Lichen sclerosus is a chronic skin condition in the vulva which will need lifelong treatment. It causes stinging or burning in the vulva with visible white or red and white patches sometimes with ulceration. It can and should be treated with steroid creams.
Below is a guide for doctors and patients
White areas on the vulva
White areas on the vulva are commonly Lichen sclerosus but can be other conditions such as Lichen planus or contact dermatitis. Most dermatological conditions can occur on the vulva including psoriasis, dermatitis, scleroderma and “idiopathic” splits. These can all be mistaken for Lichen sclerosus. As Lichen sclerosus needs long term treatment, a correct diagnosis is important.
Lichen sclerosus may appear as white patches with some red areas and associated with splits. Parts may be ulcerated.
Any white area on the vulva needs a biopsy to establish the cause.
I am sometimes surprised by unexpected results, most commonly by contact dermatitis and Lichen planus.
Most common in middle aged and elderly women but it can be either sex and at any age.
It affects 1:80 women. Without adequate treatment, around 4% may progress to vulval cancer. Untreated, it may also lead to painful contracted scars.
It most commonly affects genital and peri-anal skin.
Adequate assessment usually requires a magnified view such as with a colposcope (binocular microscope).
Treatment initially is with potent steroid application. While creams are most commonly prescribed, ointments will relieve some symptoms especially dysuria better.
The aim is to reduce the strength and frequency of steroid preparations to a single application once a day if possible. Start with betamethasone 0.05% three times a day. When the Lichen sclerosus has completely resolved, gradually decrease the frequency then change to 0.02% creams. Maintain control with the lowest dose found to work but do not stop using at least betamethasone 0.02% at least once a day.
Never stop the treatment.
Some post-menopausal women may also develop vulval atrophy during the treatment. This can be treated with topical oestriol cream (Ovestin). It may have to be used twice a day at first for several weeks.
Daily use of Betamethasone 0.02% rarely causes vulval atrophy.
Oestradiol topically (Vagifem) and systemic HRT do not adequately correct vulval atrophy.
Try a more potent steroid cream or ointment. Use mometasone (Elocon, Novasone) once a day. If not adequate for complete resolution use it twice a day.
If topical steroids do not abolish all white areas, the MonaLisa laser is useful in most to augment the steroid preparations. It may have to be used periodically. Most patients will respond well to this combined treatment
Low potency steroids like hydrocortisone rarely work.