The Itch That Isn’t Yeast
For most of an adult woman’s life - like age 10-50, the first thing you think of with an itch “down there” is a yeast infection. It’s warm, it’s moist and everywhere I’ve been a doc, it’s semi-tropical, so yeast makes sense. However, there is another common itch that happens down there - Lichen Sclerosus.
Lichen Sclerosus is an autoimmune condidtion that happens in pre-pubertal girls and post (sometimes peri) menopausal women. In young girls with an itch that doesn’t clear up with one one round of diflucan it’s almost always lichen and almost always go undiagnosed or untreated for months before finding a gynecologist who is willing to see and treat young girls. The treatment is the same as what we will discuss below, but I wanted to take a moment to address the younger ladies and the mom’s who are struggling to get their daughters care. If you have tried one thing and it’s not better, start looking for a gyno. We don’t do invasive internal exams on young girls, the exam is just a look form the outside and then we are done in about 30-60 seconds.
Ok, so what is it and how do we treat this. Lichen Sclerosus in an autoimmune condition where the body attacks the rete pegs that hold the top layer of skin on to the lower levels. The result is a shearing of the skin, wich causes patches that a super thin - almost resembling a cigarette paper (think tissue paper if, like me, you’ve never seen a cigarette paper. There are also often red patches and irritated appearing areas or somtimes everything is just shiny red depending on the amount of inflammation. Some women have the entire vulva affected and for other’s, its a small patch. Antifungals are not on the list and it’s unfortunate that many women have tried 6-10 rounds of diflucan, topical antifungals and more before they get to the right answer. Because this is an autoimmune condition, it’s best treated with medium to high potency topic steroid creams. Clobetasol is the most common and works wonders. The disease affects the labia and area around the anus in a “figure of eight” pattern that spares the internal mucus membranes. All of the itching will be external. The medicine - and only about a pea sized amount of it - needs to be applied to the entire figure of eight area twice a day.
The importance of vaginal estrogen. Lichen only happens in low estrogen women (that’s what prepubertal and postmenopausal women have in common). While estrogen isn’t required to treat the symptoms once they are established it will reduce the flares and the amount of symptoms people get when it is used consistently over time. The disease also causes a “loss of architecture” (in postmenopausal women because prepubertal ones haven’t developed their “architecture” yet) and fusion of the labia together limiting future sexual activity and causing urine to spray in weird directions. The vaginal estrogen prevents these changes from happening or slows their progression. In young women, most of this will reverse and no further treatment will be needed when puberty hits.
What happens if we don’t treat it? In young girls, it’s annoying, but eventually, they will go through puberty and be fine. In older women, failure to treat leads to significant pain and discomfort over time, urinary tract problems including increaing UTIs, loss of sexual funciton or pain with sex, difficulty achieving orgasm due to changes to the clitoris and a host of other things that sound less than pleasant. I’ve also had several patient’s who developed secondary infections because they are scratching at the area and then normal skin bacteria get in to areas where the skin has been broken, or yeast can invade these areas. For this reason, topical/systemic antibiotics or antifungals may be needed for particularly bad flares. The worst thing though is that the disease carries an increased risk of vulvar cancer (about 1%, but still, far fewer than 1% of women without this get vulvar cancer). So, even if you are asymptomatic, an annual physical exam with full inspection and biopsies of concerning areas are a must.
The bottom line of this topic is, when your symptoms don’t get better after intial treatment, request a biopsy, a swab or consider finding a provider who is willing to do a good physical exam. The number one reason this condition goes undiagnosed is the assumption that all vaginal itch is yeast and an unwillingness to examine a female patient (often by a male provider) even when the diagnosis doesn’t make alot of sense - a 75 year old woman who isn’t diabetic and doesn’t swim getting a yeast infection in winter? Not very likely. So, if you haven’t had an exam or satisfactory answers, seek a provider who will do the exam you need!