Lichen Sclerosus – Causes, Symptoms & Treatment
Lichen sclerosus is a chronic, inflammatory skin condition that I see regularly in my Vulval Clinic at Skindepth — and in my experience, it is one of the most underdiagnosed and undertreated conditions in women's health. Many patients have lived with symptoms of lichen sclerosus for years before receiving a correct diagnosis. My goal with this post is to explain what lichen sclerosus is, what it looks like, what causes it, and what modern treatment involves — in plain language, grounded in the best available evidence.
What Is Lichen Sclerosus?
Lichen sclerosus (sometimes referred to by its older name, lichen sclerosus et atrophicus) is a chronic inflammatory dermatosis that most commonly affects the anogenital skin (genital and anal areas ) — particularly the lichen sclerosus vulva — though it can also occur on extragenital sites including the upper trunk, neck, and wrists. It affects women of all ages but has a bimodal distribution, with peaks in prepubertal girls and postmenopausal women.¹
It is important to note that lichen sclerosus can also affect men, where it is sometimes known as balanitis xerotica obliterans, often involving the foreskin or glans of the penis.
It is not contagious, not a sexually transmitted infection, and not caused by poor hygiene — misconceptions I address frequently in the clinic.
Lichen Sclerosus Symptoms
The hallmark lichen sclerosus symptoms include:
- Itching (pruritus) — often severe, worse at night
- Burning or stinging, particularly with urination or sexual contact
- Soreness and rawness of the vulval skin
- Dyspareunia (painful intercourse) due to loss of skin elasticity and architectural change
- Skin splitting or fissuring, especially at the posterior fourchette
- In advanced or untreated disease: scarring, which can result in loss of the labia minora, burying of the clitoris under fused tissue (clitoral phimosis), and narrowing of the vaginal introitus
It is important to note that some women with lichen sclerosus are entirely asymptomatic, which is one reason the condition can go undetected for years.²
What Does Vulvar Lichen Sclerosus Look Like?
Clinically, what vulvar lichen sclerosus looks like depends on the stage of disease. Early disease may present as subtle pallor, loss of normal skin texture, or a slightly shiny, crinkled ("cigarette paper") appearance to the vulval skin.
As the condition progresses, the characteristic ivory-white plaques become more pronounced, often in a figure-of-eight distribution encircling the vulva and perianal skin. Ecchymosis (bruising), erosions, and fissures may be present, and secondary lichenification can develop in response to chronic scratching.³
The architectural changes of scarring — loss of labia minora, clitoral hood fusion, introital stenosis — are a consequence of delayed or inadequately treated disease. These changes are, in many cases, preventable.
What Causes Lichen Sclerosus?
The precise answer to what causes lichen sclerosus remains incompletely understood, but current evidence points to an autoimmune aetiology in genetically predisposed individuals.
Autoimmune mechanisms: There is a well-established association between lichen sclerosus and other autoimmune conditions, including thyroid disease, vitiligo, alopecia areata, and pernicious anaemia. Studies have identified elevated rates of circulating autoantibodies, including anti-ECM1 (extracellular matrix protein 1) antibodies, in a significant proportion of patients with lichen sclerosus.⁴
Genetic predisposition: A family history of lichen sclerosus is reported in a subset of patients, and HLA associations have been identified, suggesting a heritable component to risk for lichen sclerosus.
Hormonal factors: The preponderance in postmenopausal women and prepubertal girls — both low-oestrogen states — has led to speculation about the role of sex hormones, though topical oestrogen has not been shown to be an effective treatment, and the hormonal hypothesis does not fully account for the condition's occurrence in premenopausal women.
Local factors: Occlusion, trauma, and local irritation may act as triggers or exacerbating factors in predisposed individuals. The Koebner phenomenon (development of new lesions at sites of skin trauma) has been described in lichen sclerosus.
Lichen Planus vs Lichen Sclerosus
A question I am often asked is how to distinguish lichen planus vs lichen sclerosus, as both are chronic inflammatory dermatoses affecting the vulva that can look and feel similar to patients.
Key differences include:
| Feature | Lichen Sclerosus | Lichen Planus |
|---|---|---|
| Morphology | White, atrophic, crinkled plaques | Erosions, Wickham striae, glazed erythema |
| Distribution | Figure-of-eight anogenital | Often involves vaginal mucosa; can be oral |
| Scarring | Yes — architectural destruction | Yes — erosive LP especially |
| Vaginal involvement | Rare | Common in erosive LP |
| Malignant potential | Yes (Squamous Cell Carcinoma - SCC) | Yes (SCC, particularly erosive LP) |
| Histology | Homogenisation of collagen, lichenoid infiltrate | Band-like lymphocytic infiltrate, saw-tooth rete ridges |
Both conditions require specialist management and long-term follow-up. Biopsy is often required to distinguish them — particularly when features overlap, or when there is concern about malignancy.
Complications of Lichen Sclerosus: Vulvar Cancer
The association between vulvar cancer lichen sclerosus is one of the most important reasons this condition must be taken seriously and treated actively. Women with lichen sclerosus have an estimated lifetime risk of developing vulvar squamous cell carcinoma (SCC) of approximately 4–5%, compared to a general population rate of less than 1%.⁵
Malignant transformation is more likely in the context of longstanding, inadequately treated, or hyperkeratotic disease. The presence of differentiated vulvar intraepithelial neoplasia (dVIN) in association with lichen sclerosus represents the most significant precancerous change and may be subtle and easily missed.
Regular follow-up with a dermatologist experienced in vulval disease is therefore essential — not just to manage symptoms, but for surveillance. Any area of persistent ulceration, new thickening, hyperkeratosis, or raised lesion within a background of lichen sclerosus should be biopsied promptly.
How Is Lichen Sclerosus Diagnosed?
To diagnose lichen sclerosus, a clinical examination is the first step. However, a biopsy is often required to confirm the diagnosis, especially if the clinical picture is uncertain or if there is a risk of squamous cell changes. Early diagnosis and treatment are vital to prevent lichen sclerosus from getting worse.
Treatment
The current standard of care for lichen sclerosus is ultra-potent topical corticosteroid therapy — most commonly clobetasol propionate 0.05% ointment. Evidence-based treatment protocols support an initial intensive course (typically daily application for 4 weeks, then tapering) followed by long-term maintenance therapy to prevent flares, progression, and reduce malignancy risk.⁶
Key principles of management I apply in my Vulval Clinic:
- Diagnosis confirmation, with biopsy when the clinical picture is uncertain or atypical
- Patient education — understanding the chronic nature of the condition and the importance of adherence to treatment
- Steroid technique — correct amount, correct area, correct frequency. Underapplication is common and leads to poor outcomes; overapplication is rarely a significant clinical problem at the sites involved
- Emollient use and avoidance of irritants (soap, wet wipes, synthetic fabrics)
- Regular review — initially 3-monthly until disease control is achieved, then at minimum annually
- Multidisciplinary care where appropriate — pelvic floor physiotherapy for associated dyspareunia and introital stenosis, gynaecology for structural complications, psychology or sexual health for impact on intimacy and wellbeing
Emerging therapies, including topical calcineurin inhibitors, platelet-rich plasma (PRP), and fractional laser, are being studied, though the evidence base for these remains less robust than for topical corticosteroids.
Prognosis
While lichen sclerosus is a chronic condition without treatment, the prognosis is excellent for those who adhere to long-term management of lichen sclerosus. With early diagnosis and treatment, most patients achieve complete symptom relief and significantly reduce their risk of skin cancer.
When to Seek Help
If you have vulval itch, burning, soreness, or pain that is not resolving, or if you have noticed any changes in the appearance of your vulval skin, please see a doctor. Lichen sclerosus is a condition where early diagnosis and treatment genuinely change long-term outcomes.
At Skindepth's Vulval Clinic, I see patients with lichen sclerosus and other vulval dermatoses in a dedicated, specialist setting. Referrals are accepted from GPs and other specialists.
References
- Kirtschig G. Lichen Sclerosus — Presentation, Diagnosis and Management. Dtsch Arztebl Int. 2016;113(19):337–343.
- Fistarol SK, Itin PH. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol. 2013;14(1):27–47.
- Lewis FM, Tatnall FM, Velangi SS, et al. British Association of Dermatology guidelines for the management of lichen sclerosus, 2018. Br J Dermatol. 2018;178(4):839–853.
- Oyama N, Chan I, Neill SM, et al. Autoantibodies to extracellular matrix protein 1 in lichen sclerosus. Lancet. 2003;362(9378):118–123.
- Bleeker MC, Visser PJ, Overbeek LI, van Beurden M, Berkhof J. Lichen Sclerosus: Incidence and Risk of Vulvar Squamous Cell Carcinoma. Cancer Epidemiol Biomarkers Prev. 2016;25(8):1224–1230.
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Corazza M, Schettini N, Zedde P, Borghi A. Vulvar Lichen Sclerosus from Pathophysiology to Therapeutic Approaches: Evidence and Prospects. Biomedicines. 2021;9(8):950.
This blog is intended as general information only and does not constitute medical advice. If you have concerns about your skin or vulval health, please consult a qualified medical professional.