PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
This presents as a localised demarcated plaque, usually with scaling, excoriations and lichenification (increased skin markings and thickened skin) on the surface. The lesion is particularly itchy. Common sites are the calf, elbow, behind the neck, and genitalia (vulva or scrotum). Plaques are usually greater than 5 cm in diameter.
The common initial cause is eczema. The intense pruritus leads to persistent scratching and the area becomes lichenified (thick and leathery).
Other common causes include insect bites, scars (eg, traumatic, postherpetic/zoster) and venous insufficiency.
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The condition has been estimated to occur in 12% of the population. The highest prevalence is mid to late adulthood, with a peak at 30-50 years. There is no race predilection, although people with dark skin tend to develop more marked pigmentary changes. The condition is aggravated by periods of inactivity (presumably because there are no distractions to the itching) and stress. One study found that people with lichen simplex chronicus had different personality profiles from those who did not.
A wide range of dermatological conditions need to be excluded, including the dermatological manifestations of systemic diseases of the gastrointestinal, neurological and renal systems, as well as haematological conditions.
Dermatological conditions which need to be considered include:
- Acanthosis nigricans
- Acne keloidalis nuchae - keloid papules and plaques on the occipital scalp occurring almost exclusively in Afro-American men)
- Alopecia mucinosa - papules and plaques seen mainly in the young (<40) leading to hair loss
- Amyloidosis - lichen or macular
- Atopic dermatitis
- Contact dermatitis - allergic or irritant
- Cutaneous T-cell lymphoma
- Dermatitis herpetiformis
- Lichen planus or striatus
- Discoid (nummular) dermatitis
- Pretibial myxoedema
- Plaque psoriasis
- Seborrhoeic dermatitis
- Stasis dermatitis
- Tinea cruris
Narrowing the list of potential causes may be helped by doing an IgE level and patch testing to exclude atopy and allergy, mycotic studies and biopsy for histopathology.
Primary Care management
- Itching may be relieved by using potent (occasionally very potent) steroids such as clobetasol or fluocinolone. Once the lesion has lost its lichenification and thickening, it becomes less itchy and the strong steroids only need to be used if itching recurs.
- Tar or ichthyol preparations have been shown to be beneficial for their anti-pruritic effect.
- Occlusive dressings may help to break the itch-scratch cycle.
- Oral antihistamines may be required. A sedative antihistamine such as chlorphenamine may be first-line if sleep disturbance is a problem.
- Oral antibiotics may be required for swab-positive infections.
- Intralesional steroids such as triamcinolone may be considered in resistant cases.
- Other treatment options currently being investigated include topical doxepin and capsaicin, topical aspirin/dichloromethane, topical and oral immune modulators such as tacrolimus and local botulinum toxin.Topical tacrolimus may be particularly helpful for cases resistant to other treatment and promote long-lasting benefit.
- Gabapentin has also been used to good effect in cases resistant to topical treatments.
The condition often it improves well with treatment but occasional cases may become persistent, especially on the genitalia.
Further reading & references
- Thorstensen KA, Birenbaum DL; Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. J Midwifery Womens Health. 2012 May-Jun;57(3):260-75. doi: 10.1111/j.1542-2011.2012.00175.x.
- Lichen simplex chronicus on the back; Medline Plus, 2013
- An JG et al; Quality Of Life of Patients with Neurodermatitis. Int J Med Sci 2013; 10(5):593-598.
- Cahill S, Chronic pruritic vulva lesion, Journal of Family Practice, Vol. 62, No. 02: 97-99, 2013.
- Lotti T, Buggiani G, Prignano F; Prurigo nodularis and lichen simplex chronicus. Dermatol Ther. 2008 Jan-Feb;21(1):42-6. doi: 10.1111/j.1529-8019.2008.00168.x.
- Martin-Brufau R, Corbalan-Berna J, Ramirez-Andreo A, et al; Personality differences between patients with lichen simplex chronicus and normal population: A study of pruritus. Eur J Dermatol. 2010 May-Jun;20(3):359-63. doi: 10.1684/ejd.2010.0961. Epub 2010 Apr 13.
- Lichen Simplex Chronicus; Merck Manual, 2012
- Elmariah SB, Lerner EA; Topical therapies for pruritus. Semin Cutan Med Surg. 2011 Jun;30(2):118-26. doi: 10.1016/j.sder.2011.04.008.
- Cohen KR, Frank J, Salbu RL, et al; Pruritus in the elderly: clinical approaches to the improvement of quality of life. P T. 2012 Apr;37(4):227-39.
- Felber ES; Botulinum toxin in primary care medicine. J Am Osteopath Assoc. 2006 Oct;106(10):609-14.
- Aschoff R, Wozel G; Topical tacrolimus for the treatment of lichen simplex chronicus. J Dermatolog Treat. 2007;18(2):115-7.
- Gencoglan G, Inanir I, Gunduz K; Therapeutic hotline: Treatment of prurigo nodularis and lichen simplex chronicus Dermatol Ther. 2010 Mar-Apr;23(2):194-8.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr Laurence Knott
Prof Cathy Jackson