Vulvovaginal Lichen Planus

What is Lichen Planus?

Lichen Planus (LP) is a chronic (long lasting) inflammatory skin condition. It causes skin lesions that can affect many areas including inside the mouth and the genital area - both the vulva and vagina. LP can also affect the nails and scalp. It is possible to have the condition in one area without ever having a problem elsewhere. Vulvovaginal LP occurs most commonly in women aged 50 to 60 years old. Many patients with vulvovaginal LP have LP in the mouth as well, but the diagnosis may be missed. You should tell your dentist about your LP diagnosis at your next appointment.

What causes Lichen Planus?

The exact cause of LP is unknown. It is thought to be related to the immune system becoming overactive, this is called an auto-immune reaction. LP could also begin following a reaction to a medication. Often LP affects people who have other auto-immune conditions such as thyroid disease, vitiligo (white patches on the skin) and alopecia areata (patches of hair loss). LP does not lower your immunity and does not affect any internal organs. It is not known why the lesions develop in some parts of the body and not others. LP is not due to an infection, allergies or hormonal abnormalities. It is not contagious and cannot be spread through contact, including sexual intercourse.

Is LP hereditary?

LP is not known to be hereditary, but can sometimes run in families, especially twins.

What are the symptoms of vulvovaginal LP?

Vulvovaginal LP usually begins as painful patches on the skin which feels similar to burning, or rawness. Itching sensations are less common. It can affect the skin on the outside of the female genitalia (vulva) and/or the inside (vagina). Intercourse can be painful. It can also be painful to pass urine.

What does LP look like?

The outer layers of the skin break down (erosions) leaving areas which are moist and red. There may be a white lacy pattern on the vulva and around the edges of the erosions. The vulva may appear pale or pink/red. Scarring with loss of the inner lips (labia minora) may be seen. The clitoris may be covered under shiny, red, raw scar tissue. Erosions can occur inside the vagina and some women have a sticky, yellow or yellow-green discharge. The discharge may be bloodstained, especially after intercourse. The vaginal entrance may become smaller if the inner walls of the vagina or the skin around the entrance scar and stick together. Intercourse can be painful or even impossible. It can also make internal examinations by a healthcare professional very difficult and uncomfortable. Rarely, there may be thickened areas which can have a wart-like appearance. If LP affects the skin in other parts of the body, it is usually the inside of the wrists, the forearms and the ankles. The spots look purple and you may see some fine white streaks on top of them. A similar white, lacy streaking may be seen inside the mouth and there can be sore, red, ulcerated areas around the gums, tongue and inside the cheeks.

Occasionally LP can affect the tear ducts and oesophagus (the tube that carries food from the mouth to the stomach). If you experience excessive watering of the eyes, difficulty in swallowing or it feels as if food gets stuck, you should tell your doctor about this.

How will LP be diagnosed?

The diagnosis can usually be made by a health care professional who is experienced in the management of the condition. If there is any doubt, a small skin sample may be taken and examined under a microscope to confirm the diagnosis, especially if there is an open sore or a thickened area of skin. This is known as a skin biopsy and requires a local anaesthetic injection and possibly stitches to close the wound.

Can LP be cured?

There is no cure for LP. In some cases, LP seems to come and go of its own accord and it is possible for it to disappear completely. However, this is not usual for LP of the vulva and vagina, which tends to be persistent and needs long term treatment and regular follow up appointments. The symptoms and signs of the condition can be well controlled with the application of ointments to the affected skin.

How can LP be treated?

The usual treatment for vulvovaginal LP is a strong steroid ointment, such as Dermovate™ (clobetasol propionate 0.05%). This reduces the inflammation. Please do not worry about the warning inside the pack, where it might say ‘not to use these ointments on genital skin’ as these treatments are very safe for this condition. Less strong steroid ointments are not effective in controlling the condition. At the time of diagnosis, treatment is used intensively for a 3 month period. The recommended course is to use steroid ointment once daily at night for 1 month, then alternate nights for 1 month and then twice weekly for a month. After this, your healthcare professional will advise you how and when to apply the steroid ointments.

An ointment-based emollient can also be used to protect and moisturise the skin. This can be prescribed or bought over the counter.

If LP is present in the vagina, then this also needs to be treated. This might be with the same steroid ointment as used elsewhere on the body. In some cases, an applicator is used to help direct ointment to the correct area. If needed, your healthcare professional will discuss this with you.

Sometimes products marketed for use in the bowel are prescribed, such as prednisolone suppositories or budesonide foam. It is safe to use these products in the vagina to treat LP. Your healthcare professional will explain how to use them in more detail.

For scarring and narrowing of the vagina and/or the entrance into the vagina, physiotherapy or dilators are advised. Very rarely, surgery is suggested. This would be discussed with you in detail by a gynaecologist.

Self-care, what can I do?

• Avoid washing with soap and instead use an emollient soap substitute/cream.
• Avoid scented products such as bubble baths and shower gels.
• Avoid talcum powder and wet wipes.
• Avoid wearing panty liners if possible and if they are essential use fragrance free ones.
• Carefully dry yourself after passing urine to reduce the contact of urine with your skin.
• Using an emollient ointment or yellow soft paraffin (such as Vaseline®) as a barrier cream can protect your skin from exposure to urine.
• If sexual intercourse is painful because of tightening of the skin at the entrance to the vagina, the use of lubricants and, on occasions, vaginal dilators, will help.
• Keep an eye on your skin. There is a small risk (about 2%) of developing a skin cancer in the affected areas on the vulva. This can look like a lump, ulcer or crusted/raised area and is usually painful. With good control of the condition, this risk is reduced. Lifelong regular self-examination is very important for all females who have had vulvovaginal LP. If any skin changes develop which do not respond to the steroid ointment, in particular any skin thickening, soreness or ulceration lasting more than 2 weeks, you need to contact the healthcare professional who looks after your skin. You may need a biopsy taken for examination in the laboratory.
• If you are a smoker, you should stop smoking to reduce the risk of cancer. Your GP can give you information about stopping smoking or you can visit Healthy Lifestyles Gloucestershire at https://hlsglos.org or contact them on 0800 122 3788.

Caution

This page mentions ‘emollients’ (moisturisers). Emollients, creams, lotions and ointments contain oils. When emollient products get in contact with dressings, clothing, bed linen or hair, there is a danger that they could catch fire more easily, even if the emollient products have dried. To reduce the fire risk, patients using skincare or haircare products are advised to be very careful near naked flames or lit cigarettes. It is advisable to wash clothing daily and bedlinen frequently if they are in contact with emollients. However, this may not remove the risk completely even if washed at high temperatures, so caution is still needed. More information can be found at: www.gov.uk/guidance/safe-use-of-emollient-skin-creams-to-treat-dry-skin-conditions

Further information

For more information about LP, please visit the following websites:

International Society for the Study of Vulvovaginal Disease

Website: www.issvd.org/resources/vulvar-lichen-planus

DermNet

Website: https://dermnetnz.org/topics/erosive-lichen-planus

The British Society for the Study of Vulval Disease

Website: https://bssvd.org/wp-content/uploads/2021/06/BUDESOMIDE-FOAM-FOR-LICHEN-PLANUS-2.pdf