Lichen planus is an inflammatory disorder of the skin that sometimes affects the genitals and the mouth. It can affect women and men of all ages and can impact the skin around the genitals as well as skin on the rest of the body, and even the nails. Lichen planus can cause itching, pain, scarring, and burning. When it affects the mouth, it can cause burning, especially with acidic or spicy foods.
Lichen planus can cause pain with penetrative vaginal sex due to the inflammation that it causes both inside the vagina and on the external vulvar skin. It can even cause strictures inside the vagina so that the vagina scars from the inside out. This usually only happens when it is untreated for long periods of time.
We do not fully understand the cause of lichen planus, but we believe it is due to an overactive immune system that causes the body to attack itself. Treatment requires not only a very strong corticosteroid, but also attention to any vaginal infection, avoidance of irritating products such as creams, panty-liners, and soaps, and local replacement of estrogen when low estrogen has thinned the vaginal skin and decreased the vaginal blood supply.
The most common medication used to decrease inflammation in the skin is a corticosteroid ointment called clobetasol. This is applied once or twice daily until the rash is under control, and then three times weekly as maintenance. Very little medication is needed to provide relief. The medicine spreads like “pancakes and syrup,” and a little goes a long way. Sometimes, we utilize suppositories made of hydrocortisone that are inserted into the vagina. These are put in at night to decrease inflammation of the vaginal walls.
Lichen planus is controlled but not cured; therefore, medicine needs to be continued indefinitely. The risk of scarring over the clitoris, urethra, and vagina is real, so medication should never be ceased abruptly. There is also a risk of skin cancer in untreated oral and vaginal lichen planus. This risk is substantially reduced by the application of topical steroids. An ob/gyn, primary care doctor who practices gynecology, or dermatologist should check the area every six months after diagnosis to make sure that no skin cancers develop.
Rarely, oral or injectable medications are necessary to improve the condition. This is only if topical therapy does not work. The vast majority of patients are able to get their lichen planus under control and lead a normal symptom-free life.
Some patients find that their lichen planus leads to problems with sexual function and intimacy. Once the inflammation is under control, it should be possible to have comfortable manual, oral, or even penetrative sex. When scarring has progressed to the point that there are adhesions over the clitoris, some people with vulvas report that they feel a pulling or tearing sensation with stimulation of the clitoris. This sensation can interfere with the sexual experience, but it can be remedied through using plenty of lubrication and recognizing the the portion of the clitoris visible on most vulvas, is actually just a very small portion of the clitoris itself which extends down into both labia. The use of toys can be helpful when stimulation feels different than it did previously. Additionally, once inflammation is under control, a surgery called "lysis of adhesions" can be performed to rectify any scarring. This surgery should only be performed by an experienced surgeon and requires extremely close follow up to ensure that the lichen planus does not flare post-surgery. Dilator work and pelvic floor physical therapy can also be extremely beneficial when lichen planus impacts the vagina as well.
Most importantly, speak with your board certified dermatologist, gynecologist, or primary care doctor if you have any questions or concerns regarding your condition.