| Treatment action | Topical/behavioral | Oral meds | Intramuscular meds | Intralesional meds | Testing/Notes |
|---|---|---|---|---|---|
| Comfort measures, general care | Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs. Educate: 1) this is a chronic disease that needs life-long treatment; 2) steroid treatments are safe if used as directed. They do not thin the skin.
Testosterone has no value in treating LS. |
Always do pH, wet prep, and yeast culture. Consider bacterial culture if superimposed infection is suspected.
Biopsy if unsure of diagnosis. (LINK to biopsy) White plaques can be squamous cell carcinoma rather than LS. Steroid medications can enhance development of infectious conditions such as candidiasis, herpes simplex, and condyloma. Link to Lichen Sclerosus in Atlas. |
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| Reduction of itching or pain | Topical xylocaine 5%, applied as needed, usually 4-6 times a day (no more than 15 grams a day) | Hydroxyzine 10 to 25 mg orally 1-2 hrs prior to bedtime;OR
Benadryl 25-50 mg orally 1-2 hrs prior to bedtime, stopping meds as symptoms subdue. |
Anti-pruritics are not used as often in treatment of LS as in lichen simplex chronicus (LSC). Pain is usually caused by erosions from scratching.
Pain with intercourse needs to be fully evaluated. |
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| Anti-inflammatory action | Clobetasol or halobetasol 0.05% ointment applied twice a day, in a thin film, for 30 days, followed by once a day application for 14-30 days,
OR followed by once a day application three times a week OR Triamcinolone acetonide 0.1% ointment applied twice a day in a thin film until improved x 1 month |
Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or a tapering dose up to 7-10 days (for diffuse inflammation, or for those unresponsive to topical treatment) (Used rarely due to known side effects of oral steroids.) |
Triamcinolone acetonide 40 mg/ml (Kenalog 40) 1 mg per kg intramuscularly, single dose for diffuse inflammation or for those unresponsive to topical treatment | Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle; injected under plaque after application of EMLA (for large, thick areas or those unresponsive to topical treatment) | For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting. Super potent topical steroid ointments are the treatment of choice and usually subdue symptoms or changes in the skin adequately.
Only a small amount of ointment is needed. Treatment is life-long. Occasionally, remission allows reduction to a lower dose ointment or to a reduced frequency of once a week. In the peri-anal area, super-potent steroids are rarely used. Instead, use mid-potency steroid ointment such as Betamethasone valerate 0.1% or Triamcinolone 0.1%. “Flares,” where symptoms recur, are not uncommon and are usually controlled by returning temporarily to more frequent use of steroid ointment. Always look for and culture for yeast during a flare. Steroid rosacea is the most-likely side effect, almost always due to over use of the ointment. (LINK to steroid rosacea). |
| Antibiotics for superimposed infection | Dicloxacillin 250-500 mg orally 4 x a day for 10 days
OR Cephalexin 250-500 mg orally 4 x a day for 10 daysANDFluconazole 150 mg orally once weekly, if necessary, to control yeast. Use only until yeast has cleared and patient is stable. |
If giving antibiotics, consider also treating for potential yeast infection with an anti-fungal. | |||
| Alternative treatments for recalcitrant LS | Calcineurin inhibitors: Topical tacrolimus (Protopic) 0.3% or 0.1% ointmentOR pimecrolimus (Elidel)1% cream applied once or twice a day can be used as an alternative topical medication or in conjunction with the topical steroid. |
These medications may burn and they are expensive. We prescribe the tiniest amount as a trial for the patient.Burning may be ameliorated by applying topical Vaseline first.
The burning will sometimes taper off after a few applications. These meds can be used concomitantly with topical steroid ointment. |
Updated 7/11/14 Link to Lichen Sclerosus in the Atlas