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New Treatments for Lichen Sclerosis

Lichen sclerosis is a genital dermatologic condition that can produce a very abnormal examination. It is less common than labial adhesions but can be associated secondarily with them. Lichen sclerosis occurs because of a testosterone receptor insensitivity in an area that ends quite sharply, halfway across the labia majora, extending in a zone around the anus and ending at the hymeneal ring. Loss of pigmentation leaves whitened skin that can be quite striking in lichen sclerosis.  These are the tissues that form the shaft of the penis and scrotal tissues.

Histologically, the dermis becomes quite thin. Symptomatically, it commonly itches but may remain totally asymptomatic until a secondary infection sets in. Minor scratching readily forms subcutaneous hemorrhages because the tissue.

Differential Diagnosis

The degree of physical findings is typically much greater than expected from a history of lichen sclerosis, so the question of sexual abuse is often raised. Although an experienced practitioner can easily make a visual diagnosis, forensically, the histology.

If protective concerns have been raised, an examination under anesthesia is needed to diagnose between lichen sclerosis and sexual abuse. This forensic examination with the patient under general anesthesia is as described earlier except with the addition of a 4-mm punch biopsy taken from the most affected skin. One cc of 0.25% Marcaine.

Treatment

Lichen sclerosis typically resolves with the hormonal changes of puberty and is much rarer during reproductive life, but it becomes more common perimenopausally and postmenopausally. The specific therapy at any age is topical 2% testosterone propionate in petrolatum (made up by a pharmacist), applied nightly.

The frequency of application is then slowly diminished until, at some dosing schedule, symptoms recur. At this point, the dosing frequency is slightly increased.

An androgen containing skin patch (Androderm) has just become available. In providing site-specific hormonal therapy, androgen skin patches may be the most effective and convenient therapy for the same reasons estrogen patches have worked so well for labial adhesions. Androgen-dependent secondary sex characteristics (pubic hair development and increased rugation of the labia majora) also appear.

Topical steroids are an effective alternative that does not produce secondary testosterone effects but has other consequences to consider. The readily absorptive characteristics of genital mucosal skin make overuse effects more likely to occur. The most a high-potency topical steroid should be used on any one spot is in cycles of 3 weeks on.

 With clinical responses monitored and managed in an office visit schedule described earlier, the steroid formulation is tapered to a lower potency when the physical examination normalizes. With both lichen sclerosis and labial adhesions, the range of symptomatology and treatment response is so variable that the necessity to treat.