Managing Anogenital Lichen Sclerosus

Target Population: Dermatologists

Background and Objective

Lichen sclerosus (LS), a chronic inflammatory dermatosis with predilection for the anogenital tract, occurs in both sexes at any age, but most frequently in postmenopausal women and prepubertal children. It causes itching, pain, scarring, dyspareunia, painful defecation, and genitourinary tract abnormalities. As might be expected, LS often decreases quality of life. An international group of experts from several medical specialties developed guidelines for managing LS.

Key Points

• Biopsy is not necessarily required for diagnosis but can exclude disorders such as psoriasis, irritant or allergic contact dermatitis, other eczema, vitiligo, or morphea and can identify premalignant or malignant changes.

• In females, the treatment of choice is application of potent topical steroids (clobetasol and mometasone ointment). Topical steroids should be given once or twice a day for 1 to 3 months with a reduction in frequency after 1 month if there has been a clinical response. Control of symptoms, not cure, is the goal of therapy. Early disease responds better to treatment. Whether topical steroids prevent scarring is unknown. Maintenance therapy includes less-frequent application of potent topical steroids or topical calcineurin inhibitors to reduce symptom recurrence.

• In males, the goal of therapy is cure rather than control of symptoms. Therapy with potent topical steroids can be offered, but for suboptimal response, circumcision or foreskin preputioplasty is recommended.

• Second-line treatments include intralesional steroid injections or topical calcineurin inhibitors. Topical tretinoin (0.025% 5 days per week for 1 year) and systemic retinoids have proven effective. Case reports and small series show benefit from intralesional adalimumab; methotrexate with pulse systemic steroids; cyclosporine; penicillins and cephalosporins; and oral vitamin A, E, and D. Topical estrogens, testosterone, dihydrotestosterone, and 2% progesterone are not recommended.

• For anogenital LS, avoid irritation with cleansing products and frequent water exposure. Regular use of topical emollients, silk underclothing, and stool softeners are also beneficial.

• Anogenital LS is associated with increased risk for squamous cell carcinoma and requires regular physician evaluation. Increased risk for selected autoimmune diseases (especially thyroid disease) has been found, but not consistently.