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Lichen sclerosus

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Updated 2024 EDF guidelines for the management of lichen sclerosus.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of lichen sclerosus are prepared by our editorial team based on guidelines from the European Dermatology Forum (EDF 2024), the European Academy of Dermatology and Venereology (EADV 2022,2017,2015), the American College of Obstetricians and Gynecologists (ACOG 2020), the British Gynaecological Cancer Society (BGCS 2020), and the British Association of Dermatologists (BAD ...
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Diagnostic investigations

History and physical examination: as per ACOG 2020 guidelines, elicit a comprehensive medical history, perform a physical examination, and obtain evaluation of abnormal vaginal discharge, if an infectious etiology is suspected, in the initial evaluation of patients with vulvovaginal symptoms.
B
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  • Evaluation for comorbidities

Diagnostic procedures

Vulvar biopsy: as per EADV 2022 guidelines, avoid performing biopsy in typical cases of LS. Perform a biopsy in cases of:
diagnostic uncertainty
suspected dysplasia/carcinoma
failure of first-line treatment.
D

Medical management

Indications for treatment
As per BAD 2018 guidelines:
Initiate treatment in all patients with LS following a firm clinical diagnosis or with histological confirmation, where necessary.
E
Manage patients with LS by a healthcare professional experienced in treating the condition (secondary care specialist or general practitioner with specific training).
E

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  • Topical corticosteroids (initial therapy)

  • Topical corticosteroids (maintenance therapy)

  • Topical calcineurin inhibitors

  • Topical hormone therapy

  • Retinoids

  • Methotrexate

  • Antihistamines

  • Agents with no evidence for benefit

  • Management of pain

  • Management of co-occurring infections

Nonpharmacologic interventions

Avoidance of triggers and irritants: as per EDF 2024 guidelines, advise avoiding OTC medications, lenitive herbal products, topical antihistamines, anesthetics, and perfumed products due to an increased risk of inducing contact sensitization.
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  • Silk underwear

  • Topical emollients

Therapeutic procedures

UV phototherapy
As per EDF 2024 guidelines:
Consider offering UVA1 phototherapy, taking into account carcinogenicity and practicality, as second-line therapy in adult female patients with genital LS.
C
Insufficient evidence to recommend UV phototherapy in adult male patients with genital LS.
I

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  • Photodynamic therapy

  • Laser therapy

  • Intralesional corticosteroid injections

  • Intralesional adalimumab injections

  • Therapies with no evidence for benefit

Surgical interventions

Indications for surgery, female
As per EDF 2024 guidelines:
Consider performing de-adhesion, synechiolysis, or perineoplasty in adult female patients with LS having a persistent introital stenosis causing mechanical problems in voiding or sexual intercourse despite guideline-recommended treatment with topical corticosteroids.
C
Ensure that patients are informed preoperatively and agree to the continuation of topical treatment after surgery, usually with topical corticosteroids, and provide interdisciplinary counseling including specialized pelvic floor physiotherapists and sex therapists.
A

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  • Indications for surgery (male)

Specific circumstances

Pediatric patients, female: as per EDF 2024 guidelines, offer topical emollients during standard therapy in pediatric female patients with genital LS.
A
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  • Pediatric patients (male)

  • Pregnant patients

  • Patients with extragenital LS (topical therapy)

  • Patients with extragenital LS (systemic therapy)

  • Patients with extragenital LS (phototherapy)

  • Patients with extragenital LS (other therapies)

Patient education

General counseling: as per EDF 2024 guidelines, counsel patients with lichen sclerosis regarding the following:
recognition of LS changes pointing towards disease progression or cancer development (ulceration, non-healing lesions, papules, wart-like lesions)
information about the importance of adherence to treatment to help prevent disease progression
avoidance of trigger factors
awareness of symptoms of autoimmune diseases (such as thyroid disease).
A
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Follow-up and surveillance

Indications for referral, general principles
As per EDF 2024 guidelines:
Refer patients with lichen sclerosis to a specialist in cases of:
no adequate improvement of signs and symptoms after adequate treatment
complications requiring specialized approaches, such as functional impairment requiring surgical treatment or chronic pain syndromes requiring care by a pain specialist
psychological support is needed
sexological support is needed
A
Refer patients with LS with voiding problems to an appropriate specialist, such as a urologist or urogynecologist.
A

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  • Indications for referral (gynecology)

  • Indications for referral (urology)

  • Assessment of treatment response

  • Management of refractory disease