Lichen simplex of the vulva

Authors: Nicole S. Kim, Medical Student, University of Toronto, Canada; Dr Yuliya Velykoredko, Dermatology Resident, University of Toronto, Canada. DermNet NZ Editor-in-Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. DermNet NZ Editor-in-Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. September 2018.


What is lichen simplex of the vulva?

Lichen simplex of the vulva is a pruritic form of dermatitis in which excessive scratching or rubbing leads to lichenification. Characteristically, there are well-demarcated, erythematous or hyperpigmented, thickened plaques affecting one or both sides of the vulvaLichen simplex is typically secondary to an underlying skin condition or neuropathy causing a severely itchy vulva.

Lichen simplex is also known as lichen simplex chronicus and neurodermatitis [1,2,5].

See vulval lichen simplex images.

Who gets lichen simplex of the vulva?

Vulvar lichen simplex is most frequently seen in atopic adult females with sensitive skin [2,5].

What causes lichen simplex of the vulva?

The mechanism of lichen simplex of the vulva is explained by the persistent itch-scratch cycle. Pre-existing itch or pruritic conditions induce habitual scratching, which give rise to thickening of the epidermis (histological acanthosis) and the stratum corneum (hyperkeratosis). Pruritus may be associated with an underlying systemic disease and/or a predisposing psychiatric condition [2,3,4].

Contributing factors to vulval lichen simplex may include [1,2,5]:

What are the clinical features of lichen simplex of the vulva?

Lichen simplex of the vulva manifests as well-demarcated, markedly thickened plaques with a leathery appearance. It is often unilateral but it may also be bilateral. There may be a solitary plaque or multiple coalescing plaques or papules. There is unremitting pruritus. Other commonly observed features include:

  • Excoriations or linear fissures at skin folds
  • Exaggerated skin lines
  • Hypo- or hyperpigmentation of vulval or perianal skin
  • Sparse hair or broken-off hair shafts
  • Varying degrees of erythema
  • Oedema.

Signs of an underlying skin disorder may also be noted adjacent to lichen simplex of the vulva and/or on another body site.

Lichen simplex can affect other parts of the body. Common sites of involvement are the posterior-lateral neck, scalp, extensor surfaces of extremities, or the ankles/lower legs [1,2,4,5].

What are the complications of lichen simplex of the vulva?

Complications of lichen simplex of the vulva may include:

Adverse effects from treatment can also arise, particularly atrophy due to extended use of a potent  topical corticosteroid on vulval skin. Topical steroids can also cause pigmentation abnormalities [5].

How is lichen simplex of the vulva diagnosed?

The clinical features of vulval lichen simplex are generally sufficient to establish the diagnosis. When findings are atypical, further tests can be considered to make a definitive diagnosis or to exclude other similar dermatoses.

If the vulval lichen simplex is associated with generalised pruritus, a work-up for systemic causes can be undertaken as outlined on our pruritus page.

What is the differential diagnosis for lichen simplex of the vulva?

Other disorders that should be considered in a patient with  lichen simplex of the vulva include   [1,2,3]:

What is the treatment for lichen simplex of the vulva?

Treatment for lichen simplex of the vulva involves:

  • Avoiding exacerbating factors
  • Breaking the itch-scratch cycle
  • Treating any underlying dermatosis or predisposing condition
  • Re-establishment of the normal skin barrier.

Short-term use of topical corticosteroids are used first line to break the itch-scratch cycle. Treatment principles include using a medium potency topical steroid such as triamcinolone ointment until there is resolution of active lesions. If the disease is refractory after 2–3 weeks of intermediate-strength corticosteroid, more potent topical steroids can be used on a short-term basis. As the condition improves, application frequency and potency of the corticosteroid should be decreased to minimise their adverse effects.

Avoid precipitating factors such as dryness, sweating or excessive moisture, and skin irritation from tight clothes and rough materials. Silk or cotton fabric underwear can be less irritating to vulval skin than synthetic fabrics; however modern fibres that keep moisture away from the skin may be preferred [2,5].

Discontinue using soap and non-prescribed topical products, and avoid using wet wipes. Emollients and barrier cream can help reduce dryness and irritation [2,3].

  • Identify and treat any underlying inflammatory dermatosis, infection, or systemic cause of itch
  • Psychiatric disorders such as depression, anxiety, or obsessive-compulsive disorder should be treated with appropriate pharmacotherapy (eg, tricyclic antidepressants or selective serotonin reuptake inhibitors) and psychological therapy
  • Radiculopathy may be managed with tricyclic antidepressants (such as amitriptyline) or antiepileptic medications [2,4,5].

What is the outcome for lichen simplex of the vulva?

Lichen simplex of the vulva runs a chronic clinical course with exacerbations and remissions. As recurrences occur during psychological stresses or with flareup of underlying dermatoses, long-term management may be required in some patients [4].

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References

  1. Bolognia JL, Schaffer JV, Cerroni L. Dermatology, 4th edn. Philadelphia: Elsevier, 2018.
  2. Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Fitzpatrick’s Dermatology in General Medicine, 8th edn. New York: McGraw-Hill, 2012.
  3. Lotti T, Buggiani G, Prignano F. Prurigo nodularis and lichen simplex chronicus. Dermatol Ther. 2008; 21(1): 42–6. DOI: 10.1111/j.1529-8019.2008.00168.x. PubMed
  4. Lynch PJ. Lichen simplex chronicus (atopic/neurodermatitis) of the anogenital region. Dermatol Ther. 2004; 17(1): 8–19. DOI: 10.1111/j.1396-0296.2004.04002.x. PubMed
  5. BMJ Best Practice. Lichen simplex chronicus. December 2017. Available at: http://bestpractice.bmj.com/topics/en-gb/625 (accessed 18 September 2018)

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