Lichen simplex chronicus


Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Lichen simplex chronicus (LSC, or neurodermatitis circumscripta) is characterized by pruritic, lichenified plaques that most often occur on the neck, anterior tibias, ankles, wrists, and anogenital region in response to chronic localized scratching or rubbing. Primary LSC evolves on apparently normal skin from pruritus of unclear etiology, whereas secondary LSC is superimposed upon preexisting dermatoses, particularly atopic dermatitis, psoriasis, or dermatophytosis.

Psychogenic factors can play an important contributory role, and psychopathology, such as anxiety and obsessive–compulsive disorder, have been found at higher rates in LSC groups compared with control groups. An association between longstanding LSC on the limbs and chronic cervical or lumbar radiculopathy has been reported.

Management Strategy

The objective of treatment is to remove environmental triggers, break the itch–scratch cycle, and treat any underlying cutaneous or systemic disease. Patients’ understanding of their role in the itch–scratch cycle is essential to enlisting their cooperation in avoiding scratching, thereby facilitating a more complete and permanent recovery. Recurrences are frequent, and complete resolution often requires multiple approaches to therapy. Environmental triggers such as harsh skin care products or bathing regimens, friction, and excessive moisture or dryness should be minimized or eliminated. High-potency topical corticosteroids, such as clobetasol, diflorasone, and betamethasone, as creams or ointments, are the initial treatments of choice. The potency and/or frequency of application of topical corticosteroids should be decreased as the lesion resolves to avoid atrophy with long-term use. Adjunctive therapies, such as doxepin cream , may be introduced if topical corticosteroids are not easily tapered. Occlusion has been found to be a successful aid to therapy because it provides a physical barrier to prevent scratching and permits enhanced and prolonged application of topical medications. Occlusive plastic film or hydrocolloid dressings have been used alone or over mid-potency corticosteroids. Flurandrenolide tape is very effective as both an occlusive and antiinflammatory measure. It is typically changed once daily, although a short occlusion-free period each day will help minimize the side effects of occlusion therapy. In chronic, difficult cases on the lower leg, an Unna boot (a gauze roll impregnated with zinc oxide) may be applied for up to 1 week, provided there is no concomitant infection of the occluded area. Calcineurin inhibitors such as tacrolimus and pimecrolimus also have been successfully used as monotherapy to treat LSC and offer a good alternative for treatment in steroid-sensitive areas such as the genitalia.

Intralesional injections of triamcinolone at monthly intervals can rapidly induce involution. Although highly effective, repeated injections may cause depigmentation or thinning of the epidermis; therefore, other therapies should be used if several treatments with intralesional corticosteroids do not clear LSC. Transcutaneous pneumatic injection devices can decrease pain and increase the efficacy of intralesional injections. Secondary infections should be treated with appropriate topical or systemic antibiotics. Intralesional botulinum toxin has been reported to offer lasting relief in patients with recalcitrant LSC.

A variety of other therapies have been reported to be effective in the management of LSC. Doxepin cream , capsaicin cream, and aspirin/dichloromethane solution are occasionally of value as monotherapy but are probably best used as adjunctive therapy when LSC does not quickly clear with topical or intralesional corticosteroids. Oral antihistamines may be useful for their sedative effect on patients who scratch during their sleep. Surgical excision has been used infrequently to treat nodular LSC. Non-invasive transcutaneous electrical nerve stimulation ( TENS ) has emerged as a possible effective treatment for pruritic dermatoses such as LSC. Pruritus and neuralgia of varying etiologies have responded to the anticonvulsant gabapentin , which may explain its usefulness in treating LSC. In more severe or recalcitrant conditions, psychotherapy and/or the use of psychopharmacologic agents may be needed for sustained improvement. Benzodiazepines , amitriptyline , pimozide , and doxepin have been used to treat neurotic excoriations and severe neurodermatitis. Neurodermatitis has improved with habit-reversal behavioral therapy , biofeedback , and hypnotherapy in certain individuals. Acupuncture and electroacupuncture are labor intensive but have been effective in treating some cases of LSC. Alitretinoin was used successfully in a single case of LSC on the hands. Adjuvant therapy with narrowband ultraviolet B ( UVB ) phototherapy may prove useful for cases of vulvar LSC. Focused ultrasound therapy has also been shown to be effective for vulvar LSC, although this modality is not widely available and requires general anesthesia.

Specific Investigation

  • Skin biopsy with periodic acid–Schiff stain

LSC that is atypical in appearance or poorly responsive to therapy should be biopsied and cultured to look for preexisting dermatoses and underlying cutaneous malignancy or infection. Squamous cell carcinoma, though rare, has been reported to develop within longstanding LSC. Lesions should be surveyed carefully, and fixed plaques or proliferating nodules should raise suspicion for malignant transformation.

First-Line Therapies

  • Topical corticosteroids

  • A

  • Occlusion – flurandrenolide tape

  • C

  • Intralesional corticosteroids

  • C

  • Transcutaneous pneumatic injection

  • E

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

Datz B, Yawalkar S. J Am Acad Dermatol 1991; 25: 1157–60.

In 127 patients with chronic, localized atopic dermatitis or LSC, healing was reported in 65.1% of those treated with halobetasol propionate ointment (a superpotent group I topical corticosteroid) compared with 54.7% of those treated with clobetasol propionate (a weaker group I topical corticosteroid). Success rates, early onset of therapeutic effect, and adverse effects were similar in the two treatment groups.

Group I topical corticosteroids should not be used for more than 2 weeks. They are therefore best combined with adjuvant therapies such as topical doxepin or pimecrolimus cream.

Flurandrenolone tape in the treatment of lichen simplex chronicus

Bard JW. J Ky Med Assoc 1969; 67: 668–70.

Of the 18 patients in the study, 10 used flurandrenolone tape, and eight used a topical corticosteroid preparation without occlusion. Lasting remissions were seen in 70% of those using the tape versus 25% of those using topical corticosteroids without occlusion. Duration of therapy is not mentioned.

The use of occlusion with topical corticosteroids is considered the treatment of choice for LSC despite the lack of adequate clinical trials .

Update on intralesional steroid: focus on dermatoses

Richards RN. J Cutan Med Surg 2010; 14: 19–23.

In the absence of any formal clinical studies since the 1960s, Richards compiled a review of peer-reviewed literature, six standard dermatology textbooks, and questionnaires from dermatologists to summarize the available information on the use of intralesional steroids in localized dermatoses. Pooled clinical experience is presented in this review, which suggests that triamcinolone acetonide 2.5 mg/mL administered in total doses of 7.5–20 mg intralesionally every 3–4 weeks has proven to be a safe, economical, and highly effective treatment for localized dermatoses such as LSC.

Corticosteroid injections are considered first-line therapy despite the lack of adequate controlled clinical trials.

Less painful and effective intralesional injection method for lichen simplex chronicus

Jung HM, Eun SH, Lee JH, et al. J Am Acad Dermatol 2018; 79: e105–6.

Clinical Pearl discussing utilization of a transcutaneous pneumatic device to deliver triamcinolone 0.4 mg/mL at consistent quantities and depths. Each injection was spaced 2 cm apart. The authors reported significant efficacy 1 month after a single treatment to lesions that previously failed to respond to potent topical steroid application.

Second-Line Therapies

  • Doxepin cream

B
  • Pimecrolimus cream

C
  • Tacrolimus ointment

B
  • Capsaicin cream

E

The antipruritic effect of 5% doxepin cream in patients with eczematous dermatitis. Doxepin Study Group

Drake LA, Millikan LE. Arch Dermatol 1995; 131: 1403–8.

A multicenter, double-blind trial conducted to evaluate the safety and antipruritic efficacy of 5% doxepin cream in patients with LSC ( n = 136), nummular eczema ( n = 87), or contact dermatitis ( n = 86). Patients treated with doxepin versus vehicle had significantly greater pruritus relief. Of doxepin-treated patients, 60% experienced relief from pruritus within 24 hours with a response rate of 84% by the end of the study.

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