What is lichen planus? (LP)
Lichen planus is a disease that affects the skin but also the inside of the mouth and vagina. In rare cases it also involves the anal canal and can extend into the tube that goes from your mouth to your stomach (the oesophagus).
LP is a vary variable condition. That means it has many different forms. The type that involves the vulva presents itself with a painful raw inflammation of the inside of the vagina and the inner lips of the vulva (the labia minora).
Lichen planus (LP) is a rare disease. It is very difficult to diagnose.
LP can occur on any part of the skin. In addition to causing vulval disease it may also cause itchy skin rashes, nail problems and hair loss.
What causes Lichen Planus?
The exact cause of the LP remains unknown. In a few cases, it is related to Hepatitis B and C infections (these are usually the result of blood transfusion or from intravenous drug use). It has been reported after Hepatitis B vaccination.
Most cases have no known cause. It is just bad luck.
Who gets Lichen Planus?
LP is almost always a disease of adults. It is very rare in children and adolescents. The majority of women with vulval LP are middle aged and beyond.
What happens to patients with Lichen Planus?
Patients with vulval LP usually have pain with sex, soreness and heavy discharge. Itch is not a prominent feature. Most patients can’t have sex at all because of pain. If the anal canal is involved, pain when going to the toilet also occurs.
When oral disease is also present, patients notice oral soreness and sensitivity as well as tenderness, redness and difficulty eating without pain.
When you have a look there often isn’t much to see. It might just be redness but if you look closely you might notice that the surface of the inside of the vagina or inner surface of the small inner lips of the vulva can look raw and shiny.
Sometimes ulcers (open wounds) can occur. If your doctor looks inside, the same changes will often be in the vagina. On the outside of the vulva there may be grey areas interspersed with red, raw ones.
If vulval LP is not diagnosed and treated early, scarring may occur. This means that the inner lips of the vagina can shrink, the clitoris can disappear and the sides of the vagina can fuse together.
Patients with LP may also suffer from infections that cause abscesses under the areas of scarring.
How is Lichen Planus different from Lichen Sclerosus (LS)?
You may have read about Lichen Sclerosus and are wondering whether you could have that. It can be difficult to tell LP and LS apart.
Both LP and LS are scarring conditions where loss of the outside of the vulva occurs however they are very different in the following ways:
- LP involves the vagina and in many patients also the mouth. LS never does.
- LP causes rawness inside the vagina. LS may split or ulcerate but never causes raw areas like this.
- LP is a red rash with patches of grey. LS is white.
- LP is extremely rare in children. LS is found in children.
How is LP diagnosed?
The most definite diagnostic test for LP is a biopsy. This means cutting a tiny piece of skin (about 3mm) from the rash and having a pathologist analyse it under a microscope. This simple test can be done in your doctor’s office.
What treatment is available?
The initial treatment of LP in all cases is with cortisone either taken by mouth or applied as an ointment or pessary that is inserted into the vagina. If an ointment is used, it has to be a very potent one or it won’t work. If oral cortisone is used, very high doses are not required and it works fast and effectively. Many patients are initially too sore to apply ointments and are only able to do this after a few weeks of treatment with cortisone taken by mouth.
Many general practitioners are not comfortable with prescribing such strong cortisone for use on the vulva and will refer their patients to a specialist for treatment.
The potent cortisone ointments that are needed to bring LP under control can’t be used indefinitely or they will eventually make the vulval skin fragile and red, so it is important to bring in other treatments that are then used for longer periods of time to maintain control of the disease. These other treatments include oral medications and an ointment called tacrolimus. Again the use of such drugs usually means that you must see a specialist, at least initially.
Scarring may require correction but this can only be attempted once treatment has brought LP under good control.
Will I recover?
Once LP is diagnosed it is usually a long term condition that must be controlled. Most patients don’t get better without treatment and most need ongoing treatment to stay well.
Most patients can achieve good control, but it may take up to a year or even longer to achieve this. Not all patients are able to achieve intercourse without pain however.
LP is often a devastating and life changing event for patients, necessitating a huge change in lifestyle: daily medication, some of which involves significant risk and loss of sexual enjoyment and activity. The impact can be very great and you should never feel that what you have is a trivial condition.
If you are on treatment for LP which may include oral cortisone and other strong medicines, you may experience surprise from some health professionals that you take all of this for a vaginal condition. Don’t allow such comments to make you doubt the wisdom of treating LP. It is a painful and difficult condition that deserves aggressive treatment.