An Overview of Lichen Simplex Chronicus

Psoriasis on elbow

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Lichen simplex chronicus (LSC) is an area of thickened, discolored, leathery-looking skin that develops after the skin has been scratched over a long period of time. It's not a skin disease itself, but rather a result of other skin conditions that are itchy and, therefore, lead to repeated scratching (e.g., eczema and psoriasis). Even rubbing the skin can lead to lichen simplex chronicus.

Lichen simplex chronicus is more common in adults and is fairly uncommon in children. It occurs more frequently in women than in men and is often seen between the ages of 30 and 50.

LSC is also known as neurodermatitis.

Symptoms

Lichen simplex chronicus usually appears as a solitary patch or plaque with a round or oval pattern. The skin's surface often appears dry and scaly, and the surrounding skin can feel thick and leathery.

The rash is often red, with discoloration that is often irregular and pigmented. There may be associated scratch marks near the rash.

These skin changes are referred to as lichenification, as the appearance can look much like lichen (a composite organism) that grows on trees and rocks in a forest.

Commonly Affected Areas

The areas most commonly affected by lichen simplex chronicus, listed in order of frequency, are:

  • The outer portion of the calf
  • Wrists and ankles
  • Back and sides of the neck (lichen simplex nuchae)
  • Forearm and elbow crease
  • Scrotum, vulva, anal area, and pubis
  • Upper eyelids
  • Opening of the ear
  • Fold behind the ear

Complications

Over time, lichen simplex chronicus may lead to complications. The most common are scarring and changes in pigmentation in the affected area.

There is also the risk of secondary bacterial infections, especially in those who have decreased immune function. Secondary infection most often requires antibiotics, and can, in rare cases, lead to severe systemic infections (sepsis).

Causes

Lichen simplex chronicus is actually more of a symptom than a specific disease itself.

The skin eruption is created by habitually (and frequently) scratching a certain area of skin over a long period of time. This scratching causes characteristic changes, such as thickening and darkening of the skin, accentuating and deepening normal lines and creases of the skin.

While repeated itching and trauma to the skin prompts the condition to develop, the root cause behind lichen simplex chronicus is still unknown.

Risk Factors

LSC is seen most commonly in people with eczema. Although eczema can affect the whole body, the eruption of LSC in usually found in just one area.

The nerve endings in the affected area are particularly irritable and trigger a cycle of itching. The more you try to ease the discomfort, the worse it gets, prompting you to scratch some more.

Conditions that may lead to lichen simplex chronicus include most any condition that can cause itching, such as:

The rash is sometimes associated with anxiety disorders, such as obsessive-compulsive disorder, and with depression. It may also be associated with a condition that leads to neuropathy, such as disc disease in the spine.

Diagnosis

The diagnosis of lichen simplex chronicus is often made by a combination of findings, such as a history of eczema and telltale scratch marks. A skin scraping (KOH test) may need to be done to rule out conditions such as fungal infections or scabies.

Sometimes a skin biopsy is done to confirm the diagnosis and rule out other causes. There are several conditions that can look very similar to lichen simplex chronicus, including:

  • Plaque psoriasis
  • Acanthosis nigricans
  • Lichen planus
  • Scabies
  • Acne keloidalis nuchae
  • Chronic spongiotic ermtitides
  • Prurigo nodularis
  • Pityriasis rubra pilaris
  • Psoriaform secondary syphillis
  • Reiter syndrome
  • Mycosis fungoides (cutaneous T cell lymphoma)
  • Amyloidosis
  • Dermatitis herpetiformis ("the gluten rash")

Treatment

The treatment of lichen simplex chronicus is best accomplished with a combination of approaches designed to heal the rash and address the underlying condition.

Strategies include:

  • Stop scratching: The most important part of treatment is understanding that all itching, rubbing, and even touching of the rash must stop. Since many people scratch in their sleep, some find it helpful to cover the area or wear cotton gloves at night. Make sure your nails are filed down to minimize damage if and when scratching occurs.
  • Use gentle skin care products: Lichen simplex chronicus is treated very much like chronic eczema. Switch to a gentle, fragrance-free cleanser. Apply emollient creams regularly to affected areas several times daily, especially after bathing.
  • Apply topical steroid creams: Topical steroids are almost always needed to control symptoms. Since high-strength steroids are required, a healthcare provider needs to prescribe them and monitor their use. (A hydrocortisone cream obtained over the counter can be used until an appointment is made, though you should get your doctor's OK before you begin using one. Also, do not apply hydrocortisone to the eye area.) In some cases, a steroid injection directly into the plaque may be used. Note: Long-term use, especially of stronger prescription steroid preparations, can cause thinning of the skin. 
  • Try coal tar products: Coal tar products have been around for 100 years. They help reduce itching and scaling, including that associated with LSC. Coal tar products can be found in over-the-counter creams, gels, and bath soaks. Ask your pharmacist for product recommendations.
  • Choose clothing wisely: Reducing itching may be made easier by wearing soft, breathable fabrics such as cotton. Avoid rough, scratchy fabrics such as wool, and tight articles of clothing that rub affected areas. For vulvar lichen simplex chronicus, there is some evidence that wearing silk underwear may help.

Coping

Lichen simplex chronicus can have a significant psychological and social impact on those who have it. This underlines the importance of treating the rash.

You may feel embarrassed or self-conscious about your skin. You may find that you choose clothing that hides the rash, rather than options you really like. Or you may shy away from certain social activities. Just the itching alone may be so pervasive that it interferes with work, sleep, and enjoyment of activities.

Starting treatment can help you address these feelings, as can talking with others who are in the same situation. You can ask your doctor about local eczema or dermatitis support groups. There are organizations, such as the National Eczema Association, that also provide online support.

A Word From Verywell

Lichen simplex chronicus can be distressing to those who have it. Besides the intense itching, the lesions themselves can be embarrassing. Improvement of this skin issue takes time, but with the right treatments in place, it can be done. The keys are to treat the underlying skin condition that is contributing to the itching and to avoid scratching as much as possible. Your healthcare provider can devise a treatment plan that works for your particular situation.

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  1. Corazza, M., Borghi, A., MInghetti, S., Toni, G., and A. Virgili. Effectiveness of Silk Fabric Underwear as an Adjuvant Tool in the Management of Vulvar Lichen Simplex Chronicus: Results of a Double-Blind Randomized Trial. Menopause. 2015. 22(8):850-6. doi:10.1097/GME.0000000000000410


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