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Lichen sclerosus

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 American College of Obstetricians and Gynecologists (ACOG 2020), the British Gynaecological Cancer Society (BGCS 2020), the British Association of Dermatologists (BAD 2018), and the European Academy of Dermatology and Venereology (EADV 2017; 2015).
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Guidelines

1.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

2.Diagnostic procedures

Vulvar biopsy: perform vulvar biopsy of visible lesions in any of the following circumstances:
atypical lesions (such as new pigmentation, indurated, affixed to underlying tissue, bleeding, or ulcerated)
concern for malignancy
immunocompromised conditions (including HIV)
diagnostic uncertainty
lesions not responding to standard therapy
disease worsening during treatment
B

3.Medical management

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

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  • Topical corticosteroids

  • Topical calcineurin inhibitors

  • Topical hormone therapy

  • Retinoids

  • Antihistamines

  • Agents with no evidence for benefit

  • Management of co-occurring infections

4.Nonpharmacologic interventions

Skin care: as per BAD 2018 guidelines, advise avoiding irritant and fragrance products in all patients with LS.
E

5.Therapeutic procedures

Ultraviolet phototherapy: as per EADV 2017 guidelines, consider offering phototherapy in selected patients with LS.
B
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  • Photodynamic therapy

  • CO2 laser therapy

  • Intralesional corticosteroid injections

  • Intralesional adalimumab injections

  • Therapies with no evidence for benefit

6.Surgical interventions

Indications for surgery, female, EADV
Perform surgery in patients with vulvar LS only for the treatment of coexistent vulvar intraepithelial neoplasia/SCC or fusion.
B
Recognize that vulvar LS tends to recur around the scar in female patients.
B

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  • Indications for surgery (male)

7.Specific circumstances

Patients with extragenital lichen sclerosus: as per BAD 2018 guidelines, consider offering potent topical corticosteroids, acitretin, methotrexate and phototherapy in patients with extragenital LS.
C

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  • Pediatric patients (female)

  • Pediatric patients (male)

8.Patient education

General counseling
Provide all patients with LS with up-to-date patient information on the condition.
E
Advise obese male patients with a buried penis to lose weight. Consider referring to a urologist and bariatric services.
E

9.Follow-up and surveillance

Indications for referral, gynecology, BGCS: refer female patients with LS to secondary care in case of new lesions not responding to nightly ultra-potent corticosteroids within 1-2 weeks.
B

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  • Indications for referral (urology)

  • Assessment of treatment response

  • Patients with refractory disease