Lichen Sclerosus et Atrophicus Follow-up
- Author: Jeffrey Meffert, MD; Chief Editor: William D James, MD more...
Further Outpatient Care
If potent topical steroids are to be used, regular follow-up is required to monitor for the occurrence of steroid atrophy. Monitor female lichen sclerosus patients for any sign of secondary or associated genital malignancy. Extragenital cases require no specific follow-up.
Further Inpatient Care
Inpatient care generally is not required unless for surgery for malignancy or to relieve urinary obstruction is planned.
A patient requiring surgical intervention (circumcision or cancer surgery) may require transfer to another specialist if the dermatologist or primary care physician is not competent in the procedure required.
Following are male genital, female genital, and extragenital complications:
- Male genital: Complications can include painful erections, urinary obstruction, an inability to retract the foreskin, and squamous cell carcinoma (rare).
- Female genital: Complications include dyspareunia, urinary obstruction, secondary infection from chronic ulceration, secondary infection related to steroid use, and squamous cell carcinoma (rare, but not as rare as male cases). Some estimates are as high as 5% for the lifetime risk of vulvar squamous cell carcinoma in patients with lichen sclerosus. The epidemiology of lichen sclerosus patients who develop squamous cell carcinoma shows that older age, longer duration of lichen sclerosus, and evidence of hyperplastic/early vulvar carcinoma in situ changes to be significant risk factors. A 2009 study linked coexistent chlamydia infection and lichen sclerosus with increased risk of squamous cell carcinoma, but other sexually transmitted illnesses, such as human papillomavirus infection, were not completely addressed.
- Extragenital: Complications include cosmetic concerns, but only in extensive cases.
The following issues also may arise:
- Incomplete diagnosis: The patient may have lichen sclerosus, but a persistently ulcerated area or an area not responsive to therapy may be a malignancy. Another biopsy or additional biopsies may be necessary.
- Inappropriate surveillance: Repeatedly refilling a patient's topical corticosteroids without reexamining them may allow a malignancy to spread or may allow steroid side effects to develop.
- Child abuse issues: lichen sclerosus, especially when bullous and hemorrhagic or erosive, may be confused with child abuse. On the other hand, one case report suggested lichen sclerosus either coexisted with child abuse or was related to the trauma associated with the repeated sexual attacks.
- Suboptimal therapy: Topical testosterone, despite the extensive literature describing its use, may not be more effective than placebo and can be associated with virilization.
- New problem: Allergic contact dermatitis may develop with any topical therapy, including steroids. Irritant dermatitis may likewise develop. Consider these when a patient who previously was doing well suddenly seems to worsen.
Prognosis is good for more acute genital cases, especially for those in pediatric age group that may resolve spontaneously. Prognosis for improvement is poor for extragenital cases and for chronic atrophic genital disease.
Lichen sclerosus has no associated increased mortality unless the patient develops a malignancy in the area. Cancer arising in extragenital presentations is described only rarely and may be coincident with other factors. Many pediatric cases improve with puberty. In contrast, some authors suggest the rate of spontaneous resolution may be lower than 25%. Extragenital cases and many genital cases are asymptomatic except for the cosmetic aspect or pruritus. Recalcitrant cases, especially those associated with erosion or progressive scarring, may result in severe sexual dysfunction.
Education relating to sexual dysfunction and dyspareunia may be required. Patients with genital lichen sclerosus should be educated on what changes (eg, ulceration) might indicate malignant transformation and mandate an immediate reevaluation.
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