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.

Symptoms

For those who are familiar with lichen on rocks, lichen simplex chronicus has much this same appearance, but on the skin. It usually appears as a solitary patch or plaque with a round or oval pattern.

With lichen simplex chronicus, 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.

Commonly Affected Areas

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

  • Outer lower portion of the lower leg
  • Wrists and ankles
  • Back and side of the neck (lichen simplex nuchae)
  • Forearm portion of the elbow
  • Scrotum, vulva, anal area, and pubis
  • Upper eyelids
  • The opening of the ear
  • Fold behind the ear

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.

Causes

Lichen simplex chronicus, or "neurodermatitis," is actually more of a symptom than a specific disease itself.

The skin eruption is created by constantly (habitually) 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, and an accentuation of normal skin line.

These skin changes are referred to as "lichenification" as the appearance can look much like the lichen which grows on trees and rocks in a forest.

While repeated itching and trauma to the skin causes the condition to develop the underlying mechanism, or exactly how scratching leads to the development, of lichen simplex chronicus is still unknown.

Risk Factors

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

The nerve endings in this area are irritable and trigger an itch-scratch-itch cycle. The more the eruption is scratched or rubbed, the more it itches, propelling the cycle.

Conditions which may lead to lichen simplex chronicus include most any condition which can cause itching like:

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 the telltale scratch marks. A skin scraping may need to be done to rule out conditions such as fungal infections (KOH test) or scabies.

Sometimes a skin biopsy is done to confirm the diagnosis and rule out other causes. There are several conditions which 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")

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).

Treatment

The treatment of lichen simplex chronicus is best accomplished with a combination of treatments designed to heal the rash and treat the underlying condition. Treatment approaches 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, the area may have to be covered. Another option for some people is wearing cotton gloves at night and making sure nails are filed down to minimize damage when scratching does occur. When severe, a person may require medication to help with the itch temporarily while getting it under control.
  • Treat as eczema. Lichen simplex chronicus is treated like chronic eczema by decreasing water and soap contact and applying emollients.
  • 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. Even with the use of these creams (and anti-itch creams, lotions, cooling, and methylated creams), however, scratching needs to be controlled. In some cases, a steroid injection directly into the plaque may be used. Long-term use, especially of the stronger prescription steroid preparations, can cause thinning of the skin which can lead to other problems. 
  • Use coal tar products. Coal tar products have been around for a hundred years but may still offer help in the treatment of LSC. They help reduce itching and scaling. Coal tar products can be found over the counter in creams, gels, and bath soaks. Ask your pharmacist for product recommendations.
  • Choose clothing wisely. Reducing itching may be made easier with certain types of clothing over others. For vulvar lichen simplex chronicus, there is some evidence that wearing silk underwear may help.

Coping

It's worthy to note that LSC does not only affect people physically but can have a significant impact psychologically and socially as well. This underlines the importance of treating the rash.

People with this condition often feel embarrassed or self-conscious about their skin. They may choose clothing that hides the rash, rather than clothing they really like. Or they 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 bring feelings of control.

Also, talking with others who are in the same situation can be especially helpful. 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 key is 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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Article Sources

  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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