Can lichen sclerosis, particularly in a postmenopausal woman, become cancerous?

Can Lichen Sclerosus Become Cancerous?

Yes, lichen sclerosus can progress to squamous cell carcinoma, with a malignancy risk of 4-5% in women and less than 4% in men, making regular monitoring and appropriate treatment essential to reduce this risk. 1

Cancer Risk in Women

The risk of vulvar squamous cell carcinoma in women with lichen sclerosus ranges from 4-5%, with some reviews reporting rates as high as 7%. 1 More recent systematic reviews show the absolute risk varies between 0.21-3.88% for women, with an incidence rate of 0.65-8.89 per 1,000 person-years. 2

Importantly, lichen sclerosus under good control with appropriate treatment has a reduced risk of both scarring and malignancy. 1 This is a critical point—the cancer risk is not fixed but can be modified through proper management.

Risk Factors That Increase Cancer Development in Women:

• Advanced age (postmenopausal women are at highest risk) 2
• Presence of vulvar intraepithelial neoplasia (VIN), particularly differentiated type 3, 2
• Long-standing untreated disease 2
• Late diagnosis 2
• Poor compliance with topical corticosteroid treatment 2
• Persistent erosions, ulcers, hyperkeratotic or fixed erythematous areas 1

Cancer Risk in Men

The association between lichen sclerosus and penile squamous cell carcinoma is well-established but occurs at a lower rate than in women. 1 The risk is probably less than 4%, with one retrospective series showing lichen sclerosus histology in 50% of penile squamous cell carcinoma cases. 1 However, another large retrospective review of 522 patients with lichen sclerosus found only a 2% rate of squamous cell carcinoma. 1

A critical finding is that lichen sclerosus diagnosis may precede squamous cell carcinoma by up to 10 years in some cases. 1 This underscores the importance of long-term surveillance.

Important Distinction: Lichen Sclerosus vs. VIN

Lichen sclerosus itself is not a premalignant condition—the true precursor of cancer associated with lichen sclerosus is vulvar intraepithelial neoplasia, differentiated type. 3 This is an important nuance: lichen sclerosus creates an environment that may permit development of VIN, which then progresses to cancer.

Extragenital Disease

Extragenital lichen sclerosus does not carry a risk of malignant transformation. 1 The cancer risk is confined to anogenital disease.

Surveillance Strategy to Detect Malignancy

For Women:

• Uncomplicated disease responding well to treatment: Follow-up at 3 months to assess treatment response, then at 9 months (6 months after first visit) before discharge to primary care. 1

• High-risk patients requiring long-term specialist follow-up: 1

  • Ongoing troublesome symptoms despite treatment
  • Atypical disease presentation
  • Previous cancer or any type of VIN
  • Pathological uncertainty about intraepithelial neoplasia

• Biopsy indications: Persistent erosions, ulcers, hyperkeratotic areas, and fixed erythematous areas should be biopsied to exclude intraepithelial neoplasia or invasive squamous cell carcinoma. 1

For Men:

• Follow-up at 3 months after diagnosis and initial topical steroid course, then at 9 months if disease has responded well. 1
• Review histopathology of any circumcision specimens performed. 1
• Provide written information outlining symptoms and signs suggesting malignant change. 1

Warning Signs Requiring Urgent Referral (Both Sexes):

Patients must be instructed to report immediately: 1

• Any change in symptoms
• Lack of response to topical treatment
• New areas of erosion or ulceration
• Development of any lumps or nodules
• Non-healing lesions 4

Treatment to Reduce Cancer Risk

The gold standard treatment is ultra-potent topical corticosteroids (clobetasol propionate 0.05%) applied twice daily for 2-3 months, followed by maintenance therapy. 1, 4, 3 This is not just for symptom control—there is growing evidence that lichen sclerosus under good control has a reduced risk of malignancy. 1

Regular compliant treatment with topical corticosteroids is specifically recommended to reduce cancer risk, especially in older women. 2

Common Pitfalls to Avoid

• Never assume lichen sclerosus is benign and self-limiting—the cancer risk, while relatively small, is real and requires ongoing vigilance. 1, 5
• Do not discharge patients without clear written instructions about self-monitoring and when to seek urgent care. 1
• Biopsy is mandatory when there is diagnostic uncertainty, treatment failure, or any suspicion of neoplasia. 4, 6
• Do not rely solely on clinical diagnosis in cases with atypical features or non-healing lesions. 1