Anogenital dermatoses are included Lichen sclerosus (LS),Lichen planus (LP),Lichen simplex (LS),Dermatitis, Lichen simplex (LS),Psoriasis and Premalignant conditions.
Lichen sclerosus (LS)
Itching and soreness are secondary symptoms of vulvar lichen sclerosus (LS), a chronic skin disorder affecting the vulva (the skin surrounding the vaginal opening) and anus.
Aetiology: inflammatory condition of unknown cause. Linked to autoimmune disorders. Occurs 10 times more commonly in women than men and although it can present at any age (including children), it is predominantly seen in women >50 years. In men LS is known as balanitis xerotica obliterans (BXO)
Complications: risk of development of squamous cell carcinoma is unknown but thought to be <5%.
Symptoms: itch, irritation, soreness and dyspareunia (due to introital narrowing). Rarely asymptomatic
Signs: females; skin pallor or atrophy (‘cigarette paper’ appearance) either in patches or in a ‘figure of eight’ distribution (involving perianal area). Hyperkeratosis, fissuring, excoriation and purpura (ecchymosis). Loss of architecture with labial adhesions and midline fusion may be seen; males; affects the glans penis. Scarring can cause obliteration of the urethral meatus.
Diagnosis: is clinical unless uncertainty or malignancy suspected in which
case a biopsy is required.
Investigations: screen for other autoimmune conditions if indicated, e.g. thyroid disease. Take a skin swab if secondary infection is suspected.
Management: there is no cure for LS and it usually persists for years.
Treatment can substantially improve symptoms. Mainstay is ultra-potent topical steroids e.g. clobetasol proprionate. A 30-g tube should last 3 months. Ointment bases are preferable to creams.
Follow-up: review in 2–3 months. Maintenance treatment may be required. Stable disease should be reviewed annually however individuals should be advised to seek advice if they notice any suspicious changes (e.g. raised lesions).
Lichen planus (LP)
Aetiology: uncommon inflammatory condition of unknown cause. LP is linked to autoimmune disorders. It can affect the skin, genital and oral mucous membranes. It occurs equally in men and women and can present at any age. In the majority of cases (85%), it resolves within 18 months.
Symptoms: itch, irritation, soreness, vaginal discharge, or dyspareunia or
can be asymptomatic.
Signs: females; there are different subtypes of LP. Erosive LP is the commonest type affecting the vulva. It can also affect the vagina (unlike LS). The mucosal surfaces are eroded, the erosion edges are purple with a pale network of fine white lines – Wickham’s striae. As the erosions heal,
synaechiae and scarring can develop. Lesions of classical LP can be found on the keratinized anogenital skin as can hypertrophic lesions. In males; lesions of the glans penis may occur.
Complications: scarring, including vaginal synechiae formation. Risk of development of squamous cell carcinoma may be as high as 3%.
Diagnosis: clinical or biopsy and histology if uncertain.
Investigations: as per Lichen sclerosus (LS).
Management: is similar to LS, with ultra-potent topical steroids, e.g. clobetasol proprionate. Maintenance treatment may be necessary and can be with weaker steroids or with less frequent use of ultra-potent steroids. Intravaginal corticosteroid treatments may be indicated
Follow-up: as per LS (Lichen sclerosus)
Dermatitis
Dermatitis can be atopic, allergic contact, irritant contact or seborrhoeic. Dermatitis can be secondary to iron deficiency anaemia or candidal infection.
Symptoms: itch, soreness
Signs: lichenification, excoriation, fissuring, erythema
Diagnosis: clinical, general examination to look for skin disease elsewhere
Investigations: patch testing and biopsy if indicated, swab for infection
(especially candida), serum ferritin.
Management: avoid precipitating factors. Topical steroids (choice determined by disease severity). Combination preparations with antifungal +/or antibiotic for superinfection. Emollients and soap substitutes. Topical calcineurine inhibitors
Complications: secondary infection.
Lichen simplex (LS)
LS is a localized dermatitis caused by repeated rubbing and scratching inducing
a chronic itch–scratch cycle. The stimulus to scratch may be an existing skin
condition, e.g. atopic dermatitis; a systemic condition associated with pruritis,
e.g. primary biliary cirrhosis; or environmental factors, e.g., heat, sweat. It is also
associated with psychiatric disorders such as anxiety, depression and obsessive-compulsive disorder.
Symptoms: itch, soreness
Signs: can affect the anal or genital skin in both males (e.g. scrotum) and
females (e.g. labia majora). Lichenification, erosions and fissuring, excoriation.
Diagnosis: clinical.
Complications: secondary infections
Investigations: swab for infection, consider patch testing, serum ferritin,
and biopsy if indicated.
Management: avoid precipitating factors, use emollients, topical.
corticosteroid, antihistamine at night, and address any mental health issues
Psoriasis
Aetiology: a common, chronic skin condition affecting about 2% of the population. It affects adult men and women in equal proportions and has a genetic predisposition. Genital psoriasis may present as part of plaque or flexural psoriasis or be the only area affected (rare); 5% of sufferers will develop psoriatic arthritis
Symptoms: itch, soreness
Signs: well demarcated erythematous scaly plaques, fissuring, often
symmetrical. Natal cleft involvement common
Complications: Koebner effect (skin lesions appearing at sites of trauma)
Diagnosis: typical clinical appearance. Examine for lesions elsewhere.
Premalignant conditions
The commonest aetiology of vulval, penile and anal intraepithelial neoplasia
(VIN, PIN, AIN) is HPV (especially type 16) but they are also associated with
LS, smoking and immunosuppression. Clinical appearance can be variable
ranging from atypical warty lesions to raised erythematous or pigmented lesions.
Multifocal lesions are common. They can cause itch, pain and burning or be
asymptomatic. VIN is associated with CIN therefore up to date cytology should
be confirmed ± colposcopy. Diagnosis is histological. Progression to squamous
cell carcinoma can occur in 9–18.5% of VIN. Management in a multidisciplinary
vulval clinic is recommended.
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