Lichen Planus (Vulvar and Vaginal)

Lichen planus is a chronic (long-term) inflammatory condition that affects the skin and mucous membranes. When it affects the genital area – the vulva (the external genitals) and sometimes the vagina – it is called vulvar or vulvovaginal lichen planus.

It is not an infection or sexually transmitted infection. It is an autoimmune-type condition, where your immune system mistakenly attacks cells in the skin and mucous membranes, causing redness, soreness, and sometimes scarring.

The condition typically causes areas of red, purplish, or white, lacy-looking patches on the vulva. In the vagina, it can cause inflammation, pain, and narrowing of the vaginal passage. It can also affect the mouth (oral lichen planus) and, in a severe form, both the vulva, vagina, and gums – known as vulvo-vaginal-gingival syndrome.

It can affect women of any age, but it most commonly develops in women between the ages of 40 and 60. It is estimated that around 1–2% of the general population may have some form of lichen planus, but genital involvement is less frequent.

Causes

The exact cause of lichen planus is not fully understood. It is believed to be an autoimmune disorder – the body’s immune system becomes confused and attacks the skin cells instead of protecting them.

Factors that may trigger or worsen it include:

• Genetic predisposition – it can run in families, though not strongly.
• Stress – emotional or physical stress can trigger flare-ups.
• Viral infections – such as hepatitis C (more strongly linked to oral lichen planus, but can be a factor).
• Certain medications – rarely, drugs such as NSAIDs, beta-blockers, or certain blood pressure medications can trigger a lichenoid reaction.

Symptoms

The symptoms can vary from mild to severe, and they often come and go in flare-ups and remissions.

• Persistent soreness, burning, or pain around the vulva – often worse with sitting or walking.
• Itching – though less intense than in lichen sclerosus, it can still occur.
• Pain during sexual intercourse (dyspareunia) – due to inflammation and scarring.
• Vaginal discharge – which may be yellow-green or blood-stained, due to shedding of the inflamed vaginal lining.
• Bleeding or spotting – especially after sex or inserting a tampon.

Signs your doctor may see on examination:

• Red, inflamed patches on the vulvar skin.
• White, lacy streaks or spots (called Wickham’s striae) – a hallmark of the condition.
• Erosions or raw areas – where the top layer of skin has worn away.
• Scarring – the labia minora may flatten, fuse, or shrink; the clitoris may become buried; the vaginal opening may narrow (stenosis).

Diagnosis

Lichen planus can be difficult to diagnose because it can look like other vulval conditions such as lichen sclerosus, eczema, or psoriasis.

• Examination of the vulva – often using a magnifying instrument called a colposcope.
• Biopsy – a small sample of skin (about 3–4mm) taken under local anaesthetic is the gold standard for confirming the diagnosis and is important to rule out pre-cancerous changes.
• Blood tests may be requested to check for hepatitis C or other autoimmune conditions.

Treatment

• Potent or very potent steroid creams/ointments (such as clobetasol propionate) are applied directly to the vulvar skin. These are very effective at reducing inflammation.
• Medications such as tacrolimus or pimecrolimus – these are steroid-free alternatives that suppress the local immune response. They are useful for women who cannot tolerate steroids or for long-term maintenance.
• If the vagina is narrowing, your gynaecologist may recommend using vaginal dilators – a series of smooth, tube-shaped devices of increasing size.
• Surgery is rarely needed but may be considered to release severe scarring (adhesiolysis) that is causing pain or making sexual intercourse impossible.
• Regular use of vaginal moisturisers (such as Replens) and water-based lubricants during sex can help reduce discomfort.