Dr Margaret answers emailers’ embarrassing problems
in this monthly problem page.

Lichen sclerosus

Dear Dr Margaret
I am 51 and going through the menopause. I went to my doctor because of itching which I thought was thrush, and she says it is something I have never heard of, lichen sclerosus. Is it dangerous?

It is good that you went to your doctor and know what the problem is. A lot of people just try to put up with the discomfort, and never obtain the treatment they need.

Lichen sclerosus is a bit of a mystery. There are a lot of theories about its cause, but none are proved. The most popular is that it is an ‘autoimmune’ condition, in which the body’s own immune system mistakenly damages its own skin. (A lot of other conditions, such as rheumatoid arthritis and some thyroid problems, are ‘autoimmune’.) It is most common in women around or after the menopause (although it can occur at any age), so maybe hormones are partly involved.

Women with lichen sclerosus sometimes feel guilty about the condition, thinking it is the result of something they have done in the past. This is completely wrong – it is just bad luck and can happen to anyone.

Some women have no symptoms at all, but some very unpleasant symptoms can occur. Itching around the opening of the vagina, or around the anus, is common. Sex is painful, and can cause cracks and tears. Often, women with lichen sclerosus have thrush as well, because the fungus that causes thrush (candida) loves damaged skin. So any woman who is at menopausal age and has itching of the genital area that is not completely cured by thrush treatment should ask their doctor to take a look.

Your doctor will have diagnosed lichen sclerosus by its appearance, and perhaps confirmed it by taking a small sample (biopsy) and sending it to the laboratory. Lichen sclerosus usually starts as pale patches, which eventually join together into a figure-of-eight shape around the opening of the vagina and the anus. The skin looks white and thin, like cigarette paper. In some people the lips of the vagina may shrink and the vaginal opening narrows, so sexual intercourse becomes impossible.

Treatment is simple – a special steroid cream used once a night for 4 weeks, then alternate nights for 4 weeks, and then twice a week during the third month. If the symptoms return, more treatment can be given. If the vaginal opening has become too narrowed for sex, a small surgical operation can solve the problem. Some new treatments (such as tacrolimus cream) are being investigated. There is a good website, www.lichensclerosus.org, that you might like to look at.

Apart from the distressing symptoms, lichen sclerosus can cause one serious problem. About 4% of women with the condition will develop a skin cancer in the area. It is important to be aware of this, so that if you develop any sore or lump in the area you should see your doctor straight away.

Lichen sclerosus can also affect men – usually on the head of the penis and the foreskin. It can cause tightening of the foreskin, painful erections, decreased sensitivity of the head of the penis and a feeble urinary stream. Treatment is with a special steroid cream. Sometimes an operation to relieve the tight foreskin is needed.