The earliest signs are skin fragility, bruising, and sometimes blistering. Lesions typically cause mild to severe itching. When lichen sclerosus manifests in children, the appearance may be confused with sexual abuse. With time, the involved tissue becomes atrophic, thinned, hypopigmented (there may be flecks of postinflammatory hyperpigmentation), fissured, and scaly. Hyperkeratotic and fibrotic forms exist.
Severe and longstanding cases cause scarring and distortion or absorption of normal anogenital architecture. In women, this distortion can even lead to total destruction of the labia minora and clitoris. In men, phimosis or fusion of the foreskin to the coronal sulcus can occur.
Lichen sclerosus is an autoinflammatory disease that causes atrophy, hypopigmentation (possibly with flecks of hyperpigmentation), and, in severe cases, fibrosis of anogenital skin with distortion of normal anatomy.
Images courtesy of Joe Miller (top) and Brian Hill (bottom) via the Public Health Image Library of the Centers for Disease Control and Prevention.
This photo shows atrophy and hypopigmentation in the vulvar and perianal areas.
Image provided by E. Laurie Tolman, MD.
This photo shows scarring, atrophy, and distorted anatomy in the perianal area.
Image provided by E. Laurie Tolman, MD.
This photo shows porcelain white patches and areas of purpura in the labia minora, as well as early labial fusion.
Image provided by E. Laurie Tolman, MD.
This image shows hypopigmented, porcelain white patches of lichen sclerosus.
Image courtesy of Karen McKoy, MD.
Diagnosis of Lichen Sclerosus
Clinical evaluation
Sometimes biopsy
Diagnosis of lichen sclerosus can usually be based on appearance, especially in advanced cases; however, biopsy should be done on any anogenital dermatosis that does not resolve with mild conventional therapy (eg, topical hydrocortisone, antifungal drug). It is especially important to biopsy any area that becomes thickened or ulcerated, because lichen sclerosus is associated with an increased frequency of squamous cell carcinoma Diagnosis Squamous cell carcinoma is a malignant tumor of epidermal keratinocytes that invades the dermis; this cancer usually occurs in sun-exposed areas. Local destruction may be extensive, and metastases... read more 
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Treatment of Lichen Sclerosus
Topical corticosteroids
Treatment of lichen sclerosus consists of potent topical corticosteroids (drugs that otherwise should be used with extreme caution in this area). The disease is generally intractable, so long-term treatment and follow-up are necessary.
Monitoring for squamous cell carcinoma and sexual dysfunction and providing psychologic support are indicated.
Key Points
Lichen sclerosus can cause anogenital bruising, itching, or blistering early, and atrophy and scarring later.
Risk of subsequent squamous cell carcinoma is increased.
Consider the diagnosis with any persistent anogenital dermatosis.
Treat with long-term, high-potency topical corticosteroids, close monitoring, and sexual and psychologic support.
