Vulval lichen planus

This leaflet has been written to help you understand more about lichen planus. It tells you:

• what it is
• what causes it
• how it can be treated
• where you can find out more about the condition

What is lichen planus?

Lichen planus is an inflammatory skin disease. It most commonly causes an itchy rash of small purplish bumps, often on the arms, legs, back or inside the mouth. It can also affect the genital area, including the vagina, Sometimes, the nails and the scalp are also affected. It is possible to have the disease in one area without ever having a problem elsewhere. Many patients with vulval lichen planus have soreness in the mouth but they can also experience itching in other areas of their skin.

What causes it?

The cause of lichen planus is unknown. We know that it is not caused by infection, hormonal changes or ageing and is not because of anything that you did or didn’t do. It results from inflammation in the skin.

There may be a problem with your immune system. In lichen planus the immune system has become too active in the area affected. This causes inflammation in the skin or on the genital area. This is referred to as an autoimmune reaction. Why the lesions develop in some places and not others is not known.

What are the symptoms?

Most patients will feel soreness in the vulval area. There may be a painful, burning sensation which may be worse on passing urine. Intercourse may be painful. Sometimes patients may notice an increased vaginal discharge.

How is it diagnosed?

Your doctor will usually be able to give you a diagnosis from examining you. They will be looking for signs and changes typical for lichen planus. A biopsy is not usually needed to confirm the diagnosis.

Treatment

Self help: Wash your vulva with warm water using a soap substitute, see moisturisers below. Avoid washing your hair in the bath as shampoo can irritate the vulval skin. All patients with vulval skin problems are advised to avoid soaps, bubble baths, baby wipes and ‘feminine hygiene’ products as these can all strip the skin of its natural protection or cause irritation due to the chemicals and preservatives in them. It is advised to wear 100% cotton underwear and use white unscented toilet paper. It is best to avoid biological washing powders or liquids and it can be helpful to double rinse your underwear.

Moisturisers: You will be given a prescription for a cream to use such as Diprobase, Oilatum or Cetraben. We recommend that you apply the cream to the vulval area before washing or showering, rinse it off and then reapply once you are dry. It should then be used as a moisturiser several times a day.

Steroid ointment: Steroid ointment, along with moisturisers, is the main treatment. You will be advised how much and when to apply the ointment. Do not be alarmed if the instruction leaflet states that it should not be used on the genital area – it is safe to do so under medical supervision. There is concern about overuse of steroids as they can thin the skin, but using one 30g tube of steroid ointment over at least 3 months is a safe amount.

Oral medication: Oral medication may need to be used if the condition is not well controlled and the doctor will discuss this with you if necessary.

Sexual intercourse: If sexual intercourse is painful because of tightening or splitting at the entrance to the vagina, the use of lubricants and, on occasions, vaginal dilators, will help. This is something we will discuss with you.

Vulval cancer: Ladies who have lichen planus have a slightly increased risk of developing vulval cancer. Vulval cancer is extremely rare but if you do notice a change in what you normally feel when you are applying your creams please make an appointment to see your GP. Ask to be seen within a week of your telephone call or ring and ask for advice from your consultant if you are still under hospital care.

The sort of changes that you may notice are lumpy or sore areas or areas which are ulcerated, the top layer of skin is missing. As you are regularly putting creams on you will get to know what the area feels like. You are therefore much more likely to notice a change than women who do not regularly touch or examine this area.

What is the long term outcome?

Lichen planus can settle by itself but for many patients treatment will need to continue for many years, just like many other skin conditions. You will be kept under review in the clinic until the disease is stable and your symptoms are well controlled.

You can get more information about Lichen Planus from:-

Vulval Pain Society – https://vulvalpainsociety.org.uk/

British Society for the Study of Vulval Disease – https://bssvd.org/

Treatment – to be completed by your gynaecologist
Moisturiser/soap substitute:
Steroid preparation:

Use one fingertip unit once a day, in the morning, for 2 weeks. We will demonstrate this to you in clinic. After using for 2 weeks use on alternate days for a further 2 weeks.

If your symptoms improve then reduce to using twice a week until seen for review.

If your symptoms flare up, go back to using every day again for a week or two before dropping back down to twice a week again.