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Lichen Simplex Chronicus
Geoffrey Strider Farnsworth, MD
image BASICS
DESCRIPTION
  • Lichen simplex chronicus (LSC) is a chronic dermatitis resulting from chronic, repeated rubbing or scratching of the skin. Skin becomes thickened with accentuated lines (“lichenification”).
  • System(s) affected: skin
  • Synonym(s): LSC; lichen simplex; localized neurodermatitis; neurodermatitis circumscripta
EPIDEMIOLOGY
Geriatric Considerations
Most common in middle aged and elderly
Pediatric Considerations
Rare in preadolescents
Incidence
  • Common
  • Peak incidence 35 to 50 years
  • Predominant sex: females > males (2:1)
Prevalence
Common
ETIOLOGY AND PATHOPHYSIOLOGY
  • Itch-scratch cycle leads to a chronic dermatosis. Repeated scratching or rubbing causes inflammation and pruritus, which leads to continued scratching.
  • Primary LSC: Scratching secondary to nonorganic pruritus, habit or a conditioned response to stress/anxiety
  • Common triggers are excess dryness of skin, heat, sweat, and psychological stress.
  • Secondary LSC: begins as a pruritic skin disease that evolves into neurodermatitis, which persists after resolution of the primary condition. Precursor dermatoses include atopic dermatitis, contact dermatitis, lichen planus, stasis dermatitis, psoriasis, tinea, and insect bites.
  • There is a possible relation between disease development and underlying neuropathy, particularly radiculopathy or nerve root compression.
  • Pruritus-specific C neurons are temperature sensitive, which may explain itching that occurs in warm environments.
RISK FACTORS
  • Anxiety disorders
  • Dry skin
  • Insect bites
  • Pruritic dermatosis
GENERAL PREVENTION
Avoid common triggers such as psychological distress, environmental factors such as heat and excessive dryness, skin irritation, and the development of pruritic dermatoses.
COMMONLY ASSOCIATED CONDITIONS
  • Prurigo nodularis is a nodular variety of the same disease process.
  • Atopic dermatitis
  • Anxiety, depression, and obsessive-compulsive disorders
image DIAGNOSIS
PHYSICAL EXAM
  • Well-circumscribed lichenified plaques with varying amounts of overlying excoriation or scaling
  • Lichenification: accentuation of normal skin lines
  • Hyperpigmentation or hypopigmentation can be seen.
  • Scarring is uncommon with typical LSC; can be seen following ulcer formation or secondary infection.
  • Most commonly involves easily accessible areas
    • Lateral portions of lower legs/ankles
    • Nape of neck (lichen simplex nuchae)
    • Vulva/scrotum/anus
    • Extensor surfaces of forearms
    • Palmar wrist
    • Scalp
DIFFERENTIAL DIAGNOSIS
  • Lichen sclerosis
  • Psoriasis
  • Atopic dermatitis
  • Contact, irritant, or stasis dermatitis
  • Extramammary Paget disease
  • Lichen planus
  • Mycosis fungoides
  • Lichen amyloidosis
  • Tinea
  • Nummular eczema
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • No specific diagnostic test
  • Microscopy (i.e., KOH prep) and culture preparation may be helpful in identifying possible bacterial or fungal infection.
Diagnostic Procedures/Other
  • Skin biopsy if diagnosis is in question.
  • Patch testing may be used to rule out a contact dermatitis.
Test Interpretation
  • Hyperkeratosis
  • Acanthosis
  • Lengthening of rete ridges
  • Hyperplasia of all components of epidermis
  • Mild to moderate lymphohistiocytic inflammatory infiltrate with prominent lichenification
image TREATMENT
GENERAL MEASURES
  • Patient education is critical.
  • Low likelihood of resolution if patient unable to avoid scratching.
  • Treatment aimed at reducing inflammation and pruritus.
MEDICATION
First Line
  • Reducing inflammation
    • Topical steroids are first-line agents (1,2)[C].
    • High-potency steroids alone, such as 0.05% betamethasone dipropionate cream or 0.05% clobetasol propionate cream, can be used initially but should be avoided on the face, anogenital region, or intertriginous areas. They should be used on small areas only, for no longer than 2 weeks except under the close supervision of a physician.
    • Switch to intermediate- or low-potency steroids as response allows.
    • An intermediate-potency steroid, such as 0.1% triamcinolone cream, may be used for initial, brief treatment of the face and intertriginous areas, and for maintenance treatment of other areas.
    • A low-potency steroid, such as 1% hydrocortisone cream, should be used for maintenance treatment of the face and intertriginous areas.
    • Steroid tape, flurandrenolide, has optimized penetration and provides a barrier to continued scratching. Change tape once daily.
    • Intralesional steroids, such as triamcinolone acetate, are also safe and effective for severe cases.
  • Preventing scratching
    • Topical antipruritic agents
    • 1st-generation oral antihistamines such as diphenhydramine and hydroxyzine for antipruritic and sedative effects
    • Sedating tricyclics, such as doxepin and amitriptyline, for nighttime itching
    • Itching may occur at night while the patient is asleep; occlusive dressings may be helpful in these cases.
Second Line
All recommendations
  • Topical aspirin has been shown to be helpful in treating neurodermatitis (3)[C].
  • Topical 5% doxepin cream has significant antipruritic activity (3)[C].
  • Topical capsaicin cream can be helpful for treatment of early disease manifestations (3)[C].
  • P.611

  • 0.1% tacrolimus applied twice daily over 6 weeks for as an effective alternative treatment (4)[C]
  • Gabapentin was found to decrease symptoms in patients who are nonresponsive to steroids.
  • Topical lidocaine can be effective in decreasing neuropathic pruritus (3)[C].
  • Intradermal botulinum toxin injections has been reported to improve symptoms in patients with recalcitrant pruritus.
  • Transcutaneous electrical nerve stimulation may relieve pruritus in patients for whom topical steroids were not effective (5)[C].
  • A case report showed NB-UVB as a possible off-label treatment of refractory LSC (6)[C].
  • SSRIs may be effective in controlling compulsive scratching secondary to psychiatric diagnosis.
ISSUES FOR REFERRAL
  • No response to treatment
  • Presence of signs and symptoms suggestive of a systemic cause of pruritus
  • Consultation with a psychiatrist for patients with severe stress, anxiety, or compulsive scratching
  • Consultation with an allergist for patients with multisystem atopic symptoms
ADDITIONAL THERAPIES
  • Cooling of the skin with ice or cold compresses
  • Soaks and lubricants to improve barrier layer function
  • Occlusion of lesion with bandages or Unna boots.
  • Nail trimming
  • Silk underwear to decrease friction in genital LSC.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Acupuncture has been shown as an effective treatment for pruritus (7)[C].
  • Cognitive-behavioral therapy may improve awareness and help to identify coping strategies.
  • Hypnosis may be beneficial in decreasing pruritus and preventing scratching.
  • Homeopathic remedies (i.e., thuja and graphite) have been used.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Patients should be followed for response to therapy, complications from therapy (especially topical steroids), and secondary infections.
DIET
Regular balanced diet
PATIENT EDUCATION
  • Patients should understand the cause of this disease and the critical role they play in its resolution:
    • Emphasize that scratching and rubbing must stop for lesions to heal. Medications ineffective if scratching continues
  • Stress reduction techniques can be useful for patients for whom stress plays a role.
  • Avoid exposure to known triggers.
PROGNOSIS
  • Often chronic and recurrent
  • Good prognosis if the itch-scratch cycle can be broken
  • After healing, the skin should return to normal appearance but may also retain accentuated skin markings or post inflammatory pigmentary changes that may be slow to resolve.
REFERENCES
1. Lynch PJ. Lichen simplex chronicus (atopic/neurodermatitis) of the anogenital region. Dermatol Ther. 2004;17(1):8-19.
2. Datz B, Yawalkar S. A double-blind, multicenter trial of 0.05% halobetasol propionate ointment and 0.05% clobetasol 17-propionate ointment in the treatment of patients with chronic, localized atopic dermatitis or lichen simplex chronicus. J Am Acad Dermatol. 1991;25(6 Pt 2):1157-1160.
3. Patel T, Yosipovitch G. Therapy of pruritus. Expert Opin Pharmacother. 2010;11(10):1673-1682.
4. Tan ES, Tan AS, Tey HL. Effective treatment of scrotal lichen simplex chronicus with 0.1% tacrolimus ointment: an observational study. J Eur Acad Dermatol Venereol. 2015;29(7):1448-1449.
5. Mohammad Ali BM, Hegab DS, El Saadany HM. Use of transcutaneous electrical nerve stimulation for chronic pruritus. Dermatol Ther. 2015;28(4):210-215.
6. Virgili A, Minghetti S, Borghi A, et al. Phototherapy for vulvar lichen simplex chronicus: an ‘off-label use’ of a comb light device. Photodermatol Photoimmunol Photomed. 2014;30(6):332-334.
7. Ma C, Sivamani RK. Acupuncture as a treatment modality in dermatology: a systematic review. J Altern Complement Med. 2015;21(9):520-529.
Additional Reading
&NA;
  • Aschoff R, Wozel G. Topical tacrolimus for the treatment of lichen simplex chronicus. J Dermatolog Treat. 2007;18(2):115-117.
  • Engin B, Tufekci O, Yazici A, et al. The effect of transcutaneous electrical nerve stimulation in the treatment of lichen simplex: a prospective study. Clin Exp Dermatol. 2009;34(3):324-328.
  • Gencoglan G, Inanir I, Gunduz K. Therapeutic hotline: treatment of prurigo nodularis and lichen simplex chronicus with gabapentin. Dermatol Ther. 2010;23(2):194-198.
  • Goldstein AT, Parneix-Spake A, McCormick CL, et al. Pimecrolimus cream 1% for treatment of vulvar lichen simplex chronicus: an open-label, preliminary trial. Gynecol Obstet Invest. 2007;64(4):180-186.
  • Heckmann M, Heyer G, Brunner B, et al. Botulinum toxin type A injection in the treatment of lichen simplex: an open pilot study. J Am Acad Dermatol. 2002;46(4):617-619.
  • Hercogová J. Topical anti-itch therapy. Dermatol Ther. 2005;18(4):341-343.
  • Kirtak N, Inaloz HS, Akçali C, et al. Association of serotonin transporter gene-linked polymorphic region and variable number of tandem repeat polymorphism of the serotonin transporter gene in lichen simplex chronicus patients with psychiatric status. Int J Dermatol. 2008;47(10):1069-1072.
  • Konuk N, Koca R, Atik L, et al. Psychopathology, depression and dissociative experiences in patients with lichen simplex chronicus. Gen Hosp Psychiatry. 2007;29(3):232-235.
  • Lotti T, Buggiani G, Prignano F. Prurigo nodularis and lichen simplex chronicus. Dermatol Ther. 2008;21(1):42-46.
  • Shenefelt PD. Biofeedback, cognitive-behavioral methods, and hypnosis in dermatology: is it all in your mind? Dermatol Ther. 2003;16(2):114-122.
  • Solak O, Kulac M, Yaman M, et al. Lichen simplex chronicus as a symptom of neuropathy. Clin Exp Dermatol. 2009;34(4):476-480.
  • Wu M, Wang Y, Bu W, et al. Squamous cell carcinoma arising in lichen simplex chronicus. Eur J Dermatol. 2010;20(6):858-859.
  • Yosipovitch G, Sugeng MW, Chan YH, et al. The effect of topically applied aspirin on localized circumscribed neurodermatitis. J Am Acad Dermatol. 2001;45(6):910-913.
  • Yüksek J, Sezer E, Aksu M, et al. Transcutaneous electrical nerve stimulation for reduction of pruritus in macular amyloidosis and lichen simplex. J Dermatol. 2011;38(6):546-552.
Codes
&NA;
ICD10
L28.0 Lichen simplex chronicus
Clinical Pearls
&NA;
  • LSC is a chronic inflammatory condition that results from repeated scratching and rubbing.
  • Primary LSC originates de novo, whereas secondary LSC occurs in the setting of a preexisting pruritic dermatologic condition.
  • LSC is a clinical diagnosis based on history and skin examination with biopsy only indicated in difficult or unclear cases.
  • Stopping the itch-scratch cycle through patient education, skin lubrication, and topical medications is key.
  • Treatment aimed at decreasing both inflammation and pruritus utilizing topical steroids and antipruritics.