Lichen Sclerosus and Vulvar Discomfort

Understanding Chronic Vulvar Itching, Burning, White Skin Changes, Sexual Pain, Scarring, Diagnosis, Treatment and an Integrative Unani Approach

By Dr. Nizamuddin Qasmi
Founder & Chief Physician, Saira Health Care
Focused Practice in Sexual Disorders & Infertility

Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects the vulva and the skin around the anus in women.

For many patients, however, the illness does not begin with the words “lichen sclerosus.”

A woman may come to me saying:

“Doctor, I have had itching around my private parts for months.”

Another may say:

“My skin has become white.”

Another says:

“Intercourse burns and feels as if the skin is tearing.”

Some women are repeatedly treated for fungal infection because itching is assumed to mean candidiasis.

Others repeatedly use antiseptic washes, antifungal creams or home remedies without realizing that they have a completely different skin disease.

This delay matters.

Untreated or poorly controlled vulvar lichen sclerosus can gradually cause fragile skin, fissures, scarring, narrowing of the vaginal entrance, changes in vulvar anatomy and significant sexual discomfort. It is also associated with an increased risk of vulvar squamous-cell carcinoma, which is why appropriate treatment and long-term follow-up are important.

My first message to patients is therefore:

Lichen sclerosus is treatable and usually manageable, but it should be correctly diagnosed and followed rather than repeatedly mistaken for infection.

At Saira Health Care, I consider lichen sclerosus not only as a skin condition but also in relation to the woman's sexual comfort, reproductive health, body confidence, relationship wellbeing and quality of life.

What Is Lichen Sclerosus?

Lichen sclerosus, commonly abbreviated as LS, is a chronic inflammatory disorder of the skin.

In women it most commonly affects the:

• vulva,
• labia,
• clitoral area,
• perineum,
• skin around the anus.

The condition can occur outside the genital region, but the anogenital area is by far the most clinically important location.

Typical lichen sclerosus causes skin that may become:

• pale or white,
• thin,
• fragile,
• shiny,
• smooth,
• crinkled or “cigarette-paper” in appearance.

Itching is one of the most common symptoms.

The skin may also crack, bleed, bruise or hurt.

The NHS describes LS as a condition producing itchy white patches that are easily damaged and may become painful or bleed with rubbing or scratching.

Lichen Sclerosus Is Not an Infection

This is one of the most important things I explain.

Lichen sclerosus is not a sexually transmitted infection.

It is not caused by:

• poor personal hygiene,
• sexual activity,
• fungal infection,
• an unclean partner,
• semen,
• ordinary vaginal bacteria.

It is also not contagious.

A woman cannot pass lichen sclerosus to her husband or sexual partner through sexual intercourse.

The NHS specifically states that LS is not caused by infection, is not contagious and is not the result of poor hygiene.

This information alone can relieve considerable anxiety and relationship tension.

Who Can Develop Lichen Sclerosus?

Lichen sclerosus can occur at almost any age.

It can affect:

• young girls,
• reproductive-age women,
• pregnant women,
• postmenopausal women.

However, it is particularly common in women after menopause.

A major contemporary review describes postmenopausal women as the group most frequently affected, although children, adolescents, adult women and men can also develop the disease.

Therefore, a young woman should not be told:

“You are too young to have lichen sclerosus.”

Likewise, vulvar itching in an older woman should not automatically be attributed only to menopause or yeast infection.

What Causes Lichen Sclerosus?

The exact cause remains incompletely understood.

Current evidence suggests that lichen sclerosus probably results from a combination of:

• immune-system dysregulation,
• genetic susceptibility,
• local skin injury or friction,
• hormonal influences,
• tissue-remodelling abnormalities,
• inflammatory mechanisms.

An immune-mediated mechanism is strongly suspected.

The 2023 comprehensive review of lichen sclerosus describes immune abnormalities, genetic predisposition, trauma and autoimmune associations as important aspects of disease biology, while infection has not been established as the principal cause.

Is Lichen Sclerosus an Autoimmune Disease?

Lichen sclerosus is widely considered to have an important autoimmune component, although its exact mechanism is still being investigated.

Women with LS appear to have higher rates of certain autoimmune conditions.

One association that has been studied particularly closely is autoimmune thyroid disease.

A recent systematic review and meta-analysis found significant associations between lichen sclerosus and thyroid disorders, including autoimmune thyroiditis and Hashimoto thyroiditis.

This does not mean that every patient with lichen sclerosus has thyroid disease.

It means that thyroid symptoms and relevant medical history deserve attention.

Depending upon the patient's history, I may ask about:

• unexplained weight change,
• excessive tiredness,
• heat or cold intolerance,
• palpitations,
• constipation,
• hair changes,
• known thyroid disease,
• family history of autoimmune illness.

Testing should be clinically individualized rather than performed blindly in every patient.

What Does Vulvar Lichen Sclerosus Look Like?

The appearance can vary considerably.

Possible findings include:

• white patches,
• porcelain-white plaques,
• pale shiny skin,
• thin crinkled skin,
• red inflamed areas,
• bruising,
• tiny hemorrhages,
• fissures or cracks,
• erosions,
• thickened areas from repeated scratching.

The classic presentation described in modern reviews is a whitish, atrophic inflammatory eruption involving the vulvar and often perianal region.

In darker skin tones, the contrast and appearance may be different and recognition may sometimes be more difficult.

The diagnosis should therefore be based on the complete clinical appearance rather than expecting every patient to have an identical white patch.

The “Figure-of-Eight” Pattern

When both the vulva and skin around the anus are involved, the affected area can sometimes form a pattern described medically as a figure-of-eight or hourglass distribution.

This is a useful clinical clue.

However, not every woman develops this pattern.

Some have disease confined to one area of the vulva.

Common Symptoms of Lichen Sclerosus

Vulvar Itching

Itching is often the dominant symptom.

It can be:

• mild,
• intermittent,
• severe,
• particularly troublesome at night.

Repeated scratching then damages the already fragile skin.

This can create:

itching → scratching → skin injury → inflammation → more itching.

The cycle needs to be broken with correct anti-inflammatory treatment rather than simply suppressing the sensation temporarily.

Burning and Soreness

Some women experience very little itching but considerable:

• burning,
• tenderness,
• rawness,
• stinging.

This becomes especially noticeable after urination, exercise, prolonged walking or intercourse.

Vulvar Fissures

Lichen sclerosus can make skin fragile.

Small cracks may therefore develop around:

• the vaginal opening,
• clitoral region,
• labia,
• perineum.

A woman may describe:

“It feels as if the skin is splitting.”

Fissures may be particularly painful during intercourse.

Bleeding and Bruising

Fragile inflamed skin can bruise or bleed following relatively minor trauma.

This does not necessarily indicate cancer.

However, persistent bleeding, ulceration or a new abnormal lesion should always be assessed.

Pain During Intercourse

Sexual pain—dyspareunia—is a major but sometimes neglected consequence of vulvar lichen sclerosus.

Pain may occur because of:

• active inflammation,
• fissuring,
• dryness,
• fragile skin,
• scar tissue,
• narrowing of the vaginal entrance,
• clitoral scarring,
• secondary pelvic-floor tightening,
• fear of repeated pain.

A systematic review and meta-analysis estimated sexual dysfunction in approximately 59% of women with lichen sclerosus in the included studies, with dyspareunia or intercourse-related pain being among the most frequently reported problems.

This makes sexual-health assessment an important part of treatment.

Lichen Sclerosus Can Affect Much More Than the Skin

When a woman experiences vulvar pain for months or years, she may gradually stop:

• exercising comfortably,
• wearing certain clothes,
• travelling comfortably,
• sleeping normally,
• having intercourse.

The condition may affect:

• self-confidence,
• body image,
• sexual desire,
• relationships,
• emotional health.

A mixed-methods sexual-health study found substantial sexual distress and disruption of intimacy among many women living with LS.

Therefore, simply saying:

“Your skin looks better”

is not enough if intercourse remains impossible or the woman remains afraid of intimacy.

What Happens If Lichen Sclerosus Is Not Treated?

Chronic inflammation can gradually produce scarring.

This may alter normal vulvar anatomy.

Possible changes include:

• shrinking of the labia minora,
• fusion of skin around the clitoris,
• burying or hooding of the clitoris,
• narrowing of the vaginal entrance,
• perineal scarring,
• tightening around the anus.

The NHS notes that vulvar scarring can cause shrinkage and tightening, leading to pain during sex and sometimes difficulty with urination or bowel movements.

Early and effective disease suppression is therefore important not merely to stop itching but also to preserve vulvar anatomy.

Labial Resorption

Long-standing disease may cause the labia minora gradually to become smaller or disappear into surrounding scar tissue.

This is sometimes described medically as labial resorption.

Once significant anatomical loss has occurred, medication may control inflammation but cannot always completely restore anatomy.

Prevention of progression is therefore one of the objectives of early treatment.

Clitoral Scarring

Inflammation and scarring around the clitoral hood can cause the skin to become adherent.

The clitoris may become partly covered or buried.

This can potentially contribute to:

• reduced comfort,
• altered sensation,
• difficulty with stimulation,
• painful sexual activity.

Selected severe cases may require specialist surgical management after the inflammatory disease has been controlled.

Narrowing of the Vaginal Opening

Lichen sclerosus primarily affects the vulva rather than the internal vaginal mucosa.

However, scarring around the entrance can gradually reduce the width of the opening.

This can make penetration:

• painful,
• difficult,
• sometimes impossible.

This narrowing should not simply be labelled “vaginismus.”

The underlying structural disease needs treatment.

At the same time, secondary pelvic-floor muscle guarding may also develop, so some patients require both dermatological treatment and pelvic-floor rehabilitation.

Can Lichen Sclerosus Cause Urinary Symptoms?

Yes, indirectly.

Severe scarring may alter the vulvar anatomy and occasionally interfere with comfortable urination.

Urine touching inflamed or fissured skin can also cause burning.

This external burning can easily be mistaken for a urinary-tract infection.

Therefore, I distinguish between:

burning because urine touches damaged vulvar skin

and

burning caused by infection inside the urinary tract.

The treatments are very different.

Lichen Sclerosus Is Frequently Mistaken for Fungal Infection

This is one of the commonest clinical problems.

A woman develops itching.

She assumes Candida.

She buys an antifungal cream.

Symptoms improve slightly because the cream moisturizes the area, but the inflammatory disease continues.

Several months later she uses another antifungal.

Eventually significant scarring may already be present.

An Indian study of non-venereal vulvar disorders found lichen sclerosus among the most common causes of vulvar disease and highlighted the misconception that all vulvar itching represents fungal infection.

Persistent itching therefore deserves diagnosis—not endless empirical antifungal treatment.

Lichen Sclerosus Versus Candidiasis

These conditions can sometimes produce overlapping symptoms, but they are different.

Lichen sclerosus commonly causes:

• white skin changes,
• fragility,
• fissuring,
• chronic itching,
• scarring,
• anatomical changes.

Vaginal candidiasis more commonly causes:

• vulvovaginal itching,
• redness,
• swelling,
• abnormal discharge,
• fungal evidence on appropriate testing.

A woman can occasionally have both conditions simultaneously.

This is another reason treatment should be based on examination rather than assumption.

Lichen Sclerosus Versus Lichen Planus

Lichen planus is another inflammatory vulvar disorder.

It can sometimes resemble LS, but the diseases differ in their typical appearance, involvement of mucosal surfaces and clinical behaviour.

ACOG includes both LS and lichen planus among inflammatory vulvar disorders that can produce chronic pain, burning and itching.

A biopsy may occasionally be required when the clinical distinction is uncertain.

Lichen Sclerosus Versus Vitiligo

Vitiligo can also produce white vulvar skin.

However, vitiligo generally causes loss of pigment without:

• skin fragility,
• scarring,
• fissures,
• textural changes.

A white vulvar patch should therefore not automatically be labelled vitiligo or lichen sclerosus simply from colour alone.

Texture and anatomy matter.

Lichen Sclerosus Versus Vulvodynia

Vulvodynia describes chronic vulvar pain without a clear identifiable disease explaining the pain.

Lichen sclerosus, on the other hand, is a specific inflammatory skin disorder capable of causing vulvar pain.

ACOG's terminology specifically distinguishes persistent vulvar pain caused by an inflammatory condition such as lichen sclerosus from vulvodynia, in which no identifiable cause explains the pain.

However, some women whose LS is controlled may continue to have neuropathic or pelvic-floor pain and therefore require further assessment.

Does Lichen Sclerosus Increase Cancer Risk?

Yes—but this information needs to be explained carefully.

Most women with lichen sclerosus will not develop vulvar cancer.

Nevertheless, vulvar LS is associated with an increased risk of vulvar squamous-cell carcinoma and its precursor, particularly differentiated vulvar intraepithelial neoplasia.

A systematic review involving more than 14,000 women with vulvar LS found vulvar cancer in approximately 2.2% of women without a previous history of vulvar neoplasia across the included studies. Risk increased with age, while appropriate ultrapotent topical steroid treatment appeared to reduce risk.

A large Danish population study published in 2024 also confirmed substantially increased rates of vulvar high-grade squamous precancer and squamous-cell carcinoma among women with biopsy-confirmed LS compared with the general population.

The correct message is therefore:

Do not panic, but do take long-term treatment and surveillance seriously.

Lichen Sclerosus Is Not the Same as Cancer

This distinction is essential.

A diagnosis of LS does not mean that a woman has cancer.

Nor should she live in constant fear that cancer is inevitable.

The purpose of treatment and follow-up is precisely to:

• suppress inflammation,
• reduce scarring,
• identify suspicious changes early,
• reduce preventable complications.

Changes That Require Prompt Examination

A woman already diagnosed with LS should arrange assessment if she develops:

• a new lump,
• persistent ulcer,
• persistent sore,
• thickened area,
• new warty growth,
• area that repeatedly bleeds,
• lesion that fails to heal,
• significant new colour or texture change.

The NHS similarly recommends medical assessment for persistent ulcers, lumps and changes in skin texture such as thickening.

These findings do not automatically mean cancer.

But they should not be ignored.

How Is Lichen Sclerosus Diagnosed?

In many patients the diagnosis can be made clinically by an experienced clinician based on:

• symptoms,
• appearance,
• distribution,
• texture,
• anatomical changes.

The 2023 review states that the diagnosis is usually clinical.

However, not every white or itchy vulvar lesion is LS.

This is why experience in vulvar disorders matters.

When Is a Biopsy Needed?

A biopsy involves taking a small sample of affected skin for microscopic examination.

Biopsy is particularly useful when:

• the diagnosis is uncertain,
• the appearance is atypical,
• recommended treatment does not work,
• there is a persistent thickened lesion,
• there is an ulcer,
• precancer or cancer is suspected.

Current reviews specifically recommend biopsy when the clinical picture is unclear, when treatment fails or when neoplasia is suspected.

Not every uncomplicated textbook case needs repeated biopsy.

What Happens During a Vulvar Biopsy?

The area is usually numbed using local anaesthetic.

A small piece of tissue is removed and sent for histopathological examination.

The specimen may help distinguish LS from:

• lichen planus,
• dermatitis,
• psoriasis,
• vulvar intraepithelial neoplasia,
• cancer,
• other vulvar diseases.

Patients sometimes fear that biopsy itself will “spread” a disease.

It does not.

When medically indicated, biopsy can be extremely valuable.

Do Blood Tests Diagnose Lichen Sclerosus?

No blood test confirms vulvar lichen sclerosus.

Laboratory testing may instead be used to investigate associated conditions when clinically appropriate.

For example, thyroid-function testing may be considered when history or symptoms raise suspicion of thyroid disease.

But the diagnosis of LS itself rests mainly on clinical evaluation and, when necessary, histopathology.

Treatment of Vulvar Lichen Sclerosus

The most important evidence-based treatment is a potent or ultrapotent topical corticosteroid ointment.

For vulvar disease, clobetasol propionate 0.05% ointment is widely regarded as standard first-line treatment.

Modern reviews continue to describe potent/ultrapotent topical corticosteroids as the gold-standard therapy.

This is one of the areas where patients are sometimes unnecessarily frightened by the word “steroid.”

Used correctly on lichen sclerosus under medical guidance, potent topical steroid treatment can:

• control itching,
• reduce inflammation,
• help heal fissures,
• prevent progression,
• reduce scarring,
• potentially reduce cancer risk.

A Typical Clobetasol Treatment Schedule

A commonly used three-month induction schedule for adult female anogenital LS has traditionally involved:

Month 1: once daily
Month 2: every other day
Month 3: approximately twice weekly

using clobetasol propionate 0.05% ointment.

This regimen is described in the clinical literature, although the exact amount and schedule should always be individualized by the treating clinician.

Some women require different schedules according to:

• severity,
• disease activity,
• response,
• anatomical site.

Patients should therefore follow their own prescription rather than copying another patient's schedule.

Why Ointment Is Often Preferred

For vulvar LS, ointments are often preferred over creams because they generally contain fewer irritating additives and provide a protective barrier.

The affected skin is already sensitive.

Products containing fragrance, alcohol or multiple additives may sting.

Is a Strong Steroid Dangerous on the Vulva?

This is one of the most common fears.

Unsupervised or inappropriate long-term steroid use can certainly cause problems.

However, untreated active lichen sclerosus also causes tissue damage.

When an ultrapotent corticosteroid is used in the correct quantity and schedule for confirmed LS, the benefits are well established.

The important issue is correct diagnosis, correct application and follow-up—not avoidance of an effective medicine simply because it is called a steroid.

Maintenance Treatment

Lichen sclerosus is chronic.

Therefore, improvement after three months does not necessarily mean that the disease can be permanently forgotten.

Some patients require low-frequency maintenance corticosteroid treatment to prevent relapse.

The exact schedule depends upon:

• activity of the disease,
• recurrent symptoms,
• examination findings,
• previous scarring.

Long-term disease control is particularly important because effective anti-inflammatory treatment appears to reduce the risk of malignant progression.

Follow-Up Is Part of Treatment

A patient should not receive clobetasol once and never have her vulva examined again.

Follow-up allows the clinician to assess:

• symptom control,
• correct steroid technique,
• inflammation,
• scarring,
• anatomy,
• new suspicious lesions,
• sexual function.

Long-term surveillance is particularly important because LS remains a chronic condition even when symptoms disappear.

Vulvar Self-Awareness

I encourage women to become familiar with what their normal vulva looks like.

This is different from repeatedly checking it anxiously.

Occasional visual self-examination can help identify a new:

• ulcer,
• lump,
• thickened area,
• persistent wound,
• major colour or texture change.

A small mirror may be useful.

Anything new and persistent should be shown to the treating clinician.

Gentle Vulvar Skin Care

Skin care is an important supportive measure.

Useful measures include:

• avoiding perfumed soaps,
• avoiding harsh antiseptic washes,
• avoiding scented intimate hygiene products,
• using a gentle soap substitute or emollient,
• gently drying after washing,
• using a bland barrier ointment when advised,
• reducing rubbing and scratching.

The NHS specifically recommends emollient soap substitutes, barrier preparations and avoidance of scented soaps and other irritants.

The Vulva Does Not Need Aggressive Cleaning

Many patients respond to itching by washing repeatedly.

Unfortunately, excessive cleaning may increase:

• dryness,
• irritation,
• inflammation.

The vulva requires gentle care, not sterilization.

Internal vaginal douching is not a treatment for lichen sclerosus.

Clothing and Friction

Some women find symptoms are aggravated by:

• very tight trousers,
• tight synthetic underwear,
• prolonged cycling,
• activities causing repeated vulvar friction.

Loose, comfortable clothing and breathable underwear can reduce mechanical irritation during active disease.

The aim is comfort—not a permanent lifestyle prohibition.

Emollients and Barrier Ointments

Simple bland emollients may support the vulvar skin barrier.

They can reduce:

• friction,
• urine-related irritation,
• dryness.

These do not replace the anti-inflammatory steroid when LS is active.

They are supportive.

Sexual Intercourse With Lichen Sclerosus

Women frequently ask:

“Can I still have sex?”

Yes, if sexual activity is comfortable.

LS is not contagious and is not sexually transmitted.

However, intercourse should not be forced through active fissuring or significant pain.

If penetration repeatedly tears the skin, the disease needs better control and the anatomy should be assessed.

Lubricants

A suitable lubricant can reduce friction during intercourse.

The NHS specifically recommends lubricant when sexual activity is uncomfortable.

Lubricant is particularly helpful when LS coexists with:

• menopause,
• vaginal dryness,
• breastfeeding-related low estrogen.

But lubricant alone will not adequately treat active inflammatory LS.

What If Intercourse Remains Painful After the Skin Improves?

Sometimes the visible LS improves but sexual pain remains.

Possible explanations include:

• scar tissue,
• introital narrowing,
• pelvic-floor overactivity,
• fear-related muscular guarding,
• vulvodynia,
• menopausal dryness,
• another pelvic condition.

This is why sexual pain requires reassessment rather than endlessly increasing steroid application.

Pelvic-Floor Physiotherapy

Chronic vulvar pain can cause the pelvic-floor muscles to tighten defensively.

A woman expects penetration to hurt.

The muscles contract.

Penetration becomes even more painful.

A pelvic-floor physiotherapist may help with:

• muscular relaxation,
• breathing,
• desensitization,
• scar mobility,
• coordination.

This can be particularly valuable when inflammatory disease is controlled but penetration remains difficult.

Dilators

Selected women with introital narrowing or pain-related pelvic-floor guarding may benefit from graduated vaginal dilators under professional guidance.

The purpose is not forcibly to stretch active LS.

Treatment should begin only when inflammation is adequately controlled and the clinician has identified that gradual rehabilitation is appropriate.

When Is Surgery Required?

Medication is the main treatment for active LS.

Surgery is generally reserved for complications such as:

• severe introital narrowing,
• significant labial adhesions,
• clitoral phimosis,
• anatomical obstruction,
• suspected or confirmed malignancy.

The NHS notes that severe scarring may occasionally require surgery to improve a narrowed vaginal opening.

Surgery does not eliminate the underlying inflammatory tendency.

Long-term medical follow-up remains necessary.

Tacrolimus and Pimecrolimus

Topical calcineurin inhibitors such as:

• tacrolimus,
• pimecrolimus

may be considered as alternative or second-line treatment in selected patients when corticosteroid treatment cannot be used or is insufficient.

However, ultrapotent topical corticosteroids remain the best-established first-line therapy.

Alternative treatments should therefore not automatically replace properly used clobetasol.

Laser and Other New Treatments

Various treatments—including lasers, platelet-rich plasma and other procedures—have been promoted for vulvar LS.

Patients should be cautious about advertising claims.

None should be assumed to replace established anti-inflammatory treatment unless supported by convincing evidence and appropriate specialist guidance.

At present, topical corticosteroids remain the standard against which other treatments are compared.

A randomized clinical trial comparing UVA1 phototherapy with clobetasol found clinically important improvement with clobetasol and supported potent topical corticosteroid therapy as first-line treatment.

Sexual Function and Lichen Sclerosus

A woman may experience several changes:

• reduced desire because she expects pain,
• reduced lubrication,
• painful penetration,
• fear of tearing,
• orgasmic difficulty,
• reduced sexual activity,
• avoidance of intimacy.

Current research strongly demonstrates that sexual health deserves routine attention in LS.

A systematic review estimated sexual dysfunction in nearly 60% of women represented in included studies.

More recent research has continued to show difficulties with lubrication, intercourse-related pain and psychological distress, with more severe LS associated with poorer sexual quality of life.

Sexual Pain Does Not Mean a Woman Has “Lost Interest”

If intercourse repeatedly causes pain, avoidance is a rational protective response.

This should not automatically be interpreted by a partner as rejection.

The cycle may be:

inflammation → pain → fear → pelvic tension → greater pain → sexual avoidance.

Treatment should address both disease activity and the consequences of repeated pain.

Psychological Impact

Vulvar disease can affect a woman's self-image.

Some patients fear that their genital appearance has become abnormal.

Others worry:

“Will my husband think I have an infection?”

Some develop fear of cancer.

Others stop sexual activity altogether.

Proper counselling is therefore part of treatment.

We should explain clearly:

• what LS is,
• what it is not,
• how it is treated,
• why follow-up is required,
• what changes need urgent review.

Knowledge usually decreases fear.

Lichen Sclerosus and Menopause

LS is particularly common after menopause.

At the same time, menopause can cause genitourinary syndrome of menopause, including:

• vaginal dryness,
• burning,
• reduced elasticity,
• painful intercourse.

A woman can therefore have both conditions simultaneously.

The steroid controls LS inflammation.

Hormonal or non-hormonal treatment may separately be required for menopausal vaginal dryness.

One should not expect clobetasol to treat every cause of intercourse-related discomfort.

Does Lichen Sclerosus Cause Infertility?

Lichen sclerosus primarily affects the vulvar skin.

It does not usually damage the ovaries, fallopian tubes or uterus, and therefore it is not considered a common direct cause of infertility.

However, severe LS may indirectly interfere with conception if:

• intercourse is extremely painful,
• the vaginal entrance has become narrowed,
• sexual activity becomes impossible.

These are sexual-function barriers rather than destruction of fertility itself.

Lichen Sclerosus During Reproductive Years

A woman who wants pregnancy should not assume that having LS means she cannot conceive.

The more important priorities are:

• good disease control,
• comfortable intercourse,
• appropriate vulvar follow-up,
• individualized obstetric care during pregnancy.

Women with significant previous scarring should discuss pregnancy and delivery planning with their obstetric team.

Lichen Sclerosus in Children

Although this article primarily concerns adult women's sexual and reproductive health, LS can also occur in girls.

Symptoms may include:

• itching,
• soreness,
• white vulvar skin,
• painful urination,
• constipation due to painful fissuring.

Because genital symptoms in children require especially careful evaluation, diagnosis should be made by an appropriately experienced clinician.

Lichen Sclerosus Is a Long-Term Condition

At present there is no universally established permanent cure that guarantees LS can never recur.

However, this should not make patients pessimistic.

With appropriate treatment, many women achieve:

• excellent symptom control,
• healing of active fissures,
• reduced inflammation,
• preserved anatomy,
• comfortable daily life.

The NHS summarizes this well: LS cannot currently be cured in the strict sense, but treatment can effectively relieve and control symptoms.

Unani Perspective on Vulvar Discomfort and Lichen Sclerosus

As a physician trained in Unani medicine, I consider vulvar discomfort not simply as a local complaint but within the woman's broader health.

Traditional Unani medicine discusses vulvar itching and irritation under concepts including Hikkat-ul-Farj, while women's reproductive conditions are assessed in relation to local inflammation, constitutional state, humoral balance, menstrual and reproductive function, digestion, elimination, metabolic health and general wellbeing.

This holistic approach can be useful when applied responsibly.

However, an important distinction must be made:

Hikkat-ul-Farj describes a symptom complex such as vulvar itching. It is not automatically equivalent to modern histologically or clinically diagnosed lichen sclerosus.

Modern LS is a specific chronic inflammatory dermatosis with recognized risks of scarring and vulvar malignancy.

Therefore, the diagnosis should not be replaced by traditional terminology alone.

What Does Unani Research Show?

Direct high-quality clinical evidence specifically evaluating Unani medicine for confirmed vulvar lichen sclerosus remains very limited.

A small preliminary Unani study evaluated oral Post-e-Anar and local Safoof-e-Zaj in only 15 women with vulvar itching and vaginal discharge and reported symptomatic improvement. However, the patients were enrolled for vulvar pruritus, not confirmed lichen sclerosus, so this study cannot be used as evidence that the same regimen treats LS.

There are also Unani reports concerning lichen simplex chronicus, but lichen simplex chronicus and lichen sclerosus are different diseases. A 2024 Unani case report concerned vulvar lichen simplex chronicus—not lichen sclerosus—and therefore should not be extrapolated as LS treatment evidence.

The Ministry of AYUSH research portal contains a growing body of clinical and experimental Unani research, but a strong evidence base for specific Unani treatment of vulvar LS has not yet been established.

Scientific honesty about this distinction strengthens rather than weakens integrative Unani practice.

How Unani Medicine May Be Useful in an Integrative Approach

After the diagnosis has been established and appropriate anti-inflammatory treatment initiated, individualized Unani care may have a supportive role in selected patients.

Depending upon the woman's broader condition, the objectives may include attention to:

• general wellbeing,
• associated digestive complaints,
• sleep,
• stress,
• metabolic health,
• constitutional factors,
• accompanying reproductive-health concerns,
• other symptoms that influence sexual wellbeing.

But Unani medicines should not be used to delay:

• potent topical steroid treatment,
• biopsy of a suspicious lesion,
• cancer surveillance,
• treatment of secondary infection,
• surgical assessment of severe scarring.

This is particularly important because adequately suppressing LS inflammation helps protect the vulvar tissue.

My Integrative Approach at Saira Health Care

At Saira Health Care, my approach to lichen sclerosus begins with a fundamental question:

Is this actually lichen sclerosus?

I do not consider persistent vulvar itching automatically to be:

• fungal infection,
• leucorrhoea,
• allergy,
• sexual infection.

Depending on the presentation, assessment may include:

• detailed history,
• inspection of vulvar skin,
• assessment of the clitoris and labia,
• evaluation of fissures,
• assessment of introital narrowing,
• evaluation for infection when appropriate,
• review of menopausal symptoms,
• sexual-pain assessment,
• thyroid or other systemic evaluation when clinically indicated,
• biopsy or specialist referral for atypical or suspicious lesions.

Once the diagnosis is established, appropriate evidence-based anti-inflammatory treatment should form the foundation of care.

Unani principles may then be integrated supportively according to the patient's broader health and reproductive needs.

Special Attention to Sexual Health at Saira Health Care

Because my clinical work is focused particularly on Sexual Disorders & Infertility, I believe that treating LS should include questions that are sometimes omitted in a routine skin consultation:

• Does intercourse hurt?
• Where does it hurt?
• Has the vaginal opening become tighter?
• Are fissures occurring after sex?
• Has sexual desire decreased because of fear?
• Can the patient achieve comfortable penetration?
• Does the clitoral region feel painful or restricted?
• Is menopause-related vaginal dryness also present?
• Has the woman stopped intercourse completely?
• Is conception being affected because intercourse is difficult?

These questions are clinically relevant.

Sexual function is not an optional extra.

Lichen Sclerosus and Infertility Care

When a patient with LS is also undergoing infertility treatment, it is important to avoid assuming that LS explains the infertility.

The fertility evaluation should still examine appropriate factors such as:

• ovulation,
• ovarian reserve where indicated,
• tubal status,
• uterus,
• partner semen parameters,
• sexual timing.

LS may interfere with comfortable intercourse, but it does not ordinarily explain ovarian or tubal infertility.

This distinction prevents unnecessary anxiety.

When I Refer a Patient

Good medical care includes knowing when multidisciplinary management is appropriate.

Depending upon the case, a woman may benefit from assessment by:

• gynecologist,
• dermatologist with vulvar expertise,
• gynecologic oncologist,
• pelvic-floor physiotherapist,
• psychosexual therapist,
• endocrinologist.

I consider referral particularly important when there is:

• uncertain diagnosis,
• poor response to treatment,
• severe anatomical scarring,
• suspicious lesion,
• persistent ulcer,
• abnormal biopsy,
• complex sexual pain.

Integrative care should expand appropriate medical care—not isolate the patient from it.

What Patients Should Avoid

I generally advise patients with suspected or confirmed LS to avoid:

• repeatedly using antifungal medicines without diagnosis,
• scratching the vulva,
• perfumed intimate washes,
• strong antiseptics,
• repeated vaginal douching,
• aggressive scrubbing,
• unnecessary topical herbal products directly on damaged skin,
• self-prescribed steroid combinations,
• delaying evaluation of a persistent ulcer,
• discontinuing prescribed treatment as soon as itching disappears,
• forcing painful intercourse.

Persistent vulvar symptoms deserve structured treatment.

Why Combination Steroid-Antifungal Creams Can Be Misleading

In India, combination creams containing:

• steroids,
• antifungals,
• antibiotics

are widely available.

A patient may temporarily improve because the steroid suppresses inflammation.

She then assumes she had a fungal infection.

The actual LS remains undiagnosed.

Unsupervised combination creams can therefore confuse the clinical picture.

The correct drug, potency, dose and duration should be selected for the diagnosed disease.

Why Treatment Adherence Matters

LS treatment fails for several avoidable reasons.

Sometimes the woman is frightened of clobetasol and uses only a tiny amount once every few weeks.

Sometimes the medicine is applied to the wrong anatomical area.

Sometimes treatment is stopped immediately after itching improves even though inflammation remains active.

Good counselling should therefore include:

• exactly where to apply treatment,
• how much to use,
• how often,
• when to reduce frequency,
• when to return for review.

Patient education is part of the prescription.

Frequently Asked Questions

Is lichen sclerosus a sexually transmitted disease?

No.

It is not an STI and cannot be transmitted to a partner through intercourse.

Is LS caused by poor hygiene?

No.

Poor hygiene does not cause LS. In fact, excessive washing can irritate already inflamed vulvar skin.

Is lichen sclerosus a fungal infection?

No.

LS is an inflammatory skin disorder.

Candida can coexist in some patients, but antifungal treatment does not replace treatment for LS.

Why has my vulvar skin become white?

White or porcelain-coloured skin is a characteristic feature of LS, although not every white vulvar lesion represents LS.

A clinical examination is necessary.

Can lichen sclerosus cause severe itching?

Yes.

Itching is one of the most common symptoms and may be severe enough to disturb sleep.

Can it cause burning?

Yes.

Inflammation, fissures and urine touching damaged skin may produce significant burning or soreness.

Can LS make intercourse painful?

Yes.

Inflammation, fissuring, scarring and narrowing can cause dyspareunia. Sexual dysfunction is common among women with LS.

Can LS make the vaginal opening smaller?

Long-standing scarring can narrow the vaginal entrance, even though the disease primarily affects the vulva rather than the internal vagina.

Can lichen sclerosus affect the clitoris?

Yes.

Scarring can affect the clitoral hood and sometimes cause partial covering or restriction of the clitoris.

Will clobetasol make the vulvar skin thinner?

When used incorrectly, topical steroids can have adverse effects.

However, LS itself produces thinning, fragility and scarring. Properly prescribed ultrapotent topical corticosteroid therapy is the established first-line treatment and helps control the disease.

Does lichen sclerosus cause cancer?

LS itself is not vulvar cancer, but it increases the long-term risk of vulvar squamous-cell carcinoma.

Most women with LS do not develop cancer.

Appropriate treatment and long-term surveillance are important.

What percentage of women develop vulvar cancer?

Estimates differ between populations and studies.

A systematic review involving more than 14,000 women with LS and no previous vulvar neoplasia found vulvar cancer in approximately 2.2% overall. Risk varies according to age, disease control and other factors and should therefore not be converted into an exact prediction for an individual patient.

Does using treatment lower cancer risk?

Available evidence suggests that adequate ultrapotent topical corticosteroid treatment is associated with lower vulvar cancer risk, which is another reason long-term disease control matters.

Do I need a biopsy?

Not necessarily.

Many classic cases can be diagnosed clinically.

Biopsy becomes particularly important if the diagnosis is uncertain, treatment fails or a suspicious lesion raises concern for precancer or cancer.

Can LS disappear completely?

Symptoms may become completely controlled, but LS is generally considered a chronic condition capable of recurring.

Long-term monitoring is therefore recommended.

Does lichen sclerosus cause infertility?

Usually not directly.

The ovaries, tubes and uterus are generally unaffected.

Severe sexual pain or narrowing may indirectly interfere with intercourse and conception.

Can I have sex if I have lichen sclerosus?

Yes, when comfortable.

LS is not contagious.

During active fissuring or severe pain, however, forcing penetration can worsen trauma.

Disease control and appropriate lubrication are important.

Should my husband be treated?

No treatment is required simply because his partner has LS.

It is not an infection that is being passed between partners.

Can menopause make symptoms worse?

Menopause-related dryness can coexist with LS and make vulvar or intercourse-related discomfort more noticeable.

Both problems may need separate treatment.

Does every vulvar itch mean LS?

No.

Other possibilities include:

• candidiasis,
• dermatitis,
• lichen simplex chronicus,
• lichen planus,
• psoriasis,
• menopause-related atrophy,
• vulvodynia,
• precancerous disease.

Persistent symptoms should be examined.

Can Unani medicine cure lichen sclerosus?

There is currently insufficient high-quality direct clinical evidence to claim that a specific Unani medicine cures confirmed vulvar lichen sclerosus.

Unani medicine can be incorporated supportively within an individualized treatment plan, but it should not replace established anti-inflammatory therapy, biopsy when indicated or long-term cancer surveillance.

A Message From Dr. Nizamuddin Qasmi

When a woman comes to me after years of vulvar itching, I often find that she has tried almost everything except receiving a precise diagnosis.

She may have used antifungals.

She may have changed soaps repeatedly.

She may have washed the area more and more because she believes something is “unclean.”

She may have stopped intercourse because the skin tears.

She may even be afraid that she has an infection she could give to her partner.

If the problem is lichen sclerosus, none of these assumptions addresses the actual disease.

I explain to my patients:

This is an inflammatory skin disorder. It is not a sign of poor hygiene. It is not a sexual infection. And you should not feel ashamed of it.

But I also explain something equally important:

Do not neglect it simply because the itching improves for a few days.

Long-standing inflammation can scar the vulva.

It can affect comfortable sexual activity.

And it slightly but importantly increases the risk of vulvar cancer.

For me, successful treatment therefore means more than making itching disappear.

I want to:

• control inflammation,
• protect the anatomy,
• prevent avoidable scarring,
• restore sexual comfort wherever possible,
• monitor for suspicious changes,
• address the woman's reproductive and emotional concerns.

That is the difference between simply treating a symptom and caring for the whole patient.

Saira Health Care's Approach to Lichen Sclerosus and Vulvar Discomfort

At Saira Health Care, our work in sexual and reproductive health allows vulvar disease to be viewed in its complete context.

A woman with LS may need help with:

• chronic itching,
• painful intercourse,
• vulvar fissures,
• menopausal dryness,
• pelvic-floor dysfunction,
• sexual fear,
• relationship difficulties,
• infertility concerns.

The treatment plan should therefore be individualized.

Modern evidence-based therapy remains central to controlling LS.

Where suitable, Unani principles may be incorporated to support broader health and associated complaints.

The objective should never be to choose between modern diagnosis and traditional medicine.

The objective should be:

accurate diagnosis, safe disease control, appropriate surveillance and whole-person care.

When Should You Seek Prompt Medical Review?

Arrange medical assessment particularly if you develop:

• a new vulvar lump,
• persistent ulcer,
• wound that does not heal,
• a new thickened area,
• recurrent unexplained bleeding,
• rapidly changing vulvar lesion,
• severe scarring,
• inability to have intercourse because of narrowing,
• difficulty urinating,
• worsening symptoms despite appropriate treatment.

These findings do not necessarily mean cancer, but they warrant examination.

Latest Medical Understanding

Modern research increasingly supports three important messages.

First: LS is an inflammatory and probably immune-mediated disease.

It should not be managed as chronic infection.

Second: adequate treatment matters beyond symptom relief.

Effective ultrapotent topical steroid treatment can reduce inflammation, preserve anatomy and appears to reduce the risk of progression to vulvar cancer.

Third: sexual health is part of the disease.

Research consistently demonstrates a substantial burden of sexual dysfunction, pain and sexual distress among affected women.

A modern LS consultation should therefore not stop after examining the white patch.

Conclusion

Lichen sclerosus is a chronic inflammatory skin disease affecting the vulva and surrounding genital skin.

It commonly causes:

• vulvar itching,
• white skin changes,
• burning,
• soreness,
• fissures,
• bruising,
• fragile skin,
• painful intercourse.

Without adequate control, chronic inflammation can result in:

• vulvar scarring,
• loss of normal labial anatomy,
• clitoral adhesions,
• narrowing of the vaginal opening,
• sexual dysfunction.

The disease is not contagious, not sexually transmitted and not caused by poor hygiene.

Diagnosis is often clinical, but biopsy is important when the diagnosis is uncertain, treatment fails or cancer or precancer is suspected.

Potent or ultrapotent topical corticosteroid therapy—particularly clobetasol propionate 0.05% ointment—remains the established first-line treatment. Appropriate maintenance treatment and long-term surveillance are important because LS is chronic and is associated with an increased risk of vulvar squamous-cell carcinoma.

Sexual health should be discussed openly. A significant proportion of affected women experience dyspareunia and other sexual difficulties, and treatment may sometimes need to include lubrication, management of menopausal dryness, pelvic-floor rehabilitation, counselling or treatment of scar-related anatomical complications.

From the Unani perspective, chronic vulvar discomfort can be considered within the woman's broader constitutional, reproductive and general health. However, direct high-quality evidence for Unani treatment specifically for confirmed vulvar lichen sclerosus is currently insufficient. Existing Unani research on vulvar pruritus or lichen simplex chronicus should not be incorrectly presented as proof of treatment for LS.

At Saira Health Care, my preferred approach is therefore genuinely integrative:

diagnose the disease correctly, control inflammation with proven therapy, protect the vulvar anatomy, monitor long-term cancer risk, address sexual and reproductive concerns, and incorporate individualized Unani supportive care where clinically appropriate.

The most important message I want every patient to remember is:

Persistent vulvar itching is not something a woman should simply tolerate—and it should not automatically be treated as fungal infection.

Early diagnosis can prevent years of discomfort and many avoidable complications.

About the Author

Dr. Nizamuddin Qasmi

Founder & Chief Physician, Saira Health Care
Focused Practice in Sexual Disorders & Infertility

Qualifications & Professional Training

BUMS — Hamdard University, Delhi
MD
CGO
Certificate in Infertility — MGBIMS, Delhi
Certificate in Urology — London, UK
Masters in Male Infertility — MasterHealthPro (HealthPro)
Integrated Sexual and Reproductive Health (ISRH) — UNFPA

Dr. Nizamuddin Qasmi's clinical work at Saira Health Care focuses on sexual disorders, reproductive-health concerns and infertility. His approach emphasizes careful diagnosis, individualized management and responsible integration of Unani principles with appropriate contemporary medical investigation and specialist care.

Particular attention is given to the impact of chronic reproductive and genital disorders on sexual comfort, intimacy, fertility concerns and overall quality of life.

Medical Disclaimer

This article is intended for health education and general public awareness. It does not establish an individual diagnosis and does not replace examination, biopsy or treatment by an appropriately qualified healthcare professional.

Persistent vulvar itching, white patches, fissures, ulcers or pain can result from several different conditions.

Lichen sclerosus requires appropriate diagnosis, anti-inflammatory treatment and long-term follow-up because chronic uncontrolled disease can cause scarring and is associated with an increased risk of vulvar squamous-cell carcinoma.

A new vulvar lump, persistent ulcer, non-healing wound, abnormal thickened area, unexplained bleeding or lesion that changes despite treatment should be evaluated promptly.

Patients should not discontinue prescribed topical corticosteroid treatment, begin hormonal or herbal therapy, or repeatedly self-treat presumed fungal infection without appropriate medical guidance.