From the Guidelines
Diagnosing lichen sclerosus typically involves a clinical examination and, in certain cases, a skin biopsy, as outlined in the British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018 1. A dermatologist or gynecologist should examine the affected area, looking for characteristic white, thin, wrinkled patches of skin, typically in the genital or anal regions. The skin may appear shiny, fragile, and show signs of scarring, with possible symptoms including itching, pain, and discomfort during urination or intercourse. Some key points to consider when diagnosing lichen sclerosus include:
- A biopsy must always be considered in patients if there is a suspicion of neoplastic change, with a persistent area of hyperkeratosis, erosion or erythema, or new warty or papular lesions, as stated in the guidelines 1.
- The disease fails to respond to adequate treatment, which may necessitate a biopsy to confirm the diagnosis or rule out other conditions 1.
- Certain situations, such as circumcision, extragenital LS, pigmented areas, or consideration of alternative or additional therapy, may also require a biopsy for accurate diagnosis and management 1. If the clinical presentation is unclear, a small skin biopsy may be performed under local anesthesia to confirm the diagnosis. The biopsy sample is examined under a microscope for specific histological features such as thinning of the epidermis and a band-like inflammatory infiltrate in the dermis. Additional tests may be needed to rule out other conditions with similar appearances, such as vitiligo or lichen planus. Early diagnosis is crucial as lichen sclerosus can lead to scarring and has a small risk of developing into squamous cell carcinoma if left untreated, highlighting the importance of regular follow-up examinations to monitor for changes and response to treatment, as per the guidelines 1.
From the Research
Diagnosis of Lichen Sclerosus
- The diagnosis of lichen sclerosus is usually clinical, but in some cases, a biopsy can be performed, especially to exclude vulvar intraepithelial neoplasia or cancer 2.
- Anogenital itching and clinical features such as erythema, white skin changes (such as hyperkeratosis and sclerosis), and fissures should arouse suspicion of lichen sclerosus 3.
- A skin biopsy can confirm the diagnosis and early, thorough treatment should be initiated to avert a mutilating disease course and lessen the risk of cancer 3.
Diagnostic Criteria
- Lichen sclerosus is characterized by a chronic inflammatory dermatitis, with a predilection for the anogenital area, which in some cases can become seriously distorted (atrophy of the labia minora, phimosis, introital stenosis, etc.) 2.
- The disease is more common in women than in men, and occurs more often in adults than in children 3.
- About 10% of patients have other family members with the same condition 3.
Diagnostic Tests
- Biopsy is the gold standard for diagnosis, especially to exclude other conditions such as vulvar intraepithelial neoplasia or cancer 2, 3.
- Histologic changes of lichen sclerosus can be reversed with treatment, as shown in some cases where repeat biopsies were performed after treatment with pimecrolimus 4.