An Integrative Medicine Approach to Lichen Sclerosus

Lichen sclerosus is a chronic inflammatory skin condition that causes patches where the skin becomes thin, white, and shiny, most commonly on the vulva and around the anus. A functional medicine approach to lichen sclerosus identifies and addresses factors that contribute to the inflammation and autoimmune attack of the body that occurs in this condition.

Lichen sclerosus causes itchy and often painful skin changes. Over time it can significantly impact the quality of life and sexual function.

Although it can occur at any age and in both men and women, lichen sclerosus most commonly develops in post-menopausal women and prepubescent girls and is often underdiagnosed or missed. Overall, it is ten times more common in women than in men.

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What is Lichen Sclerosus?

Lichen sclerosus is a chronic skin condition that develops due to inflammation or irritation. It results in itchy and painful patches of thin, white, wrinkled-looking skin. In women, these changes are most common on the vulva or the skin around the anus, while in men, lichen sclerosus typically affects the head of the penis.

What Does Lichen Sclerosus Look Like?

Lichen sclerosus skin lesions usually begin as small, pinkish or whitish bumps in the impacted area. As the condition progresses, these skin lesions become larger and develop into patchy areas that are white and wrinkly, resembling tissue paper.

The skin in the affected areas becomes delicate and itchy. Any additional trauma, such as rubbing from clothing or itching, can cause bleeding and further inflammation. The skin can also develop bruising, erosions, ulcers, or cracks. Over time, these skin changes can lead to scarring and tightening of the skin around the genitals and anus if it is not successfully treated.

Lichen Sclerosus Symptoms

The symptoms of lichen sclerosus can range from mild with small patches of skin that have lost their pigment to extremely painful and itchy lesions that lead to scarring over time.

The most common symptoms of lichen sclerosus include the following:

• smooth patches of skin that lose pigmentation in the anogenital area
• slightly raised, red, or wrinkled patches of skin
• intense itching that becomes worse at night due to the drop in cortisol, disrupting sleep
• dull or burning pain in the skin
• constipation and painful bowel movements
• pain with urination
• torn or bleeding skin with sores or blisters

Early in the course of the disease, the skin may begin to lose pigmentation and become itchy. Swelling and wrinkled patches of skin may develop, along with pain during sex, urination, or bowel movements. As the tissues become thin and delicate, they can develop sores, tearing, and bleeding. Eventually, in the later stages of the disease, scarring may occur with loss of the labia minora (inner lips) and burying of the clitoris in the clitoral hood if it fuses over the top of it. This contributes to additional pain and sexual dysfunction.

Lichen sclerosus can also affect men, typically affecting the head of the penis.

In around 10% of women with genital involvement, lesions also occur outside the genital area. One or more white, thin, dry areas of skin may be found on the inner thighs, buttocks, lower back, abdomen, under the breasts, neck, shoulders, or armpits.

What Causes Lichen Sclerosus?

Additional study is needed to elucidate the exact cause of lichen sclerosus. But several underlying causes contribute to the risk of developing this condition. Contributing factors include genetic, hormonal, inflammatory, and traumatic components.

Autoimmunity

In many women, lichen sclerosus seems to be caused by the body attacking its own tissues. Research suggests that women with lichen sclerosus are more likely to have another autoimmune condition, especially an autoimmune thyroid condition, or a family member with an autoimmune condition.

Inflammation and Gut Imbalances

The immune dysregulation involved in autoimmunity is one factor that contributes to the chronic inflammation seen in lichen sclerosus. Studies show that involved areas of skin show inflammatory changes and markers of increased oxidative stress that damage skin tissue. Immune imbalances perpetuate an up-regulation of pro-inflammatory cytokines, which further encourage an autoimmune attack against self-antigens in the skin.

Gut health is a significant factor in overall inflammation and autoimmunity. Bacteria in the gut play important roles in regulating inflammation in the body. Damage to the intestinal wall (leaky gut) due to infection, food allergens, gluten, or toxins can allow food and other substances to cross into the bloodstream, where they provoke inflammation and may trigger autoimmunity.

Hormonal Imbalances

Lichen sclerosus is more likely to occur in girls before puberty and postmenopausal women, suggesting a connection with fluctuating hormones and lower estrogen levels. Some evidence suggests that reducing or blocking androgens may trigger lichen sclerosus skin lesions in susceptible women.

What Causes Lichen Sclerosus to Flare Up?

The factors contributing to lichen sclerosus flares are complex and not fully understood. However, there are some associated factors that can precipitate increased symptoms.

Physical trauma, friction (such as from tight clothing), scratching, or irritation to the skin in the genital area from activities like horseback riding, bike riding, or waxing can irritate the vulva's delicate skin. Friction during sexual activity and sexual abuse have also been identified as triggers for lichen sclerosus.

Imbalances or dysbiosis in the microbiota of the skin and gut also seem to increase the risk of flares with increased inflammation in the skin.

Functional Medicine Labs to Test for Root Cause of Lichen Sclerosus

Lichen sclerosus is usually diagnosed by physical examination to identify the skin lesions and can be confirmed with a biopsy by looking at a skin sample under a microscope. Functional medicine labs can help identify factors contributing to the underlying inflammation and autoimmunity.

Gut Health

The GI-MAP assesses relative amounts of healthy and unbalanced gut bacteria, inflammation and leaky gut markers, parasites, and yeast overgrowth to evaluate risk factors that can contribute to the autoimmune attack believed to occur in lichen sclerosus. When the gut bacteria are out of balance, this can trigger autoimmunity and perpetuate the cycle of inflammation. So detecting and treating gut infections and imbalances is essential for managing lichen sclerosus.

Hormone Balance

A thorough assessment of sex hormones, thyroid hormones, and stress hormones can assess underlying hormone imbalances.

Low estrogen levels are often found in patients with lichen sclerosus and can cause vaginal tissues to thin and lead to pain and itching. The DUTCH Complete, dried urine test, measures sex hormones, including estrogen metabolites, progesterone, and androgen metabolites, as well as markers of stress hormone levels such as daily patterns of free cortisol and cortisone, cortisol, and cortisone metabolites, melatonin, 8-OHdG, and six organic acids. ‍

A Complete Thyroid Panel including thyroid-stimulating hormone (TSH), T3 (free and total), T4 (free and total), and reverse T3 should be assessed using functional medicine ranges to evaluate thyroid function.

Vaginal Infections

Lichen sclerosus can be misdiagnosed as bacterial vaginosis or a vaginal candida infection in the early stages due to common symptoms of itching and irritation. The Comprehensive Vaginosis Profile differentiates between bacterial vaginosis and vulvovaginal candidiasis.  

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Functional Medicine for Lichen Sclerosus Treatment

The first line of conventional treatment for lichen sclerosus is usually topical steroid creams, which can contribute to further thinning of genital tissues when used chronically. Therefore, functional medicine treatment for lichen sclerosus strives to address the factors underlying the chronic inflammation and autoimmunity that causes this condition.

Supplements and Herbs to Help Heal Lichen Sclerosus

Calendula cream or salve is an alternative topical treatment. Calendula has anti-inflammatory, antifungal, and antibacterial properties that may reduce dryness, irritation, and swelling and combat any infections in the affected area.

Other herbs, such as chickweed and gotu kola may help reduce scarring and improve the healing of lesions.

Nutritional Needs for Lichen Sclerosus

The following nutritional recommendations may help relieve the root causes of lichen sclerosus:

Reduce Inflammation

Addressing underlying inflammation and oxidative stress that occurs due to hidden infections, food allergies, leaky gut, imbalanced gut bacteria, or other autoimmune conditions is vital as part of a lichen sclerosus treatment plan. Removing triggers and analyzing gut flora with functional medicine testing can guide individualized treatment.

Implementing a personalized anti-inflammatory diet like the Mediterranean Diet that removes any foods that one is allergic to or sensitive to, eliminates caffeine and alcohol, and emphasizes plenty of whole fresh vegetables while minimizing processed foods and additives can help reduce inflammation. Some research suggests that reducing oxalates in the diet from foods like spinach, beets, turnips, and potatoes can also help.

Some specific herbs and spices can help reduce inflammation. For example, curcumin, which is the active component of turmeric, can benefit inflammatory skin conditions like lichen sclerosus. Sea buckthorn oil contains beneficial fatty acids that lower inflammation and improve mucosal integrity in the vaginal area to reduce pain, itching, and skin changes.

Heal the Gut

Since the microbes in the gut play such an important role in regulating body-wide inflammation, optimizing gut health and the diversity of the microbiome can help treat lichen sclerosus. Probiotic-rich foods like kimchi and sauerkraut or high-quality probiotics can support the health of the bacteria in your gut. Supplements like l-glutamine, aloe, and slippery elm can help to repair the lining of your digestive tract to heal a leaky gut that is contributing to inflammation and autoimmunity.

Probiotics, especially those containing Lactobacillus reuteri RC-14 and Lactobacillus rhamnosus GR-1, can also improve the vaginal microbiome to reduce itching and resist opportunistic infections such as candida or herpes, especially if steroids are being used. They can also help to reduce genital pain.

Complementary and Integrative Medicine for Lichen Sclerosus

The following complementary and alternative medicine modalities can also help support a well-rounded treatment plan:

Reduce Irritation in Vulnerable Areas

The vulvar and vaginal skin is delicate and can be easily irritated. Since friction and irritation can trigger lichen sclerosis, opt for organic cotton underwear and loose-fitting garments instead of tight jeans or pants to allow the genital skin to breathe and avoid irritation from synthetic materials. Use a natural lubricant like organic aloe vera gel during sexual activities to reduce friction and further irritation of the delicate vulvar skin. Wash the genital area with only water, avoiding scented products for bathing and laundry.

Platelet-Rich Plasma (PRP) and Laser Treatments

PRP treatments extract platelets from the patient's own blood during an in-office procedure that are injected into the affected area. There they release growth factors that help to reduce inflammation, stimulate new blood supply, support collagen synthesis, and help repair fibrous scar tissue.

High-Intensity Focused Ultrasound (HIFU) and fractional CO2 lasers (FxCO2) are also under investigation for treating lichen sclerosus. HIFU uses focused ultrasound energy waves to stimulate cell proliferation, protein synthesis, and revascularization that can help to encourage tissue healing in lesions. FxCO2 uses a type of pulsed beam laser with a wavelength of 10,600 nm to create areas of superficial microablation to stimulate protein synthesis, helping to accelerate tissue reconstruction and decrease lichenification.

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Summary

Lichen sclerosus is a chronic inflammatory skin condition that causes the vulvovaginal tissues to lose pigmentation, become thin, and become painful and itchy. ​​It can have immense physical, emotional, and psychological effects, affecting sleep, self-confidence, intimate relationships, and quality of life.

A functional medicine approach to lichen sclerosus identifies contributing factors to the underlying inflammation and autoimmunity. Several underlying causes contribute to the risk of developing this condition, including genetic, hormonal, inflammatory, and traumatic components.

Lichen sclerosus is usually diagnosed by physical examination to identify the skin lesions, and functional medicine labs can help identify factors contributing to the underlying inflammation and autoimmunity. Treatments like topical anti-inflammatory botanicals and anti-inflammatory spices like turmeric help reduce pain, itching, and skin changes.