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Vulvar Lichen Sclerosus and Skin Color Changes

Vulvar Lichen Sclerosus and Skin Color Changes

Introduction

Lichen sclerosus can cause the skin of the vulva to change color in many people with LS. However, we frequently get asked questions like, “Why is the color changing?” and “What does this color mean?” Today, we are going to discuss all things lichen sclerosus and skin color changes. We will address hypopigmentation, hyperpigmentation, what to do if you notice new color changes, and how these changes differ in skin of color.

Disclaimers

*This post is evidence-based; I draw on the medical literature to share what you need to know about lichen sclerosus and skin color changes. 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.

What are Clinical Signs?

First things first, let’s talk clinical signs! When we talk about signs and symptoms of LS, it’s important to note that these are two separate things. Symptoms are things we feel in our bodies, like itching and burning. Signs are things that can be seen on the body, such as changes to the texture of the skin and color changes.

Therefore, when we are talking about skin color changes and lichen sclerosus, we are talking about clinical signs. 

Learn more about the differences between signs and symptoms and why the distinction is important in this video below.

Let’s Talk about Lichen Sclerosus and Skin Color Changes

Hypopigmentation

Pigmentation refers to the color of your skin. Hypopigmentation is one of the signs of lichen sclerosus. Hypopigmentation is when the skin loses pigmentation and becomes lighter than its normal color. How this loss of pigmentation presents depends on many factors, including your skin tone. For example, as will be discussed below, hyperpigmentation may present differently in darker skin tones compared to those with lighter skin tones.

But wait…why does this hypopigmentation happen at all? What causes our skin to lose its pigment?

Image of three people with different skin colors with lighter patches of skin on their body to represent hypopigmentation.

A lot of this boils down to understanding how lichen sclerosus works. We do not fully understand every detail of how LS works, but we still know a good deal. 

Here is what we know. Something triggers an immunological response in the vulvar skin where our bodies no longer recognize some of our cells/proteins as part of us; instead, it sees them as a threatening invader that must be eliminated. To eliminate them, the body produces a very strong inflammatory response. This inflammatory response leads to many changes in the vulvar tissues. For example, the inflammatory response can attack cells in our tissues called melanocytes.

What Are Melanocytes, and What Do They Have To Do with Lichen Sclerosus and Skin Color Changes

What are melanocytes? Melanocytes are cells that are responsible for the pigmentation of the skin. They contain a pigment called melanin, which gives our skin the color it has. The more melanin a cell has, the more richly pigmented and darker their skin will be. 

Sometimes, during the inflammatory response, melanocytes are attacked, resulting in fewer melanocytes; because of this, the color of our skin can begin to fade and appear lighter than it used to.

This is why loss of pigmentation is a common sign of lichen sclerosus, although not everyone experiences this.

Important Caveats

As I mentioned above, we still do not know every detail about exactly how and when certain things go wrong at a molecular-cellular level. For instance, one thing that is not clear is why not everyone with lichen sclerosus has hypopigmentation. It may have to do with the stage of lichen sclerosus. Specifically, De Luca et al., 2023, have a diagram demonstrating healthy skin, early-stage, and late-stage LS. I do not have permission to reproduce the image, but you can read the paper and see the diagram here. If you look at the diagram, you will notice that healthy skin has many melanocytes. In early-stage stage LS, there are a bit fewer melanocytes, and in late-stage LS, the melanocytes are gone.

Therefore, it’s possible that early-stage LS may not have hypopigmentation (or dramatic/obvious hyperpigmentation).

However, the jury is still out on this!

Hyperpigmentation and Lichen Sclerosus

We’ve talked a lot about hypopigmentation, but what about the opposite–hyperpigmentation? Hyperpigmentation essentially means more pigmentation. This would mean there are areas of the vulva that have become darker in color. For example, hyperpigmentation may present as darker brown or dark purple if you have light brown skin or red on lighter skin tones.

Does LS cause hyperpigmentation? If you’ve read some of the medical articles on LS, you’ll notice the focus is almost exclusively on hypopigmentation, with little to no mention of hyperpigmentation.

While hyperpigmentation is not a hallmark of LS per se, it can definitely occur with LS. This can look like bruising, which can look reddish, blue, purple, brown, or black, depending on your skin color. Further, sometimes, a reddish/hyperpigmented color can be around the hypopigmented areas. If you want to see real-life examples of LS, the Center for Vulvovaginal Disorders has a gallery of LS cases on its website. If you look at those pictures, you’ll notice the prominent skin color change is a loss of pigmentation, although there are some small reddish areas.

Lastly, in some people, as the skin begins to heal with treatment, your baseline color may not only return but you may be left with some hyperpigmentation spots. Think of this as the body almost overcorrecting to make up for past mistakes. Now that the melanocytes are back, they produce more pigment, which can result in some darker spots. This is called post-inflammatory hyperpigmentation. It does not happen to everyone, but if it does, know it is normal and safe (if you are uncertain, see your healthcare provider for evaluation).

What to Do If You Notice Skin Color Changes

If you notice any new color changes–whether it be hypo or hyperpigmentation–book an appointment with your healthcare provider for assessment and guidance. Hypopigmentation can indicate active LS, but only your healthcare provider can answer this. Significant redness can indicate vulvar/perianal yeast, dermatitis, an allergic reaction, and more. Hyperpigmentation can indicate several things, such as bruising, irritation, or post-inflammatory hyperpigmentation. Again, your healthcare provider can provide insight on this.

Image of a patient and doctor discussing skin color changes at a doctor's appointment.

Lichen Sclerosus and Skin of Color

Scientific Work on Hypopigmentation

One research area that needs much more attention is how signs and symptoms may differ in darker skin types. For example, color changes look different on darker skin tones than on lighter skin tones. 

Dr. Nina Madnani recently published the “Atlas of Vulvovaginal Disease in Darker Skin Types,” which contains numerous photographs of richly pigmented vulvas with different vulvar conditions. The book also explains some differences that can occur between darker skin types and lighter skin types. The section on lichen sclerosus shows hypopigmentation presenting as a stark white or various shades of pink. Dr. Madnani also notes early LS may present more as pallor and develop into pale, ivory-colored lesions as it progresses. The stark white and different shades of pink hypopigmentation on folks of darker skin types was echoed during Dr. Ekeowa-Anderson’s presentation on Vulval disorders in patients of colour at the British Society for the Study of Vulval Disease and Dr. Akinshemoyin Vaughn's presentation on considerations in vulva of color at the 2023 Vulvovagina health update. 

In darker skin types–e.g., Fitz. Types 5 and 6, the hypopigmentation can be quite obvious and look incredibly similar to vitiligo. In fact, LS is often misdiagnosed as vitiligo in darker skin types because of the stark contrast between the hypopigmented areas and the surrounding skin color. It is important that healthcare professionals look beyond the skin color contrast in this situation and pay attention to clinical signs such as scarring and skin thickening (which are less common in patients with vitiligo). The misdiagnosis of vitiligo instead of lichen sclerosus is a point made by Dr. Madnani and Dr. Akinshemoyin Vaughn.

To learn about VLS and misdiagnosis in people with darker types, watch this video with Dr. Akinshemoyin Vaughn here.

Hyperpigmentation in Folks of Darker Skin Types

Hyperpigmentation can often be a helpful clue as to what is happening in a person’s body. For example, redness can sometimes be a sign of steroids overuse or steroids being too strong. However, hyperpigmentation is sometimes harder to see in people with darker skin. I was able to ask Dr. Akinshemoyin Vaughn how steroid overuse presents in darker skin types. Her response was that, unlike lighter skin types that may present as red, steroid overuse often presents as hypopigmentation in folks of dark skin color. This is another reason why research into this area is so critical.

Image of 4 people with different skin color types standing together representing the how color changes can differ depending on your skin color type.

Community Findings and a Call for More Funding and Research

Outside the world of medical research, many folks of darker skin types in our community have reported instead of white; their skin looked grey or ashy. Many of them have expressed they do not feel represented in the literature to date.

It is critical that we have more funding allocated to research investigating the differences in symptoms and signs in people of darker skin types to reduce misdiagnosis.

Questions that Need to Be Addressed in Research

We need research looking at the different stages–early and late-stage LS–and how it presents clinically in darker skin types. We need data on the prevalence of misdiagnoses in darker skin types. Symptoms are also important; questions like “Do symptoms present differently in people with dark skin types?” and questions like “Is LS medication absorbed differently in different skin color types?” need to be addressed. 

Conclusion on Lichen Sclerosus and Skin Color Changes

In sum, skin color changes are common with lichen sclerosus, with hypopigmentation being the most common. Sometimes mild hyperpigmentation can be seen in instances of bruising or even healed areas of the vulva (called post-inflammatory hyperpigmentation). If you notice new color changes, get assessed by your healthcare provider and ask them if you need to modify your treatment plan or if you need a new medication. Importantly, skin color changes can present differently depending on your skin color. We need a lot more research into the differences between LS in lighter versus darker skin types.

Finally, share any color changes that you have experienced in the comment section below. 

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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:

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References

1.     Ekeowa-Anderson, A. Vulval disorders in patients of colour. Presentation presented at the British Society for the Study of Vulval Diseases, March 9th, 2023, Nottingham, UK.

2.     Madnani, N. Atlas of vulvovaginal disease in darker skin types. CRC Press, 2023.

3.     Vaughan, S. Fundamentals of vulvar conditions in skin of color. Presentation presented at the Vulvovaginal Virtual Health Update April 28th, 2023, Virtual Conference (hosted by the University of British Columbia). 

4.  Center for Vulvovaginal Disorders, Lichen Sclerosus – https://vulvodynia.com/conditions/lichen-sclerosus (includes image gallery)

5.   De Luca DA, Papara C, Vorobyev A, et al. Lichen sclerosus: The 2023 update. Frontiers in      Medicine. 2023;10:1106318. doi:https://doi.org/10.3389/fmed.2023.1106318

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