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Authors: Nicole S Kim, Medical Student, University of Toronto, Toronto, Canada; Dr Yuliya Velykoredko, Dermatology Resident, University of Toronto, Toronto, Canada. DermNet NZ Editor in Chief: A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell/Maria McGivern. September 2018.
Lichen simplex of the vulva is a pruritic form of dermatitis in which excessive scratching or rubbing leads to lichenification. Characteristically, there are well-demarcated, erythematous or hyperpigmented, thickened plaques affecting one or both sides of the vulva. Lichen simplex is typically secondary to an underlying skin condition or neuropathy causing a severely itchy vulva.
Lichen simplex is also known as lichen simplex chronicus and neurodermatitis [1–3].
(See our page of vulval lichen simplex images).
Vulvar lichen simplex is most frequently seen in adult women with atopic sensitive skin [2,3].
The mechanism of lichen simplex of the vulva is explained by the persistent itch–scratch cycle. Pre-existing itch or pruritic conditions induce habitual scratching, which gives rise to histological acanthosis (thickening of the epidermis) and hyperkeratosis (thickening of the stratum corneum). Pruritus may be associated with underlying systemic disease and/or a predisposing psychiatric condition [2–5].
Contributing factors to vulval lichen simplex may include [1–3]:
Lichen simplex of the vulva manifests as well-demarcated, markedly thickened plaques with a leathery appearance. It is often unilateral but it may also be bilateral. There may be a solitary plaque or multiple coalescing plaques or papules. There is unremitting pruritus. Other commonly observed features include:
Signs of an underlying skin disorder may also be noted adjacent to the lichen simplex of the vulva and/or on another body site.
Lichen simplex can affect other parts of the body. Common sites of involvement are the posterior-lateral neck, the scalp, the extensor surfaces of extremities, and the ankles or lower legs [1–4].
Complications of lichen simplex of the vulva may include :
Adverse effects from treatment can also arise, particularly atrophy due to the extended use of a potent topical corticosteroid on vulval skin. Topical steroids can also cause pigmentation abnormalities .
The clinical features of vulval lichen simplex are generally sufficient to establish the diagnosis. When findings are atypical, further tests can be considered to make a definitive diagnosis or to exclude other similar dermatoses; such tests to be considered include [4,5]:
If the vulval lichen simplex is associated with generalised pruritus, a workup for systemic causes can be undertaken (as outlined on our pruritus page).
Other disorders that should be considered in a patient with lichen simplex of the vulva include [1–2,5]:
Treatment for lichen simplex of the vulva involves:
Short-term topical corticosteroids are used as first-line therapy to break the itch–scratch cycle. Treatment principles for lichen simplex of the vulva include using a medium–potency topical steroid (such as triamcinolone ointment) until there is a resolution of active lesions. If the disease is refractory after 2–3 weeks of an intermediate-strength corticosteroid, more potent topical steroids can be used on a short-term basis. As the condition improves, the application frequency and potency of the corticosteroid should be decreased to minimise the adverse effects.
Other treatment recommendations include those below [2–5].
Lichen simplex of the vulva runs a chronic clinical course with exacerbations and remissions. As recurrences occur during psychological stresses or with the flare-up of underlying dermatoses, long-term management may be required in some patients .
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