Medical Care
Treatment is aimed at reducing pruritus and minimizing existing lesions because rubbing and scratching cause lichen simplex chronicus. Location, lesion morphology, and extent of the lesions influence treatment. For example, a thick psoriasiform plaque of lichen simplex chronicus on a limb is commonly treated with a highly potent topical corticosteroid or intralesional corticosteroids, whereas vulvar lesions are more commonly treated with a mild topical corticosteroid or a topical calcineurin inhibitor. Widespread lesions are more likely to require systemic treatment or total body phototherapy.
Topical steroids are the current treatment of choice because they decrease inflammation and itch while concurrently softening the hyperkeratosis. [24, 25, 26] Because lesions are by nature chronic, treatment most likely is lifelong. On larger and more active lesions, a midpotency steroid may be used to treat acute inflammation. Occasionally, occlusion is used to increase potency and enhance delivery of the agent. Occlusion also provides a physical barrier to the scratching. Midpotency topical steroids are not recommended for thin skin (eg, vulva, scrotum, axilla, face). Direct long-term therapy more at daily use of low-potency nontrophogenic topical corticosteroids. High-potency topical corticosteroids may be used for 3-week courses on thicker-skinned areas.
Intralesional injection of corticosteroids is useful for refractory lesions. A 2018 report describes the use of a transcutaneous pneumatic injection device for lesions refractory to 1 month of treatment with a potent topical steroid. Triamcinolone injected into the lesions at 2-cm intervals led to significant improvement. [27]
Oral antianxiety medications and sedation may be considered in certain patients. According to individual need, treatment can be scheduled throughout the day, at bedtime, or both. Antihistamines such as diphenhydramine (Benadryl) and hydroxyzine (Atarax) are common. Doxepin (Sinequan) and clonazepam (Klonopin) may be considered in appropriate cases.
For infected lesions, a topical or oral antibiotic can be considered.
Other topical medications reported to decrease pruritus include doxepin cream [28] and capsaicin cream. [29]
One study suggests that topical aspirin/dichloromethane is effective in patients with lichen simplex chronicus who have not responded to topical corticosteroids. [30]
For topical corticosteroid unresponsive patients or those with lesions on thin skin, a few case reports and small studies have shown efficacy of topical immunomodulators tacrolimus and pimecrolimus. [31]
A more investigational treatment for patients who fail conventional therapy is local botulinum toxin injections. [32, 33]
Transcutaneous electrical nerve stimulation (TENS) has been reported as a possible effective treatment in a small, open trial of cases of lichen simplex chronicus resistant to topical corticosteroid treatment. [34]
Consultations
Consultation with a dermatologist may be considered for severe cases requiring more than topical treatments or to facilitate patch testing.
Consultation with an allergist may be considered in individuals with multisystemic atopic symptoms.
Consultation with a psychiatrist may be considered, given the association with underlying depressive and anxiety disorders.
Prevention
Direct patients to stop scratching. Lichen simplex chronicus is worsened or improved depending on the patient's ability to stop scratching. Discussing individual ways to change habitual scratching is helpful.
Extremes of temperature and/or humidity, psychic stress, and exposure of previously affected or predisposed areas to cutaneous irritants and allergens provoke relapse.
Long-Term Monitoring
Periodically examine patients with lichen simplex chronicus in an outpatient dermatology clinic to evaluate lesions for changes. Perform follow-up examinations more frequently in patients being treated with potent class I topical corticosteroids or oral agents.
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Plaque of lichen simplex chronicus demonstrating accentuated skin markings. Courtesy of San Antonio Uniformed Services Health Education Consortium Dermatology Program.
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Area of lichen simplex chronicus originally believed to be chronic contact dermatitis. The true nature was revealed when the patient admitted to rubbing this area while watching television. Courtesy of San Antonio Uniformed Services Health Education Consortium Dermatology Program.
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Plaques of lichen simplex chronicus on the hand.
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Lichen simplex chronicus of the dorsal hand and wrist demonstrating increased skin thickness and accentuation of skin markings.
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Plaque of lichen simplex chronicus of the leg with accentuated skin markings and excoriations.
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H and E biopsy of lichen simplex chronicus from forearm skin viewed at 40x magnification. Note the characteristic hyperkeratosis, hypergranulosis, pseudoepitheliomatous hyperplasia, and papillary dermal fibrosis.
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H and E biopsy of lichen simplex chronicus from forearm skin viewed at 100x magnification. Note the characteristic hyperkeratosis, hypergranulosis, pseudoepitheliomatous hyperplasia, and papillary dermal fibrosis.
