Lichen sclerosus treatment

Unlike osteoarthritis of the hip or the common cold, lichen sclerosus is one of those diseases that hardly anyone talks about. The chronic skin disease affects primarily, but not only, women. In addition to the physical complaints, there are often psychological consequences of the disease: those affected literally feel uncomfortable in their skin. The earlier a therapy starts, the better lichen sclerosus can be treated.

What is Lichen Sclerosus?

The term “lichen sclerosus” comes from the Greek and means something like “dry lichen”. This name derives from the appearance of the disease: it is characterized by the whitish, hard skin nodules, which later resemble scar tissue (“sclerosis” for “scarring”). Lichen sclerosus is a chronic disease of the skin, or more precisely, of the connective tissue. The fibroblasts, which build connective and scar tissue, are overly active. The structure of the skin is thus disturbed, leading to inflammatory processes in the skin. Why the skin becomes ill is uncertain. Experts suspect hormonal imbalances or damage to the immune system as the cause. Although the causes of lichen sclerosus are still unknown, one thing is certain: the disease is not contagious.

How common is lichen sclerosus?

It is estimated that 2 to 4 percent of all women suffer from lichen sclerosus. This means that at least one in 50 women is affected by the disease. 0.5 to 2 percent of men develop lichen sclerosus in the course of their lives. In children, one in 900 suffers the disease. It is possible that the number of unreported cases is higher because many patients avoid going to the doctor for a long time out of feelings of shame.

Risk Groups: Who gets lichen sclerosus?

Most often, adult women suffer from lichen sclerosus. For many sufferers, the first symptoms appear at childbearing age and disappear for years, only to flare up again after menopause. The “typical” lichen sclerosus patient is 50 years old. Doctors assume that ten percent of those affected have a family background – so there may be a predisposition to lichen sclerosus. It is estimated that about half of all cases are genetic.

There is also a connection to hormonal changes. For example, women who have used contraception with the “pill” until menopause have a higher risk of developing lichen sclerosus. Often, the skin disease also occurs in connection with other conditions. These include diabetes mellitus, especially in men, and thyroid disease in women. Various autoimmune and inflammatory bowel diseases are also among the concomitant diseases.

It is possible that trauma to the genital area plays a role in triggering the onset of lichen sclerosus. This can be caused by: heavy scratching, tight clothing, surgical procedures, intimate jewelry and sexual abuse.

Lichen sclerosus: symptoms

“Typical” for the disease are the whitish skin changes in the genital and/or anal area. However, lichen sclerosus can also be atypical.

Possible symptoms include:

  • Itching and burning
  • Redness
  • dry, flaking skin
  • Hardening of the skin
  • Tearing of the skin during sexual intercourse
  • white spots
  • fissures
  • Keloid scarring
  • Narrowing of the foreskin (phimosis) in men
  • Pain when urinating/bladder discomfort without bacteria in the urine
  • regression of the labia in women, narrowing of the vaginal entrance
  • pain during intercourse

The symptoms occur mainly in the genital area – including the perineum, buttock fold and anus. In women, the insides of the labia minora and labia majora, as well as the clitoral hood, are often symmetrically affected. Experts also refer to the visual manifestation of the symptoms as the “figure of eight”.

Without therapy, severe changes in the vaginal area can occur due to scarring. In about 10 percent of women, skin changes are also found in other areas, such as the under breast fold. In men, symptoms usually occur on the glans and foreskin while the perianal region and the rest of the skin are almost never affected.

Possible sequel of lichen sclerosus

If lichen sclerosus is not treated, not only can the symptoms worsen drastically, but it can also lead to secondary diseases.

Since the barrier function of the skin in the affected area is weakened, patients with lichen sclerosus are prone to fungal infections and genital warts, among other things.

In about 4 to 6 percent of affected women, malignant tumors in the form of squamous cell carcinomas develop during the course of the disease. Hardened plaques, nodules and non-healing, sore spots should therefore be biopsied promptly. The increased risk of cancer is probably caused by chronic inflammation in combination with oxidative damage to DNA.

Suspected lichen sclerosus- when to see a doctor?

When should you see a doctor? Many people who notice discomfort or changes in the genital area are hesitant and prefer to wait and see. Not a good idea. This is because the earlier lichen sclerosus is diagnosed, the faster treatment can curb the symptoms, improve quality of life and prevent unpleasant long-term effects.

In case of itching or other complaints in the genital area, those affected should therefore consult a doctor as soon as possible. Dermatologists, gynecologists or urologists are suitable contacts for changes in the skin in the genital area.

Lichen sclerosus diagnosis

In most cases, the description of the symptoms in combination with the characteristic white patches of skin leads to a visual diagnosis on the part of the expert. Some doctors want to confirm the visual diagnosis in adults by means of a biopsy. Subsequently, the removed tissue is examined in a laboratory. However, the usefulness of biopsies in lichen sclerosus for initial diagnosis is controversial. They are considered useful above all for the exclusion of malignant changes and after unsuccessful therapy.

Since lichen sclerosus weakens the skin’s immune defenses, symptoms can occur together with fungal infections, for example. This can make it difficult to diagnose the underlying skin disease. For example, a fungal disease is also accompanied by severe itching. Also, white skin areas do not always form early in lichen sclerosus. Experienced specialists will be able to make a differential diagnoses to lichen sclerosus accordingly.

These include circumscript scleroderma (CS), also known as “morphea”, lichen planus, vitiligo, eczema, psoriasis, autoimmune and blistering dermatoses, and candida fungal infections.

Treatment of lichen sclerosus

So far, there is no cure for lichen sclerosus – at least in women. However, with the right therapy, the majority of those affected can lead a largely symptom-free life. Drug therapy with steroid ointments, has proven to be effective. Modern laser therapie and PRP can also significantly alleviate the symptoms (see below).

Gynecologists, dermatologists or urologists are the ideal contacts to provide patients with an individual therapy regimen. It is important to stick to it even after the symptoms have subsided to avoid relapses.

Cortisone therapy for lichen sclerosis

The greatest success is achieved by initial relapse therapy with glucocorticosteroids in the form of highly potent cortisone ointments. Women and men affected by genital lichen sclerosus apply a fingertip of the respective ointment to the skin areas once or twice a day. A hand mirror can be helpful, especially at the beginning of therapy. In addition, calcineurin inhibitors – see below – are often used.

More than three-quarters of patients experience significant improvements in symptoms over the course of three months. About half of the men react to therapy with ointments with a significant improvement in symptoms. Alternatively, cortisone therapy can be carried out via injection into the affected areas of the skin.

After twelve weeks, the therapy must be adjusted. Depending on the severity of the symptoms, the intervals between cortisone administration can be extended. Many patients achieve freedom from symptoms when a moderate or strong corticosteroid is administered twice a week. It is important to continue therapy to prevent relapses. Even with long-term use of ointments containing cortisone, side effects rarely occur. The attending physician recommends special skin care products for the genital area. These include moisturizing ointments, such as ointments containing paraffin and vaselin without fragrances, or oils. These nourish and keep the skin elastic. Maintenance therapy not only reduces the risk of new flare-ups, but also the risk of genital cancer.

Latest after the initial treatment, i.e. after three months with cortisone ointments, a check by the doctor should be carried out. He or she can then adjust the dosage and initiate maintenance therapy in the best possible way. For the subsequent long-term treatment, a check-up every six months is recommended, later annually. If male patients do not experience a reduction in symptoms after relapse therapy, circumcision is an alternative option with excellent prospects of complete remission.

Calcineurin inhibitors for lichen sclerosus

Cortisone ointments are the first choice for lichen sclerosus. Calcineurin inhibitors such as the active ingredients tacrolimus and pimecrolimus have an anti-inflammatory effect and suppress the immune system. They are often used in addition to cortisone ointments for lichen sclerosus, which has a positive effect on the success of therapy. If there is an intolerance to cortisone, they offer an alternative treatment option. Experts also refer to calcineurin inhibitors as calcineurin inhibitors (CKD) or immunomodulators.

Circumcision in men and boys

Circumcision of the foreskin (circumcision) is considered a therapy with excellent chances of recovery in men and boys with uncomplicated lichen sclerosus. In men and boys, this procedure leads to the complete and long-term disappearance of all symptoms in 90 to 100 percent of those affected.

Therapy in children

The therapy of children is specially adapted to them. In some children – an estimated 25 percent of affected girls – lichen sclerosus completely regresses during puberty and does not come back. In the majority of children, however, symptoms recur many years later. Therapy and intervals of examinations can vary greatly in children and young adults with a history of lichen sclerosus. For boys with genital lichen sclerosus, circumcision is one of the surgical therapies with the best chances of recovery.

Laser therapy

Vaginal laser therapy has now established itself as an effective and sustainable treatment of (chronic) complaints in the female genital area. The laser treatment does not require any surgical interventions or the use of hormones, but is based on light energy. Vaginal laser therapy also shows convincing effects in the treatment of lichen sclerosus. Within a few treatment sessions, light therapy improves the structure of the skin and prevents new flare-ups. Ideally, laser therapy is combined with cortisone therapy.

Laser Therapy (also called Mona-Lisa treatment) is not covered by medicare.

Learn more about Mona-Lisa Therapy in our article on Vaginal Atrophy

PRP for Lichen

The conventional Platelet-Rich Plasma (PRP) rejuvenation procedure is used in the cosmetic industry a lot (also known as vampire facials).

This process stimulates the multiplication of stem cells and promotes the growth of younger tissue. The Growth Factors released from the activated PRP aid in collagen and elastin production, leading to tissue thickening and expansion around the affected area. This results in overall healthier skin.

Other therapeutic approaches

In addition to the classics, therapy with the ointments mentioned, male circumcision and laser therapy, there are other therapy options. These serve in particular to curb the symptoms caused by lichen sclerosus.

These therapeutic approaches include:

  • Physiotherapy, for example for severe tension in the pelvic floor
  • Stretching with dilators for vaginal entrance narrowing
  • Light therapy for extragenital lichen sclerosus
  • Estrogen ointments for vaginal dryness
  • Rare: oral intake of vitamin A supplements
  • in exceptional cases: surgery, e.g. in case of adhesion of the labia
  • In addition, depending on the severity of the symptoms, concomitant therapies are available. This can include special relaxation exercises. Sex life and partnership can also be affected.
  • Anyone who suffers psychologically from the consequences of the disease should not hesitate to seek professional help. Psychotherapists or sex therapists can be suitable contact persons. Exchanging ideas with other sufferers can also help.

Everyday life with lichen sclerosus

For many sufferers, the diagnosis of “lichen sclerosus” is accompanied by the realization that they are suffering from an incurable disease. This is especially true for women, who usually require lifelong therapy.

However, the skin disease in the genital area is easily treatable. If you contact an expert such as a specialist in dermatology, gynecology or urology at an early stage, you will receive a tailor-made therapy.

This also reduces the risk of malignant changes associated with untreated lichen sclerosus in women. The exchange with other sufferers can help to cope better with the psychosocial consequences of the disease.

Since lichen sclerosus cannot yet be ‘cured’, the primary aim of treating the skin disease is to improve the symptoms and prevent flare-ups. In addition to medical treatment, the following tips can improve everyday life with lichen sclerosus and prevent new flare-ups:

  • Silk underwear instead of cotton or synthetic underwear
  • airy clothing
  • soft bicycle saddle
  • no moist toilet paper or baby wipes
  • mild washing lotions
  • only light vaginal irrigation
  • use a bidet or shower to wash your bottom instead of toilet paper.
  • dry the area with a hair dryer or soft towel
  • If necessary, support vaginal flora with special probiotics
  • use lubricant suitable during sexual intercourse.
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