Lichen sclerosus (LS) (also known as "Lichen sclerosus et atrophicus") is an uncommon disease of unknown cause that results in white patches on the skin, which may cause scarring on and around genital skin.
Several risk factors have been proposed, including autoimmune diseases, infections and genetic predisposition. There is evidence that LS can be associated with thyroid disease.
Synonyms and short history
Lichen sclerosus (LS) is also known as Lichen Sclerosus et Atrophicus (LSA), Balanitis xerotica obliterans (BXO), Csillag's disease, White Spot Disease and kraurosis vulvae. Typically it's called LSA or BXO when it affects men, LS when it affects women or in referring to the disease in general.
Lichen sclerosus et atrophicus was first described in 1887 by Dr. Hallopeau. Since not all cases of lichen sclerosus exhibit atropic tissue, et atropicus was dropped in 1976 by the International Society for the Study of Vulvovaginal Disease (ISSVD), officially proclaiming the name lichen sclerosus. Since then this is the official medical name for this disease.
Signs and symptoms
Women are more commonly affected than men, particularly around and after menopause, but younger women or girls may also develop the disease. The condition most commonly occurs on the vulva and around the anus with ivory-white elevations that may be flat and glistening. There may be marked itching or the condition may be without any symptoms. There may also be thinning and shrinkage of the genital area that may make coitus, urination and defecation painful.
In males, the disease may take the form of whitish thickening of the foreskin, which cannot be retracted easily (phimosis). In contrary to women, there is no perianal involvement. In men, this genital involvement has traditionally been known as balanitis xerotica obliterans (BXO).
On the non-genital skin, the disease may manifest as porcelain-white spots with small visible plugs inside the orifices of hair follicles or sweat glands on the surface. Thinning of the skin may also occur.
Although it is not clear what causes LS, four theories have been postulated.
Autoimmunity is a process in which the body fails to recognize itself and therefore attacks its own cells and tissue. In case of LS, specific antibodies have been found. Furthermore, there seems to be a higher prevalence of other autoimmune diseases such as diabetes mellitus type 1, vitiligo and thyroid disease.
Both bacterial as well as viral pathogens have been implicated in the etiology of LS. A disease that is similar to LS, acrodermatitis chronica atrophicans is caused by the spirochete Borrelia burgdorferi. Viral involvement of HPV and hepatitis C are also suspected.
Since LS in female is primarily found in women with a low estrogen state, hormonal influences were postulated. To date though, very little evidence has been found to support this theory.
Local skin changes
Some findings suggest that LS can be initiated through scarring or radiation, although these findings were sporadic and very uncommon.
The disease often goes undiagnosed for several years, as it is sometimes not recognized and misdiagnosed as thrush or other problems and not correctly diagnosed until the patient is referred to a specialist when the problem does not clear up.
It's rare for a biopsy of the affected skin to be taken, especially so in children. A biopsy is only performed if suspecting of cancer or VIN. Histologically there's hyperkeratosis, atrophic epidermis, sclerosis of dermis and lymphocyte activity in dermis. The biopsies are also checked for signs of dysplasia.
LS is usually treated with application of potent steroids, which may cause relief and prevent scarring.
To correct the phimosis, a circumcision can be performed. It is not beneficial to remove LS-affected skin that is not located on the genitals, as it also tends to relapse.
The morbidity of LS can stretch beyond the skin damage. Sufferers can feel depressed due to the physical pain LS causes. This can develop into low self-esteem issues and psychological issues concerning sex. In such situations, it may be helpful to speak with a counselor. Support groups may also allow sufferers to realize that they are not alone, and that there are others who understand how they feel.
The disease can last for a considerably long time. Occasionally, "spontaneous cure" may ensue, particularly in young girls.
Lichen sclerosus is associated with a higher risk to cancer. Skin that has been scarred as a result of lichen sclerosus is more likely to develop skin cancer. Women with lichen sclerosus may develop vulvar carcinoma. Periodic consultation is therefore necessary.