Lichen planus is an inflammatory dermatosis which can affect the skin, nails and all mucous membranes, including the genitalia ( and ).1
The aetiology is largely unknown but thought to involve an autoimmune mechanism of activated T cells directed against basal keratinocytes. It is associated with the DR1 HLA class II antigen.2
It can also be drug induced with β-blockers, non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin converting enzyme (ACE) inhibitors, lithium, methyldopa, quinine, carbamazepine and penicillamine all being linked to the condition.3
The cutaneous form is associated with liver disease, especially advanced hepatitis C, with interferon treatment causing exacerbations.3
(A) Erosive vaginal lichen planus. (B) Erosive vaginal lichen planus with fissuring and narrowing of the interoitus. Courtesy of Dr A Oakley.
Vulval lichen planus showing the typical “lacy” border (Wickham’s striae.) Biopsy is important to exclude vaginal intraepithelial neoplasia (VIN). Courtesy of Dr J Adams.
This uncommon condition, first described by Erasmus Wilson in 1839, represents 1% of new referrals to dermatology clinics.2
All age groups are affected with incidence peaking in the sixth decade.4
It is more frequent in females, with 50% having vulvovaginal involvement. This presents with vulval soreness, burning, pruritis, dyspareunia, post-coital bleeding, persistent and copious vaginal discharge, dysuria or difficulty in urinating. Often these symptoms are incorrectly attributed to persistent candidiasis.
Three types of lichen planus can affect the vulva/vagina.3
- Papulosquamous—Small pruritic papules; involves keratinised and perianal skin.
- Hypertrophic—Rarest form with appearances similar to vulval squamous cell carcinoma; hypertrophic, rough lesions on perineum and perianal area.
- Erosive (as in our case)—Glassy and brightly erythematous erosions with white striae or a white border (Wickham’s striae); architectural destruction with loss of the labia minora and clitoris and narrowing of the introitus. The epithelium is denuded leading to contact bleeding, discharge and vaginal adhesions. Care must be taken when obtaining biopsies; this is because if only areas of erosion are sampled, features associated with lichen planus will not be found, but instead those of desquamative inflammatory vaginitis—acute and chronic inflammation involving the mucosa and submucosa.5
Histological features of lichen planus are irregular acanthosis of the epidermis, liquefactive degeneration of the basal cell layer, and band-like dermal infiltrate of lymphocytes in the upper epidermis. The epithelium may be absent with areas of hyperkeratosis.6
Treatment of lichen sclerosis is based on anecdotal reports and small case series, the largest involving only 65 patients. Prevention of vaginal stenosis resulting in loss of sexual function is often the most challenging aspect of care. The use of Colifoam enemas intravaginally has not previously been reported. General principles in a multidisciplinary clinic include explanation of the chronicity of the disease with provision of support and education.
Sedating antihistamines used at night prevent scratching, and emollients reduce friction. Local anaesthetic gel, simple analgesia or low dose tricyclic antidepressants or anticonvulsants may ease discomfort. Superimposed infections should be treated promptly and any drugs associated with lichenoid reaction discontinued.
Ultrapotent topical steroids in a tapering dose are the treatment with the best evidence of efficacy.6,8
Enemas used intravaginally are an effective, patient friendly and widely available formulation. Flares or resistant disease may require oral steroids. Other treatments include cyclosporins, griseofulvin, dapsone, retinoids, hydroxychloroquine, and minocycline. The irritant properties of retinoids mean they cannot be used on eroded epithelium.7
Topical tacrolimus was shown to be more effective than topical steroids in two case series,8,9
but symptoms return on stopping treatment and side effects are more frequent and severe. Long term safety (>1 year) is unknown.
Surgery may be needed to breakdown vaginal adhesions and restore sexual function.10
Potent topical steroids and vaginal dilators must be used postoperatively to help prevent restenosis. Dedicated nursing support improves compliance and efficacy.
The risk of lichen planus leading to malignancy is unknown. Of 61 cases of squamous cell vulval carcinoma, three were found to have coexisting lichen planus.1
It is thought that longstanding inflammation may facilitate a neoplastic cellular clone to develop in epithelium undergoing continuous renewal. Long-term follow-up is necessary to monitor disease activity with a low threshold for repeat biopsies.
This case highlights that a combination of treatments provided in a multidisciplinary setting can result in a successful outcome for this challenging condition with high patient morbidity.
- Lichen planus is an uncommon multisystem disease that can present to a variety of specialities.
- Always ask patients with lichen planus if they have any genital symptoms.
- Biopsy is needed to exclude malignancy or vaginal intraepithelial neoplasia.
- Vaginal stenosis with loss of sexual function is a challenging aspect of care.
- Surgery followed by use of intravaginal Colifoam enemas and vaginal dilators is an effective treatment regimen.
- Treatment in a combined clinic often improves patient satisfaction and outcome.