Information
What is lichen?
In dermatology, «lichen» is a term that describes a type of skin lesion, usually small, flat or slightly raised and itchy. There are different diseases that share this name.
Types of lichen
Vulvar lichen sclerosus
Vulvar lichen sclerosus (VLS) is a chronic and progressive inflammatory skin disease that mainly affects the anogenital region (85–90%).
The true prevalence of VLS is unknown. Although it is one of the most frequent reasons for gynaecological consultation in postmenopausal women, its prevalence is likely underestimated. Existing records indicate that 1 in 30 adult women (around 3%) and 1 in 1,000 girls (0.1%) have VLS.
VLS is diagnosed most frequently in Caucasian people. This may be related to better access to healthcare, but could also suggest an association with genetic or autoimmune factors.
Lichen planus
Lichen planus (LP) is an inflammatory disease of the stratified squamous epithelium of unknown aetiology. It often affects the skin, skin appendages (nails and hair follicles), oral mucosa and genital mucosa.
Erosive LP, also known as mucosal LP, is the most common form in the vulva; it is associated with high morbidity and can cause significant tissue damage with pain, discharge and urinary and sexual disorders.
Concurrent involvement of the oral and genital mucosa by erosive LP is relatively common and, given its clinical significance, this clinical picture is called «vulvovaginogingival syndrome».
Lichen simplex chronicus
Lichen simplex chronicus (LSC) or neurodermatitis is a dermatosis that develops as a result of chronic scratching. It can appear anywhere on the skin, including the genital area.
In men it predominantly affects the scrotum, and in women the labia majora. This condition is one of the most frequent causes of primary vulvar pruritus.
It usually affects adults, more commonly women than men, at any age, but most frequently between 30 and 50 years.
Key differences
| Vulvar lichen sclerosus | Lichen in men | Lichen planus | Lichen simplex chronicus | |
|---|---|---|---|---|
| Area affected | Genitals (labia, clitoris…) and perianal area | Genitals (glans, foreskin…) and perianal area | Skin and mucosae | Any area |
| Typical colour | White | White | Violaceous | Reddened or dark |
| Cause | Probable autoimmune | Probable autoimmune | Autoimmune | Repeated scratching |
| Cancer risk | Yes, low incidence | Yes, low incidence | Rarely | Not usual |
Causes
The cause of vulvar lichen sclerosus (VLS) is unknown. It may be associated in some patients (and/or their close relatives) with autoimmune diseases, such as thyroid disorders or vitiligo.
Autoimmune diseases arise when the cells and proteins the body uses to defend itself against infections begin to damage the body's own tissues.
Stress is a factor that can trigger the disease or cause a flare. Lesions can worsen with skin irritation, for example from scratching the area, or from any skin infection (fungi or bacteria).
VLS is not infectious or contagious. It cannot be transmitted to a sexual partner.
Symptoms and signs
Symptoms
Vulvar pruritus
The main symptom of the disease. In some cases it is associated with stinging, burning or a sensation of heat. It is often worse in the evening and can be so intense that it interferes with sleep.
Dyspareunia
Pain during sexual intercourse and other forms of sexual dysfunction are common. In the early stages inflammation explains the discomfort; in advanced stages, sequelae (introital stenosis, fissures, etc.) cause pain or even the impossibility of having sexual relations.
Dysuria
Difficulty urinating. It occurs in advanced stages of the disease, usually secondary to the fusion of the labia minora over the urethral meatus.
Anal symptoms
Involvement of the perianal skin is relatively common and can produce symptoms such as anal pruritus, painful defecation, anal fissures and bleeding. In girls, chronic constipation may be a presenting symptom.
Signs
Small skin fissures and ulcers arising spontaneously or due to friction.
Whitish patches.
Anatomical changes: loss of vulvar tissue (disappearance or fusion of the labia minora, narrowing of the vaginal introitus, fusion of the clitoral hood).
In rare cases, it can make urination difficult.
Does not involve the vagina.
Diagnosis
Doctors familiar with the disease can diagnose it simply by examining the skin and recognising its characteristic appearance. The diagnosis is usually confirmed by a skin biopsy.
This means taking a sample of the affected skin after applying a local anaesthetic. The skin is examined under a microscope. This procedure is very simple and can be carried out in a medical clinic.
Lichen may be asymptomatic. Regular check-ups with a gynaecologist or dermatologist are essential, as lichen sclerosus can slightly increase the risk of long-term complications.
Treatments
There is no definitive cure for VLS, but symptoms can be treated very effectively. Appropriate treatment aims to prevent further inflammation and scarring in the area.
Topical corticosteroids
High-potency corticosteroids are the main treatment. These treatments are very safe and can be used in the genital area. Usually, a pea-sized dose is sufficient. Treatment should not be stopped unless indicated by the doctor, as VLS can recur. Many patients report that regular moisturising creams can be very helpful when used in combination.
CO₂ laser
Some studies have explored the use of fractional CO₂ laser for chronic vulvar lichen sclerosus cases, especially when there are scars or stenoses that impair sexual function. Results indicate it can improve skin elasticity and reduce pain and itching, but it does not treat the cause of the disease. It is only considered in cases resistant to standard medical treatment.
Radiofrequency
Fractional or microablative radiofrequency has been studied to rejuvenate and hydrate the vulvar mucosa. It can provide temporary improvement of dryness and painful intercourse, but it does not cure the disease or replace topical corticosteroids. It is a complementary treatment always under specialised medical supervision.
Regenerative techniques
Regenerative techniques have been initiated, including platelet-rich plasma, shock waves and stem cells. Appropriate treatment must be individualised for each woman and always accompanied and monitored by a multidisciplinary team of specialists.
Living with lichen
Caring for the genital area is essential to reduce discomfort and prevent lesions. Here you will find some practical tips.
Gentle hygiene
Avoid using aggressive soaps and gels. Daily cleansing can be done with warm water alone, or with a very mild soap, without scrubbing.
At night
Many women notice that symptoms worsen at night. It is important to keep nails short to avoid accidental injuries while sleeping.
Sexual relations
Using mild lubricants can ease friction. If there is dryness or you are approaching menopause, ask your doctor about using vaginal oestrogens.
Clothing and intimate hygiene
Wear loose clothing and cotton underwear, preferably without dyes. Avoid tampons or pads that may irritate the area.
Skin hydration
Moisturising the skin with natural oils such as coconut or almond oil helps keep it soft and protected.
General wellbeing
Stress, lack of exercise or dehydration can worsen symptoms. Maintaining a physical activity routine, staying well hydrated and managing stress all contribute to general wellbeing.
Working life
People with lichen sclerosus may experience intense itching, pain or fissures, which make it difficult to concentrate and maintain usual performance. Certain activities, such as sitting for long hours, doing physical work or wearing tight clothing, can worsen discomfort.
In addition to physical difficulties, lichen sclerosus can generate stress, anxiety or shame, affecting confidence and relationships with colleagues or clients.
During intense flares, medical appointments or temporary sick leave may be necessary. Adapting the workplace — such as taking regular breaks, wearing comfortable clothing and following medical treatment — can help minimise the impact.
Myths and reality
“It is a sexually transmitted disease”
Lichen sclerosus is not contagious and is not transmitted sexually. It is not an infection.
“It only affects older women”
It is more common in postmenopausal women, but can also appear in girls, younger women and men.
“It is caused by poor hygiene”
It is not related to hygiene. It is an inflammatory disease with a possible autoimmune and genetic component.
“There is no treatment”
Although it is chronic, it does have treatment. High-potency topical corticosteroids usually control symptoms and prevent complications.
“It always becomes cancer”
There is a slightly increased risk of vulvar cancer in uncontrolled cases, but with appropriate medical monitoring the risk is low.
“It is just a cosmetic problem”
It can cause intense itching, pain, fissures and discomfort during sexual intercourse. It is a real disease that requires monitoring.