What is the treatment for lichen sclerosus?

Treatment of Lichen Sclerosus

The gold standard first-line treatment for lichen sclerosus is clobetasol propionate 0.05% ointment applied once daily for 1-3 months, followed by individualized maintenance therapy based on disease activity. 1, 2

Initial Medical Management

First-Line Topical Therapy

• Apply clobetasol propionate 0.05% ointment once daily for 1-3 months as the cornerstone of treatment for all patients with genital lichen sclerosus 1, 2, 3
• Use an emollient as a soap substitute and barrier preparation alongside the topical steroid 1
• A 30g tube should last approximately 12 weeks when used appropriately 4
• Educate patients on proper application technique using the fingertip unit method to minimize side effects 4
• Avoid all irritants and fragranced products that may exacerbate the condition 4

Treatment Goals

The three primary objectives are: relief of symptoms and discomfort; prevention of anatomical changes and scarring; and theoretical prevention of malignant transformation 5

Gender-Specific Considerations

Female Patients

• After the initial 12-week treatment period, review all patients to assess response 4
• Successful treatment should resolve hyperkeratosis, fissuring, and erosions, though pallor may persist 1, 4
• For ongoing active disease despite good compliance, continue clobetasol propionate 0.05% with an individualized maintenance regimen titrated to control symptoms and prevent scarring 1
• Most patients with ongoing disease require approximately 30-60g of clobetasol propionate annually 4, 2
• Refer to a specialist vulval clinic if disease does not respond to topical steroids or if surgical management is being considered 1

Male Patients

• Apply clobetasol propionate 0.05% once daily for 1-3 months initially 1, 2
• For phimosis that does not respond to ultrapotent topical steroids after 1-3 months, refer for circumcision 1, 2
• Circumcision has a 96% success rate when lichen sclerosus is confined to the glans and foreskin 2
• All tissue removed at circumcision must be sent for histological examination to confirm diagnosis and exclude penile intraepithelial neoplasia or malignancy 1, 2
• For meatal involvement, apply clobetasol propionate 0.05% once daily via cotton wool bud or meatal dilator for 1-3 months before urological referral 1

Management of Refractory Disease

Steroid-Resistant Hyperkeratotic Areas

• Consider intralesional triamcinolone (10-20 mg) after biopsy excludes intraepithelial neoplasia or malignancy 1, 4
• This applies to both male and female patients with localized resistant areas 1

Urethral Complications in Males

• Refer all male patients with urethral stricture to a urologist specialized in lichen sclerosus management 1
• For short, distal strictures: circumcision plus relief of distal obstruction, potentially with staged urethroplasty 2
• Never use genital skin for reconstructive procedures due to 90% recurrence rate 1, 2
• Only nongenital skin or tissue grafts (buccal mucosa, bladder mucosa, split-thickness skin grafts) should be used for urethral reconstruction 1, 2
• Perineal urethrostomy using a flap-based technique may be appropriate for patients unwilling or unfit for complex reconstruction 1

Diagnostic Confirmation

When to Biopsy

• Biopsy is essential if there is any suspicion of neoplastic change or atypical features 1, 4
• Always biopsy before initiating treatment in males to confirm diagnosis and rule out squamous cell carcinoma or penile intraepithelial neoplasia 2
• In young adult females presenting in reproductive years, consider biopsy to confirm diagnosis before starting treatment 1
• Take biopsy from the most active sclerotic area and ensure good clinicopathological correlation 1

Long-Term Surveillance and Malignancy Risk

Cancer Risk

• Lichen sclerosus carries a 3-5% risk of squamous cell carcinoma development in female patients 1, 5
• Approximately 60% of vulval squamous cell carcinomas occur on a background of lichen sclerosus 1
• Long-term follow-up is mandatory due to malignant transformation risk 2, 5
• Any new lesions, ulcerations, or areas of disease reactivation require immediate biopsy 2

Surveillance Protocol

• Patients should be kept under indefinite long-term review 3, 6
• Early and continuous treatment with potent topical steroids may decrease malignancy risk 7

Common Pitfalls and How to Avoid Them

• Inadequate duration of initial treatment: Ensure a full 1-3 month course before declaring treatment failure 4
• Abrupt discontinuation: Always taper topical steroids gradually after initial treatment to prevent rebound flares 2
• Using genital skin for urethral reconstruction: This results in 90% failure rate; only use nongenital tissue 1, 2
• Performing surgery for uncomplicated disease: Surgery should be limited exclusively to patients with malignancy or to correct scarring complications 5
• Failure to send circumcision specimens for histology: Always examine tissue to exclude neoplasia 1, 2

Surgical Indications

Surgery has no place in uncomplicated lichen sclerosus and should be reserved for: 5

• Treatment of malignancy
• Correction of scarring and anatomical complications (phimosis, urethral stricture, introital stenosis)
• Symptomatic patients who fail multiple medical treatments (noting high recurrence rates) 8