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LichensimplexchronicusTreatmentStepbystepBestPracticeEnglish

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Lichen simplex

Treatment approach
LSC can be a difficult
condition to treat, causing
frustration in both the patient
and physician. [1] The main
goals of treatment are to
remove any triggering and
exacerbating environmental
factors, repair the barrier
function of the skin, identify
and treat any underlying
dermatological or systemic
condition that could be
driving the condition in
secondary LSC, and disrupt
the itch-scratch cycle
characteristic of LSC through
reduction in the degree of
skin inflammation and control
of nocturnal pruritus. [2]

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Last updated: Jul 13, 2015

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Although there is no
standardised treatment for
LSC and management of the
condition is very much
tailored to the individual
patient, the mainstay of treatment involves the package of a topical corticosteroid, emollients, and
lifestyle modification; a sedating agent for nocturnal pruritus; and the addition of an antipruritic for
breakthrough pruritus as required.

Non-systemic corticosteroids
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Topical corticosteroids
These are the preferred initial treatment in all adults and children >12 years of age. [26] [27] [28] It
is generally considered to be more effective and equally safe to use a higher-potency topical
corticosteroid for a short therapeutic period than a lower-potency preparation for a longer time.
[2]
Potent topical corticosteroids such as fluocinonide or clobetasol should be prescribed for a
maximum of 2 weeks' continuous use on any one lesion, with avoidance of the face and
intertriginous areas, to avoid adverse effects, which include atrophy, striae, hypopigmentation,
corticosteroid-induced folliculitis and rosacea (in facial locations), and corticosteroid-induced
dermatophyte infections (tinea incognito). [2]
Any class I or II (potent) topical corticosteroid may be used, with class I more effective for thicker
lesions of LSC.
Creams and ointments are appropriate for the body, while solutions or gels should be used on
hairy areas such as the scalp. On eroded skin, ointments avoid the stinging and burning
associated with creams, solutions, or gels.
To minimise the risk of topical corticosteroid-associated adverse effects, particularly atrophy and
striae, the application frequency or potency should be decreased as the condition improves.
When the long-term use of topical corticosteroids is indicated, as in the presence of an underlying
chronic dermatosis, a corticosteroid-sparing agent such as a topical calcineurin inhibitor may be
used in both adults and children. [29] [30] [31]
Due to the increased incidence of adverse effects related to high-potency topical corticosteroids,
in children <12 years of age, a low- to mid-potency topical corticosteroid such as hydrocortisone
or triamcinolone should be used. [2]
Intra-lesional corticosteroids
Triamcinolone acetonide can be used intra-lesionally as an alternative to high-potency topical
corticosteroids if they prove to be ineffective.
If given at weekly intervals for periods of 6 to 8 weeks at a time, [32] intra-lesional corticosteroids
are efficacious in the treatment of LSC in adults and children >12 years of age. [33]
With improper technique and use, intra-lesional corticosteroid therapy may lead to adverse
effects. If injected too superficially, too often, or for prolonged periods of time, intra-lesional
corticosteroids can cause epidermal and dermal atrophy and depigmentation. If injected too
deeply, they may cause fat atrophy. If injections are used on infected lesions, intra-lesional
corticosteroids can lead to abscess formation, and tendons may weaken or rupture if injections
are given over these structures. [34] [13] Prolonged use may also result in adrenal suppression.
The risk of adverse effects can be reduced by using the lowest effective concentration of intralesional corticosteroid and ensuring they are not given more frequently than every 6 weeks.

Occlusion

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Occlusion alone can be used in both adults and children and is an effective physical barrier against
scratching. Occlusion overlying a topical corticosteroid is appropriate in thickened lesions of LSC and
when a topical corticosteroid alone is not optimally effective, as it increases the efficacy of these agents.
[35] Topical corticosteroid-impregnated tapes such as flurandrenolone tape are available and have
demonstrated positive therapeutic effects in the treatment of LSC. [36] Occlusion with a plastic film or
hydrocolloid dressing such as Tegaderm or DuoDerm can be applied over topical corticosteroids, but
this causes an increase in topical corticosteroid-associated adverse effects. [37] Therefore, this
technique should be restricted to several hours per day for a maximum of 1 to 2 weeks at a time. In
recalcitrant disease involving the lower legs, an Unna boot (zinc-impregnated gauze roll dressing) can
be applied for 1 week at a time to prevent scratching. [34]

Removal of exacerbating factors and repair and maintenance of the epidermal

barrier
Environmental triggering and exacerbating factors such as dry or excessively moist skin, chronic friction
from tight or rough clothing, and harsh skincare products should be eliminated in all patients. In patients
with genital lichen simplex chronicus, especially vulvar disease, silk fabric underwear is less irritating
than cotton fabric underwear and may improve the condition. [38]
The barrier function of the epidermis can be restored and maintained with the frequent application of
bland, non-perfumed emollient creams or ointments to moisturise the skin, and this should be done by
all patients. The most efficacious time to apply an emollient is immediately after showering while the
skin is still moist. Emollients should be used at least twice a day and more frequently if the patient is
able. [2]

Treatment of any underlying dermatosis, systemic condition, or psychiatric

disorder
Any underlying dermatosis including atopic dermatitis, allergic contact dermatitis, stasis dermatitis,
superficial fungal (tinea and candidiasis) and dermatophyte infections, lichen sclerosis, viral warts,
scabies, lice, an arthropod bite, and a cutaneous neoplasia [1] [2] or systemic condition causing pruritus
such as renal failure, obstructive biliary disease (primary biliary cirrhosis and primary sclerosing
cholangitis), Hodgkin's lymphoma, hyper- or hypothyroidism, and polycythaemia rubra vera should be
identified and treated in the presence of secondary LSC in all patients to prevent re-establishment of
the itch-scratch cycle following resolution of the acute episode. [2]
A flare of atopic dermatitis is a common cause of secondary LSC in children.
Underlying depression, anxiety disorder, obsessive-compulsive disorder, and a prominent itch-scratch
cycle with intractable daytime pruritus should be treated with psychopharmacology and psychological
therapy.
The tricyclic antidepressant clomipramine or an appropriate selective serotonin-reuptake inhibitor
(SSRI; fluoxetine, paroxetine, sertraline) should be prescribed following specialist psychiatry advice. [2]
[39] [40] [41]
Cognitive behavioural therapy has also been found to be effective in the treatment of LSC. [42] [43] [44]

Sedating agents
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LSC is associated with significant nocturnal pruritus that occurs only in the lighter stages of sleep. [17]
Sedatives increase the ratio of deep to light sleep and are therefore the preferred treatment for
nocturnal pruritus. [2] Because of the possible risk of habituation with conventional sedatives such as
benzodiazepines, older-generation sedating antihistamines such as hydroxyzine (in both adults and
children) and tricyclic antidepressants such as doxepin (in adults only) are the preferred agents. [2]
Doxepin has the benefit of a longer half-life and is thus more useful for patients who are woken during
the night with pruritus, as it helps patients to stay asleep throughout the night. [45]
These drugs should be given 2 hours before going to bed to reduce the risk of a morning 'hangover' with
sedation, a dry mouth, and blurred vision. [2] Lower doses should be considered in older patients, as they
are more likely to experience CNS depressive adverse effects, including confusion.

Topical calcineurin inhibitors

When long-term use of topical corticosteroids is indicated, as in the presence of an underlying chronic
dermatosis, topical calcineurin inhibitors may be used as corticosteroid-sparing agents in both adults
and children to reduce the risk of topical corticosteroid-associated adverse effects, particularly atrophy
and striae. [29] [30] [31] Topical calcineurin inhibitors are prescribed in conjunction with pulsed topical
corticosteroids in a regimen involving the use of topical calcineurin inhibitors on weekdays and topical
corticosteroids on weekends.
These drugs can also be used on facial, intertriginous, and genital lesions in both adults and children, as
the application of topical corticosteroids should be avoided in these areas where possible. [31]
Adverse effects of topical calcineurin inhibitors include transient skin burning, which can limit their use
in some patients, and increased risk of local skin infections at the site of application. While cases of
malignancy have been reported in patients who have used topical calcineurin inhibitors, there is no
clinical evidence to establish that treatment with these drugs increases the risk of malignancy. [46]

Topical antipruritics
Topical capsaicin (in both adults and children >2 years of age) or topical doxepin (in adults only) can be
added to the treatment regimen of LSC for relief of breakthrough pruritus despite treatment with
topical corticosteroids. [47] [48] The adverse effects of burning and stinging after application of
capsaicin may limit its use in some patients, and doxepin may cause allergic contact dermatitis,
especially when used on inflamed skin. [49]

Cryosurgery
Cryosurgery is an effective adjunct to high-potency topical corticosteroids for small localised lesions of
LSC in adults and children >12 years of age. [50] It is typically performed with liquid nitrogen using either
a cotton-tipped applicator or hand-held spray delivery device.
Complications include blister formation, haemorrhage, infection, excessive granulation tissue
formation, pigmentation abnormalities, and altered sensation. Avoiding freeze cycles of >30 seconds
and deep freezing over nerve bundles can reduce many of its complications. As pigmentation
abnormalities are very common with the use of cryosurgery in dark-skinned people, consideration of an
alternative form of treatment in these patients is warranted.

Light therapy
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UV light therapy with UV-A and psoralen (PUVA) or UV-B (narrow or broadband) can be used in adults
and children >12 years of age in LSC lesions resistant to treatment with high-potency topical
corticosteroids and intra-lesional corticosteroid injections or as an adjunct to high-potency topical
corticosteroids in diffuse disease. [1] [39]
PUVA may be more efficacious than broadband UV-B, but narrow-band UV-B (NBUVB) has equal efficacy
to PUVA, is safer with a lower incidence of adverse effects, and does not require the patient to wear UVA blocking eye protection after the procedure, as it does not involve the ingestion of a photosensitising
agent such as psoralen. NBUVB is therefore the preferred form of light therapy.
PUVA and UV-B are carried out by a dermatologist 2 and 3 times per week, respectively.
Adverse effects of UV light therapy include the risk of sunburn, cataracts (with PUVA) and increased risk
of skin cancer, especially with prolonged PUVA therapy. The risk of developing cataracts with PUVA
therapy can be avoided by wearing UV-A blocking eye protection for 24 hours following ingestion of the
psoralen-sensitising agent if any sunlight exposure is expected. [51]

Systemic corticosteroids
LSC lesions resistant to several weeks of treatment with topical corticosteroids and other therapies may
benefit from either a short course of oral corticosteroids (in both adults and children) or a once-only
injection of intra-muscular corticosteroid (in adults only). [2] As intra-muscular injection is an invasive
technique, oral is the preferred route for giving systemic corticosteroids. Oral and intra-muscular
corticosteroids should not be used together.
Rebound of the condition may be seen after systemic corticosteroid dose-tapering, and other adverse
effects associated with the short-term use of systemic corticosteroids may occur. These adverse effects
can be minimised by taking the medication only in the mornings and using as low a dose for as short a
time as possible.
LSC should never be managed with long-term systemic corticosteroids and, therefore, many of the
long-term adverse effects associated with their use are not encountered in the treatment of the
condition.

Surgical excision
If problematic areas of LSC persist despite all other treatments, surgical excision of small localised
lesions may be warranted as a last-line treatment in adults and children >12 years of age. [52] Although
not contraindicated in children between 12 and 18 years of age, surgery may not be an appropriate
treatment for all children in this age group.
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