Vulvar Lichen Planus
A recent document published by the Mayo Clinic, states that lichen planus is an inflammatory condition that typically affects your skin and other mucus membranes including the nails, mucus membranes of the mouth, esophagus, conjunctiva, bladder, stomach, anus, and vagina.
Lichen planus is not contagious and cannot be transferred from one person to the next. It may appear as lacy white patches or sores that can be painful. For some unknown reason, the disorder is likely to occur when the immune system attacks the cells of the skin or mucous membranes.
According to a recent Medscape article, lichen planus may also be found with other diseases of altered immunity; these conditions include ulcerative colitis, alopecia areata, vitiligo, dermatomyositis, morphea, lichen sclerosus, and myasthenia gravis. In a recent meta-analysis, 16 percent of patients with lichen planus also had hepatitis-C infection.
Symptoms
The signs and symptoms of lichen planus vary depending on what part of the body is affected. The onset or aggravation of lichen planus has been linked to stressful events. Symptoms may be present for months or even several years. On the skin, it may appear as itchy bumps that have a purple coloration, appearing in the ceases in the skin or in areas where a scratch or injury has occurred. The most significant kind of lichen planus is the erosive type which has bright red ulcerations on the surface.
According to the syllabus from the International Society for the Study of VulvoVaginal Disease (ISSVD) on diagnosis and management, the vulvar bumps may have a fine lacy white border (Wickham Striae). These purple bumps may be anywhere but often occur on the inner forearm and near the wrists or ankles. Other areas include the lower back, neck and legs.
Other symptoms include itchiness, and in rare occasions crust-like lesions. The vulva may be very painful with open sores on the vulva or on the lining of the vagina. The labia may flatten, shrink or even appear resorbed. Because scarring can happen, it is important to get treatment. Patients with lichen planus may also complain of burning, rawness and itchiness in and around the vaginal opening. The skin may change to a darker coloration when the lesions resolve.
Lichen planus can occur in the mouth (oral lichen planus). Symptoms may include changes in the gums, lips or tongue. You may also have sores in the mouth that cause burning and pain. It can also affect men on the tip of the penis (glans). Scalp lichen planus (lichen planopilaris) is rare and can result in scarring, temporary or permanent hair loss, and scalp discoloration. Lichen planus can also affect the nails and fingers.
Diagnosis
Your vulvar specialist will often make the diagnosis based on history and physical examination. It is important to record and report all your symptoms to the provider to assist in an accurate diagnosis. A detailed and specialized examination of the vulvar skin will take place. Sometimes specialized testing may be indicated, including a vulvoscopy. The health care professional should also do an oral cavity examination to look at the teeth, gums and surrounding tissues to make sure there is no mouth involvement.
Patients may report severe painful intercourse, and a narrow vaginal opening. Genital cultures may be necessary to rule out vaginitis. Lichen planus may coexist with lichen sclerosus, especially in the late stages of the disease where anatomical changes have taken place.
Although a vulvar biopsy is non-specific, it may help to rule out other conditions. Hepatitis C testing may be warranted. Allergy tests may be performed to see if there is a specific agent that has contributed to the development of the disease.
Treatment
Lichen planus (LP) may at times be self-limiting and can resolve within 8-12 months. Treatment to decrease or suppress itchiness may be helpful (oral or topical anti histamines). Mild cases can be treated with topical steroids. Sitz baths may also be helpful to relieve local symptoms of itchiness and burning.
More severe cases, especially those with scalp, nail, and mucous membrane involvement, require more aggressive treatment. Phototherapy may be a viable option for lichen planus of the skin.
A treatment option for lichen planus that involves the genitals includes ultra potent corticosteroids (topical ointments or pills) to reduce inflammation. Tacrolimus (Protopic ointment) and pimecrolimus (Elidel cream) may also be used. Caution should be exercised since it can be absorbed into the vaginal tissue.
In other regions, retinoids or synthetic versions of vitamin A, can be topically or locally applied as a treatment option. Retinoids have been associated with congenital birth defects, so it is critical that women of childbearing age use effective contraception. Pregnant women and those who are planning pregnancy should not use retinoids. Cyclosporine and methotrexate, drugs which may help prevent rejection of transplants, may also be effective treatment options. Treatment for diagnosed hepatitis C should occur by an expert in liver disease.
A vaginal dilator program should be started as part of the comprehensive treatment for lichen planus. Since painful intercourse (also known as dyspareunia) is common, treatment should occur to prevent vaginal stenosis or narrowing.
Specialists
You will more than likely require a vulvar specialist who is experienced in vulvar disease, vulvoscopy and the new treatments of lichen planus, in order to effectively manage your symptoms.
It is advisable to seek out a specialist if you think you may have lichen planus. The National Vulvodynia Association (www.nva.org) has a comprehensive data base of providers who treat vulvar conditions including lichen planus and lichen sclerosus. It provides web address and additional information concerning specialty, type of practice and number of cases seen on a monthly basis. It can be searched by geographical area as well.
The International Society for the Study of Vulvovaginal Disease (www.issvd.org) may also be an excellent resource for up to date information, research and providers who specialize in vulvovaginal disorders.
You may also need an internist or medical expert in infectious disease or liver conditions if you are also affected by Hepatitis C. An allergist may also be consulted if it is felt that the lichen planus was triggered by an allergy.
If you are suffering from sexual complaints associated or caused by the lichen planus, including painful intercourse or painful sex, then a good therapist or counselor who specializes in sexual pain may be located at the International Society for the Study of Women’s Sexual Health (www.isswsh.org) or American Association of Sexual Educators, Counselors and Therapists (www.aasect.org). The International Society for Sexual Medicine (www.issm.info) and the European Society for Sexual Medicine (www.essm.org) are also excellent resources.