Lichen Sclerosus

The disease usually manifests around the labia, clitoris and anal regions in women and the head of the penis and on foreskin in men. Symptoms include:

• Whitened, flaky skin around the labia or penis
• Dull pain around the vulva
• Intense itching around the genitals to the point of disrupting sleep 
• Bleeding, fissures and pain in the anal area. Small cracks (fissures) can develop in the skin in the anal and genital area because of constant itching and thinning of the skin. In some cases this can lead to bleeding as well. Bruising may occur as well. 
• Painful sex (dyspareunia) can occur because of the flaking of the skin. The walls of the labia can also fuse together, narrowing the entry into the vagina, which also makes sex painful. 
• Scarring, tightness of the foreskin in men.

The cause of LS is not well understood. But certain factors have been associated with it, including:

• Genetic factors: Those with blood relatives who have LS are more likely to have the disease.
• Autoimmune disorders: LS may be caused by a misfiring immune system that attacks and damages the skin. Those with autoimmune diseases such as type I diabetes, autoimmune-related thyroid disease, autoimmune-related anemia, and alopecia areata are more likely to get LS. Similarly, if you have LS, you are more likely to develop the above diseases as well.
• Hormonal factors: Since the disease occurs most commonly is postmenopausal women, hormonal changes are assumed to play a role. 
• History of sexual abuse: Past injuries to the genital area including sex-related injuries have been associated with a higher prevalence of LS.
• Urine: In men, urine can sometimes get trapped between the penis glans and folds of the foreskin. This may increase the likelihood of getting the disease. Getting circumcised greatly reduces the likelihood of developing LS.

LS is not a contagious disease and no links have been drawn with any infections causing the disease. Further, the disease is not caused by poor personal hygiene either.

The presenting symptoms of LS may have an overlap with other dermatological conditions. Therefore, some tests will need to be performed to eliminate differential diagnoses. Diagnostic methods include:

• Considering family history: A personal history of LS will greatly increase suspicion of the disease.
• Physical examination: The lesions, scarring (if present) and/or bruises will be examined. A full body exam may be conducted to check for dermatological issues elsewhere as well. The spread and type of lesions will help to narrow the cause of the disease.
• Biopsy: Samples from the affected areas may be taken. This is primarily done to eliminate other suspicions and to check for infections since they can arise independently as well. Similarly, blood work may be carried out to check for hormonal imbalances as well.

Treatment objectives include controlling symptoms such as intense itching and painful sex. Steroid ointments are the mainstay of LS treatment. Your doctor will decide the strength of the steroid medication depending on the severity of the disease. At first, you will be required to use the medication twice a day. After several days, a ‘maintenance dose’ may be sufficient which is much less frequent but enough to contain symptoms. Since this is a long-term disease, you will need to check in with your doctor regularly to check the response to the steroid treatment and check for side effects. 

Steroid injections and other types of more aggressive therapy may be needed for more stubborn cases. Circumcision is also effective in men.

So far, hormone replacement therapy has not yielded positive results.

You may need to get further checkups for dyspareunia (painful sex) since there are often other reasons for it. In women, estrogen creams that act as vaginal dilators may be useful if LS causes the lips of the labia to fuse together. 

Further, LS does increase the likelihood of squamous cell skin cancer of the genitals. Therefore, it is necessary to get regular checkups even after symptoms subside. If you notice lumps in the area, or there are patches that do not improve even after treatment, inform your doctor. Early detection and proactive treatment of vulvar and other types of cancer have more favourable outcomes. 

Also, while LS is not caused by other infections, skin conditions such as vitiligo can coexist with it. If you notice patches in new areas or changing symptoms, inform your doctor.