Lichen Simplex Chronicus

Background

• Lichen simplex chronicus is characterized by lichenified skin plaques associated with intense pruritus. Skin inflammation and scratching may be perpetuated by an ongoing "itch-scratch" cycle.
• Often an initial pruritic trigger, such as mechanical irritation from clothing or an underlying skin irritation, condition, or infection can be identified.
• Lichen simplex chronicus is most often seen in adults and is more common in patients with a history of atopy.

Evaluation

• Patients typically present with pruritic patches of thickened, erythematous, leathery skin. Affected areas most commonly include the nape of the neck, the forearms, shins, ankles, scalp, vulva, scrotum, pubis, or anus.
• Lesions are often associated with excoriations, fissures and/or scaling, and skin may be hyperpigmented, hypopigmented, and lacking usual overlying hair.
• The diagnosis can usually be made clinically. Evaluation should include an assessment of underlying triggers. For women with vulvar lesions, evaluate for associated vulvovaginitis or hygienic behaviors that may be an underlying inciting factor.

Management

• The goal of management is to stop the "itch-scratch cycle" and allow the skin to heal.
• Advise behavior modifications to remove possible triggers and provide symptomatic relief of pruritus.
• Treat any underlying skin conditions, such as atopic dermatitis, psoriasis, or vulvovaginal infections.
• Consider counseling and treatment for psychological conditions such as depression or increased anxiety that may lead to increased or habitual scratching.
• Consider short-term use of topical high-potency corticosteroids, such as clobetasol 0.05% or halobetasol 0.05% ointment to reduce skin inflammation and pruritus. Also consider the use of topical calcineurin inhibitors (pimecrolimus 1% cream or tacrolimus 0.1% ointment) as steroid-sparing alternatives.
• For more severe or unresponsive lesions, consider intralesional triamcinolone 60-80 mg once monthly until improved.
• Consider sedating oral antihistamines at bedtime, such as hydroxyzine 10 mg (up to 30 mg if necessary) orally 2 hours before bedtime, or doxepin 10-25 mg orally 2 hours before bedtime, to reduce nocturnal pruritus.
• For recalcitrant lesions, consider other management options such as gabapentin, transcutaneous electrical nerve stimulation, botulinum toxin A injection, or phototherapy.