Introduction
We have a series of posts looking at lichen sclerosus and other vulvovaginal conditions. For example, we have lichen sclerosus and menopause and lichen sclerosus, and lichen simplex chronicus. We do these posts to promote vulvovaginal education and because some folks have lichen sclerosus and other conditions. Further, many folks find the overlap of symptoms confusing and hard to navigate. In this post, we continue this series and will look at lichen planus and lichen sclerosus.
If you are curious about the difference between lichen sclerosus and lichen planus, want to know what to look out for, and wonder if you can have both lichen sclerosus and lichen planus, this post is for you!
*This post is evidence-based; I draw on the medical literature to share what you need to know about lichen planus and lichen sclerosus. Importantly, what I share is my interpretation of the science and data.
Always speak to your healthcare provider before making any changes to your health plan.
*Further, this post is meant as an introductory piece/general overview and does not capture the complexity of lichen planus. Stay tuned for more content on this topic in the future.
Lichenoid Skin Conditions
There is a lot of overlap with lichenoid skin conditions.
Wait, what?!
What is a lichenoid skin condition?
Lichenoid skin conditions are a group of inflammatory skin conditions that share similar traits. For example, lichenoid skin conditions have a band-like strip of inflammatory cells in the dermis (the middle layer of the skin). A pathologist (i.e., the medical specialist who examines body tissues) would see this on a biopsy sample from someone with a lichenoid disorder.
Clinically, for skin to have lichenification or to become lichenified means the skin has become thickened, leathery, tough, and rigid.
Both lichen sclerosus and lichen planus have that band-like strip of inflammatory cells in the dermis and have thickened, stiff skin.
Let us review both and then go over some similarities and differences.
What is Lichen Sclerosus?
This a quick primer for folks who are new and unfamiliar with LS.
Lichen sclerosus is a chronic, inflammatory skin condition considered to be an autoimmune condition by most of the medical community. It causes symptoms like pain and itching. It primarily affects the genitals but can occur in other body parts. Signs of lichen sclerosus involve:
- Hypopigmentation (lightening of the skin).
- Scarring.
- Architectural changes.
- Thickening of the skin/ skin that resembles cigarette paper.
The gold standard treatment for LS is ultrapotent topical corticosteroids.
If you are new here and want to learn more about LS, check out my video.
Lichen Planus
Lichen planus is a chronic, inflammatory, autoimmune condition that often affects the mucosal membranes of the body (e.g., the mouth, the vulva, and the vagina), although folks can have lichen planus anywhere else on the body (Goldstein & Metz, 2005; Goldstein, Pukall, Goldstein, and Krapf, 2023).
When lichen planus involves the vagina/vulva, it is called erosive lichen planus. I am referring to this in the rest of this blog post.
Symptoms of Erosive Lichen Planus
- Soreness, burning, and rawness of the vulva and/or vagina
- Itching
- Vaginal discharge is usually a sticky, yellowish discharge (sometimes stained with blood).
- Vaginal bleeding or spotting when not inside your menstruation window
- Painful sex
(BC Centre for Vulvar Health, Lichen Planus Patient Handout, 2022; Goldstein and Metz, 2005, Goldstein, Pukall, Goldstein, and Krapf, 2023).
Signs of Erosive Lichen Planus
- Changes to the physical appearance of the vulva (aka architectural changes). This may include a flattening of the anatomy, scarring of the clitoris, loss of labia minora, etc.
- Redness, erosions, and/or ulcers in the vestibule (most commonly around the entrance of the vagina.
- These red erosions are often described as bright, glassy patches of skin.
- Sometimes these red erosions have a white, lacy-looking overlay called Wickham’s stria. Think something like a spider-web.
- Redness, erosions, and/or ulcers in the vagina and cervix. This is typically something doctors would see with specialized equipment.
- Scarring and narrowing of the vagina.
- Vaginal discharge is usually a sticky, yellowish discharge (sometimes stained with blood).
- Vulvovaginal skin that bleeds more easily (e.g., from a speculum at a gynecology exam).
(BC Centre for Vulvar Health, Lichen Planus Patient Handout, 2022; Goldstein and Metz, 2005, Goldstein, Pukall, Goldstein, and Krapf, 2023).
Diagnosis
A lichen planus diagnosis is often made clinically. A clinical examination is where the doctor will take your medical history and symptoms and thoroughly examine the vulva and the vagina. Sometimes a biopsy is done, but if the skin is too inflamed or eroded, the doctor may just give a clinical diagnosis (BC Centre for Vulvar Health, Lichen Planus Patient Handout, 2022).
Misdiagnoses
Lichen planus is often misdiagnosed as lichen sclerosus because, clinically, they can present similarly. For example, both can have thick plaques of skin, scarring, and architectural changes. They also both have itch and pain as symptoms (ibid).
It can also be misdiagnosed as immunobullous diseases like mucous membrane pemphigoid (Goldstein & Metz, 2005).
Therefore, seeing a competent doctor who can tell the two apart is crucial. Lichen Sclerosus Support Network has a provider directory if you are searching for doctors who are knowledgeable in this area.
Treatment
Similar to lichen sclerosus, there is currently no cure for lichen planus. Instead, treatment focuses on symptom management and preventing further progression and changes to the vulvar anatomy.
Treatments vary depending on the provider and how the patient responds to treatment. Most doctors will start with topical corticosteroids applied to the vulva. Patients may either use hydrocortisone suppositories inserted into the vagina or apply the topical corticosteroid on a dilator and insert and massage it into the vagina. (BC Centre for Vulvar Health, Lichen Planus Patient Handout, 2022; Goldstein and Metz, 2005, Goldstein, Pukall, Goldstein, and Krapf, 2023).
Patients not responding to topical corticosteroids may be given oral, systemic steroid medication such as Prednisone or different immunomodulators (Goldstein & Metz, 2005; Goldstein, Pukall, Goldstein, and Krapf, 2023).
The doctors at the Centers for Vulvovaginal Disorders state they see more success with their lichen planus patients using calcineurin inhibitors (click to learn more about them) such as Tacrolimus or Pimecrolimus.
Similarities between Lichen Sclerosus and Erosive Lichen Planus
At this point, you must be thinking, “Wow, lichen planus sounds a lot like lichen sclerosus.” Moreover, if you are thinking that, you would be correct. There are many similarities between the two.
In terms of symptoms, both lichen planus and lichen sclerosus can cause itching, burning, soreness, and pain with sex. In terms of clinical signs, both conditions can cause physical changes to the appearance of the vulva, such as fusing, loss of labia, and clitoral scarring (burying of the glans clitoris).
Differences between Lichen Sclerosus and Erosive Lichen Planus
However, some key differences set the two apart.
- Lichen sclerosus presents more as hypopigmentation (i.e., a lightening of the skin), and erosive lichen planus presents more as bright red, glassy-looking erosions.
- Erosive lichen planus can affect the vulva and vagina. However, lichen sclerosus does not affect the vagina (although it can affect the vaginal opening) (Goldstein, Pukall, Goldstein, and Krapf, 2023).
- Only a tiny percentage of patients have LS in other parts of their body (e.g., arms, abdomen). However, about 25% of patients with LP will have it in other areas of the body (especially the mouth/gums) (ibid).
Can I Have Both Lichen Sclerosus and Erosive Lichen Planus?
Yes! You can have both lichen sclerosus and lichen planus. If you have been diagnosed with lichen sclerosus and notice bright red, glassy-looking erosions, have vaginal pain and narrowing, and/or experience a yellowish discharge, we suggest you see a specialist to discuss the potential of lichen planus.
Conclusion
In sum, lichen sclerosus and lichen planus are both lichenoid skin conditions. If you have not yet been diagnosed, you may want to see a board-certified dermatologist or gynecologist specializing in vulvar skin conditions or a vulvar specialist. The two have many similarities, but the main differences are that the erosive lichen planus affects the vulva and vagina. In contrast, LS just affects the vulva (though it can affect the vaginal opening). Erosive lichen planus presents more as bright red glossy patches, and lichen sclerosus presents as hypopigmentation (loss of pigmentation/color).
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Reach Out to Me
Whether you are debating booking a support call with me, have a quick question, or want to share something related to my content, I can be reached via:
Email: Jaclyn@lostlabia.com
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Support Resources
FREE Lichen Sclerosus Virtual Meetup hosted by myself and Kathy of Lichen Sclerosus Podcast – sign up here.
Feel free to book a 1:1 call with me to discuss mental health or sexual health or have general questions about lichen sclerosus. Simply click this link to learn more about lichen sclerosus peer support calls.
LSSN Membership – sign up here.
Check out my LS resources page here for a more detailed list of free and paid support resources.
Sources Cited & Consulted
BC Centre for Vulvar Health – Patient Handouts, Lichen Planus (2022)
Goldstein AT, Metz A. Vulvar lichen planus. Clin Obstet Gynecol. 2005 Dec;48(4):818-23. doi: 10.1097/01.grf.0000179670.98939.b7. PMID: 16286828.
Goldstein, Pukall, Goldstein, and Krapf. When Sex Hurts: Understanding and Healing Pelvic Pain. Hachette Books, New York, 2023.
The CVVD’s Lichen Planus Overview – there is a gallery containing images of lichen planus at the end. Please be mindful of your mental state and ensure viewing supports your healthcare journey.
