Lichen Sclerosus et

atrophicus

Introductions
Lichen sclerosus et atrophicus name now
lichen sclerosus (LS) by International
Society for The Study of Vulvovaginal
Disease
Other name kraurosis vulvae and
hypoplastic dystrophy
Def chronic atrophic disorder mainly of
the anogenital skin of females but also of
males and of the general skin

LS occurs vulva, glans penis and other

keratinized skin surface never effects on
vagina.
LS occur most often in postmenopausal
woman know LS occurs in all ages but
tends to be most symptomatic in a setting
of the estrogen deficiency of early or late
life
Sex Females ten times more often
affected than males

Etiology
Unproven etiology autoimmune
mechanism
Other theories abnormalities of keratin
synthesis and defects in androgen metabolits
or receptors functions
Abnormal keratin decreased collagenase,
increased collagen inhibitors and increased
in elastase activity all have been reported as
well
Finally, there is known but small
hereditary predisposition for this disease

Clinical manifestation
LS begin asymptomaticallymost patients
1. LS in woman
Many women classic symptom of itching or pain
exhibit late signs of LS including remarkable
texture change or scarring
Woman tolerate their disease comfortably until
they develop a superimposed complicating event
such candidiasis or atrophic vaginitis produces
itching followed scratching becomes self
perpetuating

Most common symptom pruritus can be

mild or severe
Vulvar skin affected by LS fragile
scratching often produces painful erosions
With late scarring and narrowing of the
introitus pain with and even an inability
to tolerate intercourse may occur

LS begin white papules or plaque often

occur first on the anterior vulva and
periclitorally papules and plaque
sometimes smooth and waxy especially
when occuring on moist skin classic
presentations hyperpigmented, welldermacated plaque with a crikled or
cellophane paper-like texture

Other disease such lichen planus can

produce hypopigmentation and scarring
characteristic crinkled texture only in LS
Common manifestation the skin quite
fragile and thin, with erosion and purpura
Some woman particularly those who are
excruciatingly itchy, exhibit thickened,
hyperkeratotic skin and accompanying
changes eczema

Superimposed changes of eczema and

hyperkeratosis can obscure underlying
pathognomonic texture changes
Fully developed LS with hypopigmentation
and distinctive shiny or crinkled texture
changes easily recognized

2. LS in man

Penile LS most commonly in middle

ageoften asymptomatic symptomatic
itching, burningwith urination, painful
erection, diminished sensation of the
glans, or diminution in the caliber & force
of the urinary steam In uncircumcised
sclerotic, constricting band forms 1-2 from
distal end prepuce, phimosis

Clinically ivory or porcelain white

macules & plaques surface lesion
smooth, hyperkeratotic, elevated or same
plane as normal skin hemorrhage occur
beneath surface macules & plaques
epidermis atrophic lession may sheer off
resulting erded or ulcerated loci within the
lesion
Most commonlyglans & inner aspect
prepucemay occurcircumferentially
around urethal meatus

Rare complicationsdevelopment SCC of

the penis arising in involved sites

Differential Diagnosis
LS often obscure by and mistaken for
secondary lichen simplex chronicus
Disease with more subtle texture changes
can be mistaken for vitiligo
LS occasionally exhibit uniform white
papules or plaque and scarring resemble
lichen sclerosus although vulvar lichen
planus usually is accompanied by oral or
vaginal disease

Scarring produced by lichen sclerosus

with immunobullous disease & any
intensely inflammatory process
Postinflammatory hypopigmentation
Biopsy indicated when doubt of the
diagnosis exists because course &
treatment of lichen sclerosus differ from
those of these other disease

Histopathologic
Usual thinning & effacement of the
epidermis with hyperkeratosis
occasionally acanthosis
Chronic inflammatory infiltrate in early
lesion in the upper dermis, abutting the
epidermis occur vacuolar degenerations
of the basal cell layer characteristic
homogenization of the upper dermis &
pathognomonic

Later lession zone of edematous &

homogenized dermis displaces the
inflammatory response from upper dermis
into middermis

Management
1. Ultrapotent topical glucocorticois

LS effectiveness ultrapotent topical

glucocorticoid such clobetason propionate
twice a day alleviates symptoms within a
few days several months of therapy
required for reversion of the clinical texture &
color changes to normal
Midpotency topical glucocorticoid reduce
symptom not normalize the skin texture or
prevent scarring

Patients require 3 to 5 months once or

twice daily application reach maximal
improvement do well with chronic
application of an ultrapotent glucocorticoid
thrice weekly an ongoing basis to
eliminates itching & pain, restores a normal
texture & resiliency to the skin usually
eliminates hypopigmentation preexisting
scarring of vulvar structure remains
unchanged

Very quickly experience dramatic relief from

itching or pain superpotent gluco corticoid
Especially severe itching or pain, with
significant secondary eczematous &
estrogen deficient females such prepubertal
& postmenopausal woman often improve
more quickly with additional therapy for
the first 2 weeks to control scratching &
secondary infections

Nighttime therapy with sedating doses of

an antihistamine or tricyclic antidepresant
control scratching & secondary infection
2.Antifungal oral
Combination antibiotic & glucocorticoid
particularly likely to allow for development
yeast infection addition 150 mg oral
fluconazole weekly to prevent during
therapy antibiotics

 3. Hormone topical

Estrogen deficiency in postmenopausal

corrected with topical therapyinsertion
estrogen cream or estradiol vaginal tablet
3x/week
Beneficial effects with topical
progesterone & estrogenminimal &
equivalent to lubrication alone

 4. Surgical therapy

Cryotherapy, vulvectomy & carbon dioxide

laser vaporization not adequately
treated medically

Examination
Reexamined to evaluate
1. The posibility of an intercurrent bacterial or yeast
infection
2. The occurrence of contact dermatitis to the
topical medication, cleanser, topical anesthetics
3. The presence of a secondary squamous cell
carcinoma
4. The posibility of a different or additional
diagnosis e.g erosive lichen planus can produce
white plques & scarring often does not respond
well to therapy