Early diagnosis of lichen sclerosus et atrophicus often proves difficult

Houston - Recognizable, but not always easily diagnosed, is lichen sclerosus et atrophicus. Occurring more often in prepubescent girls and postmenopausal women, and believed to be an autoimmune disorder, LS presents as white, shiny, atrophic patches and plaques with an erythematous halo.

Although the condition can occur on different parts of the body, it does occur in the genital area, and is more common in women than men.

Carolyn A. Bangert, M.D., assistant professor, University of Texas at Houston, says although LS can be diagnosed visually, the condition usually comes to a physician’s attention through other means.

“Unfortunately, it really isn't that obvious sometimes,” Dr. Bangert says. “While an OB/GYN may notice it during an exam, usually it’s because the woman will have symptoms, which can include dryness, itching, pain and irritation in the vaginal area, and occasionally pain with urination. A particularly common symptom is pain with intercourse. That can be a real problem for women.”

Diagnosis difficulties
Besides a visual diagnosis, doctors can perform a biopsy, but that has its own issues, Dr. Bangert says.

“The problem is that when LS is not advanced enough for the visual diagnosis to be clear-cut, a biopsy tends to parallel the examination in that when skin changes are subtle, so are the biopsy results,” Dr. Bangert says. “The problem can be exacerbated if the biopsy is ordered by an OB/GYN, and the sample is sent to a general pathologist rather than a dermatopathologist, without an adequate history. If the OB/GYN isn’t thinking lichen sclerosus, the pathologist would not necessarily make the diagnosis either. It may not be until the skin changes are advanced, that histological changes become more definitive.

“Obviously, you don’t want the LS get to that point,” she says. “You want to make a diagnosis before it progresses to the point where there are very obvious external changes on the vulva.”

Other conditions can look like LS, which can contribute to difficulty in diagnosing LS, Dr. Banger says.

“In young girls, obviously, as a physician, you’re worried about something like abuse, and lichen planus can look very similar in that area. It may also look like an irritant or an allergic dermatitis in that area - so many products we use have scents or preservatives that people can become allergic to. Vaginal yeast infections may also present like LS,” she says.

Signs of LS
There are signs indicating that the condition is LS.

“What you’re looking for clinically is subtle, early signs of skin thinning or sclerosis. These changes can be seen in the vulvar area only, or in what’s called a figure eight pattern, which includes both the vulvar and the perianal area.

“With more extensive disease, women can experience the loss of the external labia minora. It can start to become effaced and eventually be completely obliterated by this process,” Dr. Bangert says. “Similar findings can also occur on the labia majora.”

Because patients will generally consult an OB/GYN when her symptoms occur, the condition often is first diagnosed by that specialist, who may then begin treatment. That may not be the best option for the patient, according to Dr. Bangert.

“OB/GYNs are sometimes a bit more concerned with higher potency steroids, so they may be a little more conservative. So, oftentimes the patient will get a little undertreated by gynecologists. That’s why many OBs will refer their patients to a dermatologist after they've made the diagnosis,” she says.

Dr. Bangert says it is important for physicians to keep LS in mind when symptoms are first reported, because when LS clinical changes of the skin become more severe, they aren’t easily returned to a pristine state.

Treatment options
High potency topical steroids are the primary treatment for LS. Dr. Bangert recommends applying 0.05 percent clobetasol once a day, with ointment preferable to cream because it is less irritating. Topical tacrolimus applied twice daily is another option that has shown some efficacy.

“Results are variable,” Dr. Bangert says. “Usually, you’re hoping to see an improvement in the symptoms over the course of several months. Then we’ll continue to use it until we have controlled the symptoms and get as much benefit as we can out of the steroid cream. It’s usually a prolonged course of treatment because this is a more chronic process, which can recur with stopping therapy.

“If the condition is identified early enough, the patient may not have any permanent changes. If, however, treatment begins later, there will probably not be a complete normalization of the anatomy, although the symptoms can be controlled,” she says. “In very severe advanced cases, surgery may be required to restore normal anatomic function.”