, please book an appointment with Dr Mounsey or speak to your GP. If you have a mole or skin lesion that is changing, bleeding or growing quickly, please seek medical advice promptly.