Nothing to Like About Lichen Sclerosis

Just about every woman has experienced at least one itchy vagina episode that’s so unbearable it culminates in an emergency midnight trip to the drugstore. Over the counter remedies will generally do the job if a yeast infection is the culprit, but if it’s not, no amount of antifungal medication will give relief.
One common cause of non-fungal itchy genitalia is lichen sclerosis (LS). This condition is not an infection or a sexually transmitted disease, but an inflammation of the skin causing an itching so severe that some women literally scratch until they bleed. One of my patients hadn’t had a decent night’s sleep for months – every time she would drift off she would awaken to find herself scratching furiously. Another patient even confessed to using her hairbrush on her vulva in a desperate attempt to get some relief.
While LS most commonly affects postmenopausal women, I have seen it in every age group, including the occasional teen. It usually occurs on the skin around the clitoris and/or labia, which appears white, thin and slightly wrinkled. In addition to intense itching, there can be cracks in the skin, bleeding and pain. No surprise, in the most severe cases intercourse is pretty much out of the question – the skin not only splits, but scarring can cause a narrowing and tightening of the opening of the vagina.
Usually I suspect someone has LS by her skin’s appearance, but the only way to know for sure is to biopsy the skin since other conditions can have a similar appearance.
It’s not clear how or why women get LS. There does seem to be a genetic predisposition, and in many cases, it is associated with an immunologic problem such as thyroid disease.
Steroids are the almost magical cure, but it needs to be the right steroid and it needs to be used the right way. Clobetasol is the prescription-strength cream that is generally the first line of attack. It needs to be applied daily at first and then is reduced to a maintenance dose. This is one of those conditions that if the medication is completely stopped, the recurrence rate is very high. While some women are able to eventually stop using the cream and apply only if symptoms come back, most need to apply the medication on a fairly regular basis to prevent recurrence.
Steroids tend to make the skin thin, so many treatment protocols also require using topical estrogen cream to make the tissue thicker and more elastic. It’s a balancing act; the right combination of steroid and estrogen cream do the trick for the majority of women.
The most important thing to know is that this is a manageable problem. Virtually every patient with LS is able to restore her sex life and her sanity. So, if these symptoms sound familiar, please put the hairbrush away and go see your gynecologist.

Originally published 8/4/2011 Revised Sept 4, 2015