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Lichen Sclerosus or Vulvar Dermatitis

Lichen Sclerosus or Vulvar Dermatitis

Introduction

Vular itch and pain. Many of us are all too familiar with one or both of these symptoms as people with lichen sclerosus. However, these are also common symptoms of other vulvar conditions, not just lichen sclerosus. So, you may be wondering, “OK, then how do I know if my itch or pain is happening from LS or something else?” Great question! You follow our educational blogs and videos to help you better understand the different vulvar conditions out there and what to do if you suspect you may have one.

For example, we have blog posts on lichen sclerosus and lichen simplex chronicus, lichen sclerosus and lichen planus, and lichen sclerosus, menopause, and genitourary syndrome of menopause. Today, however, we will be discussing vulvar dermatitis and lichen sclerosus. We will review the signs and symptoms of lichen sclerosus and vulvar dermatitis. We will then review how each is treated and managed and what to do if you suspect you are experiencing vulvar dermatitis.

Disclaimers

*This post is evidence-based; I draw on the medical literature to share what you need to know about lichen sclerosus as well as irritant and allergic contact dermatitis. Importantly, what I share is my interpretation of the science and data.

**If this post is helpful to you, we’d love your support so we can continue providing important education like this. Make a donation today, volunteer with us, or share our posts in your support groups.

Lichen Sclerosus Signs and Symptoms

Before we dive into the different types of vulvar dermatitis, let us briefly review what vulvar lichen sclerosus (VLS) is. Lichen sclerosus is a chronic, inflammatory skin condition considered an autoimmune condition by most of the medical community. It causes symptoms like pain (stinging, burning, rawness, irritation) and itching (mild to severe). Signs of lichen sclerosus involve hypopigmentation (where the skin loses its pigment and becomes lighter in color), scarring and architectural changes, and thickening of the skin/ skin that resembles wax or cigarette paper. The gold standard treatment for LS is ultrapotent topical corticosteroids, with more frequent application in the beginning and maintenance treatment for life.

If you are new here and want to learn more about LS, check out this video I made on the topic. Conversely, If reading is your preferred medium, grab my FREE LS eBook (over 100+ pages of LS information and support resources).

Vulvar Dermatitis

Dermatitis is a common skin condition that causes the skin to swell and become irritated; this can affect the whole body, including the arms, backs of the knees, legs, etc. It can cause the skin to become red, dry, and flaky, or you may develop a rash. Sometimes, the skin can develop blisters and ulcers that can be painful and itchy (Madnani, 2023). There are three main types of dermatitis–atopic dermatitis (aka eczema), contact dermatitis, and seborrheic dermatitis. 

Often, when we hear of these types of dermatitis, it is in the context of the extragenital skin–aka the non-genital parts of our body such as the arms, stomach, and legs. However, contact dermatitis can also affect the genitals. 

Contact dermatitis of the vulva is common, and statistics show it presents in anywhere from 20-30% of people visiting a vulvar clinic with vulvar burning, itch, and redness (Margesson, 2004; Sand & Thompson, 2018) and 54% of patients presenting at a vulvar clinic (Woodruff et al. 2018). When dermatitis affects the vulva, it is one of two types–irritant contact dermatitis or allergic contact dermatitis. 


Let’s review each.

Irritant Contact Dermatitis (ICD)

Signs and Symptoms

Irritant contact dermatitis (ICD) is a skin condition that causes symptoms such as vulvar burning, stinging, irritation, and itching (Corazza et al., 2021; Goldstein et al., 2023). In terms of clinical signs–aka what you can physically see on the vulvar skin–there may be redness, blisters, papules (looks like a small, raised pimple), and flakey skin (Corazza et al., 2021).

ICD occurs from damage to the vulvar skin from things in our external environment, either chemical (e.g., a soap) or physical (e.g., a menstrual pad or panty liner). The offending product can disrupt and irritate the delicate epidermis (the top layer of skin) (ibid). This can result in an inflammatory reaction in the vulvar skin, causing burning, stinging, irritation, and itch. 

Graphic design images of a panty liner, a box of menstrual pads, a perfume bottle to signify fragrance and a bar of soap, which are all common irritants for ICD.

Risk factors (things that make you more likely to develop ICD) are complex and depend on a number of things, including the type of irritant, the length of exposure to the irritant, and the presence of other vulvar skin conditions (ibid).

Irritants

When it comes to irritants, it’s important to note that everyone is different. What causes irritation in one person may not cause it in another. The following is a non-exhaustive list of some of the common irritants for ICD.

  • Menstrual pads and panty liners
  • Baby wipes
  • Laundry detergent and fabric softener
  • Lubricants
  • Medications (e.g., topical Imiquimod, trichloroacetic acid, podophyllin, etc.)
  • Vulvar deodorants
  • Urine, feces, sweat, semen, and saliva

(Corazza et. al, 2021; Woodruff et al. 2018)

Diagnosis and Treatment

Diagnosis is made by examining the skin and listening to the patient’s symptoms by a dermatologist, gynecologist, or vulvar specialist. There is no need for a biopsy for suspected ICD.

Treatment is relatively simple. The primary focus is on eliminating the offending irritant. However, it’s often difficult to know what the offending irritant is. If I think about any given day, I might have sweat, urine, coconut oil, lubricant, or other substances/products that could be the culprit. Therefore, most healthcare providers recommend stopping all chemical/physical products until the irritation has subsided. You may then choose to reincorporate certain products one at a time gradually. For example, once the ICD has subsided, you may try your emollient again. If there is no reaction after a week, then that probably was not the culprit. You may choose to keep reintegrating substances/products. However, if you reintroduce one and it reproduces ICD, it is likely that it was the offending irritant, and it is advised you discontinue it.

Remember, many of the products on the list above are unnecessary. For instance, you do not need to wash your vulva with soap; simple warm water is sufficient. If you prefer a soap, opt for a dermatologist-approved, fragrance-free, gentle cleanser. Learn more about washing and emollients in my Instagram live with Dr. Sesay.

Usually, the elimination of chemical/physical products is sufficient for treating ICD. However, in some cases, patients are instructed to treat with topical corticosteroids for one month to calm the underlying inflammation and provide symptom relief (Goldstein et al., 2023). 

Allergic Contact Dermatitis (ACD)

Allergic contact dermatitis (ACD) is similar to ICD. However, ACD tends to cause more irritation than ICD. Furthermore, ACD involves an allergic reaction to an irritant, which triggers the body’s immune system.

ACD has two types–acute and chronic. If the vulva is exposed to a strong allergen, you may experience acute ACD. Acute ACD presents as a red rash/redness, swelling, blisters, and ulcers. The pain and itch are usually quite severe and distressing with acute ACD.

Chronic ACD occurs when the allergen is weaker and the vulva is exposed to the allergen periodically over time. Chronic ACD presents as a red rash/redness and lichenified (thickened) patches of skin. This presentation is more subtle, and chronic ACD is sometimes missed in people with heavily pigmented skin by providers who do not have a lot of experience with vulvas of darker skin types (Madnani, 2023; Woodruff et al., 2018). People with darker skin types may experience dyspigmentation–any abnormal color change, either lighter or darker (Madnani, 2023).

Allergens

As with irritants for ICD, it’s important to note that everyone is different with respect to allergens. What causes ACD in one person may not cause it in another. The following is a non-exhaustive list of some common ACD allergens:

  • Fragrances (these may be found in your soaps, emollients, etc.)
  • Preservatives (e.g., parabens, ethylenediamine dihydrochloride, stearyl alcohol, etc.)
  • Emollients and vehicles for medications (e.g., propylene glycol, which is used as a base for some corticosteroid medications and lanolin, which is the ingredient in Aquafor healing ointment).
  • Medications (e.g., Clotrimazole and Nystatin used for yeast infections, some corticosteroids such as Clobetasol-17 propionate and Hydrocortisone-17-butyrate, and antibiotics such as Neomycin and Bacitracin)
  • Botanical extracts like arnica Montana and oak moss
  • Metals such as nickel sulfate and cobalt
  • Menstrual pads and panty liners

(Ibid).

Diagnosis and Treatment

ACD is diagnosed clinically and often involves patch testing for allergies to determine the allergen(s) responsible for the reaction. Treatment involves stopping the allergen(s) causing ACD. Doctors should provide counseling on proper hygiene and gentle skin care. Many doctors recommend washing the vulva with water and using your fingertips instead of a cloth or loofah. After washing, pat dry with a towel and apply a bland emollient like petroleum jelly (ibid). Sometimes topical steroids are needed to calm inflammation–be sure to ask your doctor what your new dosing protocol is and when you can return to your LS protocol. In severe cases, oral steroids are sometimes used temporarily (e.g., oral prednisone 0.5 to 1.0 mg for 1 to 7 weeks) (ibid). For cases that involve severe itching, sedating oral antihistamines like hydroxyzine can be temporarily prescribed (ibid). 

Graphic design image of a glove hand performing a patch test on a patients arm with the word "Patch Testing" above.

Is it Lichen Sclerosus or Vulvar Dermatitis? What to Do If You Suspect Irritant or Allergic Contact Vulvar Dermatitis 

At the end of the day, there is a lot of overlap between the clinical signs and symptoms of lichen sclerosus and vulvar dermatitis. Stinging, pain, burning, and itch can happen with both conditions. Regarding clinical signs, one big difference tends to be a very distinct red rash on the vulva. While there is sometimes mild redness/hyperpigmentation with lichen sclerosus, it is not nearly as prominent as with vulvar dermatitis. We can’t share medical images here, but there are open-access journals with pictures of both lichen sclerosus and dermatitis. 

If you suspect either ICD or ACD (whether acute or chronic), seek medical attention to ensure a proper diagnosis. Ideally, you would see the doctor who follows your LS case, and, assuming they are well-versed in vulvar conditions, they should be able to determine if your symptoms are caused by lichen sclerosus or if a dermatitis-type reaction is occurring.

Graphic image of a patient sitting on a chair with brown skin, black hair and a yellow top and tops. They are talking with a doctor with short brown hair, tan skin, and a blue lapcoat.

While waiting for the appointment, stopping all chemical and physical products may not be a bad idea (to the extent you can). While you may not be able to stop medications, you can stop using fragranced soaps, detergents, and other non-medication-based products. However, seeing our doctors can sometimes take weeks or even months. Therefore, if you can and if you feel comfortable, I often recommend taking a picture of the rash. This way, if you discontinue using chemical/physical products and the rash improves and the skin looks better, you can still show them the picture and say, “This happened a month ago. I became red, raw, irritated, and had severe burning. Do you think this was an LS flare, dermatitis, or something else”. Depending on their answer, ask how you should treat should this happen again in the future.

Is Your LS Treatment and Care Causing ACD?

This is a complex topic; the following is a general overview. If there is interest in a more in-depth post on this in the future, please let us know in the comment section.

In the list of common allergens for ACD, some allergens may have stood out to you. Specifically, many of us are treated with corticosteroids, which are included on the list. Woodruff et al. (2018) note that positive patch tests (which help determine allergies) for Clobetasol and Tixocortol Pivalate have been seen in patients with vulvar lichen sclerosus. Another study showed that 4.5% of people in a group of 66 patients with vulvar itch showed topical steroid sensitivity. 

Another thing you may have noticed was preservatives and emollients/vehicles as potential allergens. Preservatives are used in topical medications such as steroids, and it’s possible you have an allergy to a preservative like parabens. Further, topical medications need a base or a vehicle to deliver the medication–this is often a cream or ointment. However, some bases contain allergens, such as propylene glycol.

Perhaps some of your emollients include propylene glycol or lanolin (one of the main ingredients in Aquafor healing ointment). 

What To Do If You Suspect Your LS Treatment or Care is Causing ACD

Discuss your concerns about treatment and ACD with your doctor. They may send you to an allergist for patch testing to determine what substance(s) are causing the reaction. Allergy testing can determine if the allergen is the medication (the steroid), the preservative (parabens), or the base (propylene glycol or lanolin). 

If your reaction is indeed caused by the medication, discuss other steroid options (Clobetasol is not the only option) or calcineurin inhibitors with your doctor. If the allergen is a preservative or base, talk to your doctor about compounding your medication into your own custom formula that will omit the allergen(s) in question. Learn more about compounding medications and compounding pharmacies here.

Conclusion on Lichen Sclerosus or Vulvar Dermatitis

In sum, it is not always easy to differentiate between lichen sclerosus and vulvar dermatitis like ICD or ACD. All three can cause symptoms like burning, itching, and pain. The main difference between lichen sclerosus and ICD/ACD is that ICD/ACD presents as a red rash all over the vulva. However, even then, it’s not always clear. We recommend always talking to your healthcare provider to get a proper diagnosis. If it is ICD/ACD, diagnosis is made clinically, and treatment includes removing the irritants/allergens in question and sometimes treating with a topical steroid. 

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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

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Feel free to book a 1:1 call with me if you struggle with grief and emotions. Simply click this link to learn more about lichen sclerosus peer support calls.

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For a more detailed list of free and paid support resources, check out my LS resources page here.

References

Corazza, Monica, et al. “Contact Dermatitis of the Vulva.” Allergies 1.4 (2021): 206-215.

Goldstein, A., Pukall, C., Goldstein, I., & Dr. Jill Krapf. (2023). When Sex Hurts. Hachette Go.

Madnani, N. (2023). Atlas of Vulvovaginal Disease in Darker Skin Types. CRC Press.

Margesson LJ. Contact dermatitis of the vulva. Dermatol Ther. 2004; 17(1): 20-27.

Sand FL, Thomsen SF. Skin diseases of the vulva: eczematous diseases and contact urticaria. J Obstet Gynaecol. 2018; 38(3): 295-300.

Woodruff CM, Trivedi MK, Botto N, Kornik R. Allergic contact dermatitis of the vulva. Dermatitis. 2018; 29(5): 233-243.

5 Comments

  • This is a fantastic and timely article for me. Thank you. I recently saw a dermatologist for the first time. I’d been using Clob for 2.5 years. (I commented on your Instagram and didn’t write it clearly and you thought the dermatologist had told me to use it) After examining me the consultant dermatologist said there was no evidence of LS but it may be well controlled. She said it may be contact dermatitis and told me to reduce the use of steroid. I’d dropped to a less potent steroid a few weeks before this visit and had improved a bit. I’ve managed to do this and am improving but still get quite sore some days and use my sitz bath and Epsom salts and a bit of Elocon (my new steroid). I’ve never had the classic signs of LS: itch, white patches or tears/splits. Thank you again for your hard work helping us all. I’m in the UK.

    • Jaclyn Lanthier

      Hi, Angela. So sorry I misunderstood you on Instagram. The world of vulvar care is tricky, even for the best of experts, as there can be so much overlap. Sorry to hear you are still getting sore; that’s awful. I hope next time you see them they have some insight on the soreness. With love,

  • Debra Baird

    I think this is the issue that I am having with Clobetasol ointment. I either have a sensitivity or allergic to something in it. My skin looks very red. I need to go back to the doctor, but last time I was there he said it almost looked like maybe I had a yeast infection on the skin maybe due to the steroid treatment. I think now it’s more of an irritation that’s causing the redness. I would love more info on the topic! Thank you!

    • Jaclyn Lanthier

      Hi, Debra. Thanks for sharing. In this case, he needs to swab the vulva. Topical corticosteroids can, in some people, cause dermatitis type reactions and/or vulvar yeast – both can cause redness. Please see my post on yeast infections – http://www.lostlabia.com/yeastinfection for more details on different types of yeast, testing, etc. Hopefully he can test appropriately and make adjustments to your care plan. With love,

  • Margaret

    Very useful and informative post. Would never have thought a new symptom might not be the LS (as the words LS are so embedded in my head!) but reading this has enabled me to look at this possibility as currently having reactions to substances in ? vaginal/vulval products.

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