What's Up "Down There": Lichen Planus vs. Lichen Schlerosus

Lichen Planus and Lichen Schlerosus are both skin conditions that affect the vulval area. The vulva is a woman's external genital organs (including her mons pubis, labia majora, labia minora, clitoris and vaginal opening). Lichen Planus and Lichen Schlerosus can also affect men and the penis, although this seems to be less common.

Is it cancer?

Lichen Planus and Lichen Schlerosus are not cancer. However both may develop into a type of skin cancer called squamous cell cancer over a period of many years.

This is not certain to occur.

However, if it does happen, note that squamous cell cancer is the second most common cancer and can often be treated. It is most-often slow-growing and rarely spreads.

However, it is still cancer.

If you have Lichen Planus or Lichen Schlerosus, you should be checked every six months by a doctor for signs of change.

Is it an STI?

No. There is absolutely no connection between sex and Lichen Planus or Lichen Schlerosus.

Nuns can get Lichen Planus and Lichen Schlerosus. Virgins can get it.

Furthermore, it's not contagious, so merely being diagnosed with Lichen Planus or Lichen Schlerosus ought not prevent you enjoying a full and active sex life. However, the itchy, fragile skin around the vulva can make sex uncomfortable. The conditions can also cause vulval pain, which may make you disinclined to have sex.

One study found that women with Lichen Schlerosus were unlikely to be sexually active.

 So, what does cause Lichen Schlerosus and Lichen Planus?

It's thought that an autoimmune response may be partly to blame. Women who have a thyroid disorder, diabetes, or pernicious anaemia are more likely to experience Lichen Schlerosus or Lichen Planus.

It can also run in families (with mothers-and-daughters, and groups of sisters, reportedly affected), so it's thought that there may be an inherited factor involved.

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Symptoms: Lichen Planus

Lichen Planus affects the skin of the vulva, but may affect the mouth, anus and (rarely) the oesophagus (a.k.a. the gullet; the tube that passes food from your mouth to your stomach).

Lichen Planus is hardly ever found in children or adolescents. It is most common in women of middle-age and older.

In Lichen Planus:

• There is a red rash with patches of grey
• Open ulcers may occur in all these areas (including inside the vagina and mouth)
• There may be rawness inside the vagina
• Sex will usually be extremely painful
• The mouth will usually be affected, making eating extremely painful

If Lichen Planus is not diagnosed promptly, scarring can occur. This means your vaginal lips will shrink, your vagina will fuse together, and your clitoris will vanish.

Symptoms: Lichen Schlerosus

Lichen Schlerosus only affects your vagina. However, unlike Lichen Planus, which mainly affects women of middle-age and older, Lichen Schlerosus affects all ages, including young children.

It looks completely different to Lichen Planus:

• In Lichen Schlerosus, the skin is patched with white
• It may look like a "figure of eight" encircling your vulva and anus, but can occur anywhere on your genitals
• Over time, scar tissue can collect around the vagina, making sex painful.
• If unmanaged for a long time, the labia minora will shrink, the vaginal opening will reduce and the clitoris will become smaller.

Diagnosing and Treating LP and LS

Diagnosing Lichen Schlerosus and Lichen Planus

Both conditions are similar to each other, and to other vulval conditions, so it is important that they are correctly diagnosed.

In order to do that, a biopsy (a tiny sample of your vulval cells) is essential.

This will be performed at your local hospital under local anaesthetic. About 3mm of cells will be removed. You may have minor pain afterwards, similar to menstrual cramps. Over-the-counter painkillers should help to reduce the cramping.

Treatment: General

When you're treating Lichen Planus and Lichen Schlerosus, there are some medications that you'll be prescribed to get your condition under control.

Steroid Cream/Ointment

Such as "Dermovate". It's the main treatment. Although cortisone creams and ointments have a bit of a bad reputation (call them the Joan Jett of the medicine cabinet), they don't deserve it. If used sparingly (30g should last at least three months) they are a safe and effective treatment.

Usual advice will be to use twice daily for three months and then twice weekly. But always follow the advice of your own doctor. They reduce the inflammation and increase the suppleness of your skin.

However, you can't use these potent steroid creams indefinitely, as they thin the skin leaving them as fragile and red than the Lichen Planus or Lichen Schlerosus.

Emollient

An emollient cream, such as Diprobase (applied to the vagina and anus) might be beneficial. Use them after urinating, to apply a protective barrier to the skin. You could also use an emollient (such as this, or Aqueous cream) instead of soap or bubble-bath - but do not leave Aqueous cream on your skin after cleansing.

Treatment: Lichen Schlerosus Only

Surgery

Sometimes, with scar tissue, the vaginal passage becomes too narrow, and sex is too difficult. In that case, you may require surgery to widen the opening.

Treatment: Lichen Planus Only

Oral treatments

With oral (mouth) Lichen Planus, there are a number of treatments aimed at the specific symptoms you may experience:

• Anaesthetic mouthwash: to numb the area and make eating less painful
• Corticosteroid sprays and lozenges: to get rid of the inflammation and patches in the mouth

Oral steroids

If the Lichen Planus is spread over several areas of your body, or is not being controlled with cream, it may be more convenient and effective to take a short course of oral steroids.

Note, these have side-effects, including: weight-gain, insomnia, and mood-changes.

Acitretin

Originally used as a medication for psoriasis, Acitretin is only used under advice of a specialist and only for very severe Lichen Planus that is not responding to other treatments. It has a variety of side-effects, interacts with many medications, and precludes you from giving blood or having a child for for three years as it has been linked to birth defects.

However, it might work where other medications have failed.

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Self-Help

Before you reach for the Acitretin, try these simple self-help methods, which many patients find helpful:

• Keep dry: After urination, Lynn (a patient living with Lichen Schlerosus in the United Kingdom) was advised by her gynaecologist to dry her labia with a hairdryer on a cool setting. Although she found it a strange feeling at first, she has found keeping the area dry has led to an improvement in her symptoms.
• Don't wear undies when you're in the house. Let the area breathe. Just a long-skirt. People won't notice. Contrary to what Joan (living with Lichen Planus in the U.K) thought, there won't be a flashing red-light over your head as you walk around, baking a cake, a foghorn announcing to all who pass by: "No knickers! No knickers!".
• If you must wear knickers when you go out, wear plain cotton, and no pantyliner. It's vital that you let your vulva breathe. That means that all your clothes are loose. And no synthetic fibres (they're not as breathable).
• Some women find stockings better than tights.
• Do not put any fragranced products near or around your vulva: soap, toiletries or talcum powder. Plain water is enough.
• If you want to enjoy an active sex-life but find sex painful, be sure to use a lubricant.
• If you have lichen planus, keeping your mouth in good condition is important, so take these additional steps:
  • Stop smoking
  • Avoid alcohol
  • Eat a healthy, balanced diet with plenty of fruit and vegetables, complex carbohydrates (brown rice, whole-grain bread and pasta), protein (lean meat and oily fish; beans) and dairy.

The future

We began by talking about the raised cancer risk caused by Lichen Planus and Lichen Schlerosus.

Although the risk is real, do not be afraid. You do not have to run your lives around a fear of cancer. Current estimates say that around 2-6% of women untreated Lichen Schlerosus will get cancer, while around 2% of people with Lichen Planus will get one type of cancer (mouth, vulval, or penile).

You should make an effort to regularly check your body for any changes (using a mirror). Watch out for ulcers that don't heal, changes to the size of your vaginal passage, corrosion or thickening of your skin, or anything else that suggest your condition is getting worse.

Report any changes to your doctor. You may need another course of intensive treatment.

Every six months, you should see a doctor as a matter of course, and have your Lichen Planus or Lichen Schlerosus checked for any changes. If you have Lichen Planus, you may also need your mouth checking more regularly (perhaps every three months).

By monitoring your condition regularly, you can keep your body in the best possible condition, so that you can go on enjoying your life.