Approach
LSC can be a difficult condition to treat, causing frustration in both the patient and physician.[1] The main goals of treatment are to remove any triggering and exacerbating environmental factors, repair the barrier function of the skin, identify and treat any underlying dermatological or systemic condition that could be driving the condition in secondary LSC, and disrupt the itch-scratch cycle characteristic of LSC through reduction in the degree of skin inflammation and control of nocturnal pruritus.[2]
Although there is no standardised treatment for LSC and management of the condition is very much tailored to the individual patient, the mainstay of treatment involves the package of a topical corticosteroid, emollients, and lifestyle modification; a sedating agent for nocturnal pruritus; and the addition of an antipruritic for breakthrough pruritus as required.
Topical and intra-lesional corticosteroids
Topical corticosteroids
These are the preferred initial treatment in all adults and children >12 years of age.[6][22] It is generally considered to be more effective and equally safe to use a higher-potency topical corticosteroid for a short therapeutic period than a lower-potency preparation for a longer time.[2]
Potent topical corticosteroids such as fluocinonide or clobetasol should be prescribed for a maximum of 2 weeks' continuous use on any one lesion, with avoidance of the face and intertriginous areas, to avoid adverse effects, which include atrophy, striae, hypopigmentation, corticosteroid-induced folliculitis and rosacea (in facial locations), and corticosteroid-induced dermatophyte infections (tinea incognito).[2]
Any class I or II (potent) topical corticosteroid may be used, with class I more effective for thicker lesions of LSC.
Creams and ointments are appropriate for the body, while solutions or gels should be used on hairy areas such as the scalp. On eroded skin, ointments avoid the stinging and burning associated with creams, solutions, or gels.
To minimise the risk of topical corticosteroid-associated adverse effects, particularly atrophy and striae, the application frequency or potency should be decreased as the condition improves. When the long-term use of topical corticosteroids is indicated, as in the presence of an underlying chronic dermatosis, a corticosteroid-sparing agent such as a topical calcineurin inhibitor may be used in both adults and children.[29][30][31]
Due to the increased incidence of adverse effects related to high-potency topical corticosteroids, in children <12 years of age, a low- to mid-potency topical corticosteroid such as hydrocortisone or triamcinolone should be used.[2]
Intra-lesional corticosteroids
Triamcinolone acetonide can be used intra-lesionally as an alternative to high-potency topical corticosteroids if they prove to be ineffective, particularly for very thick plaques.[7][17]
If given at weekly intervals for periods of 6 to 8 weeks at a time, intra-lesional corticosteroids are efficacious in the treatment of LSC in adults and children >12 years of age.[32][33]
With improper technique and use, intra-lesional corticosteroid therapy may lead to adverse effects. If injected too superficially, too often, or for prolonged periods of time, intra-lesional corticosteroids can cause epidermal and dermal atrophy and depigmentation. If injected too deeply, they may cause fat atrophy. If injections are used on infected lesions, intra-lesional corticosteroids can lead to abscess formation, and tendons may weaken or rupture if injections are given over these structures.[12][34] Prolonged use may also result in adrenal suppression.
The risk of adverse effects can be reduced by using the lowest effective concentration of intra-lesional corticosteroid and ensuring they are not given more frequently than every 6 weeks.
Occlusion
Occlusion alone can be used in both adults and children and is an effective physical barrier against scratching.
Occlusion overlying a topical corticosteroid is appropriate in thickened lesions of LSC and when a topical corticosteroid alone is not optimally effective, as it increases the efficacy of these agents.[35] Topical corticosteroid-impregnated tapes such as flurandrenolone tape are available and have demonstrated positive therapeutic effects in the treatment of LSC.[7][36] Occlusion with a plastic film or hydrocolloid dressing such as Tegaderm or DuoDerm can be applied over topical corticosteroids, but this causes an increase in topical corticosteroid-associated adverse effects.[37] Therefore, this technique should be restricted to several hours per day for a maximum of 1 to 2 weeks at a time.
In recalcitrant disease involving the lower legs, an Unna boot (zinc-impregnated gauze roll dressing) can be applied for 1 week at a time to prevent scratching.[34]
Removal of exacerbating factors and repair and maintenance of the epidermal barrier
Environmental triggering and exacerbating factors such as dry or excessively moist skin, chronic friction from tight or rough clothing, and harsh skincare products should be eliminated in all patients. In patients with genital lichen simplex chronicus, especially vulvar disease, silk fabric underwear is less irritating than cotton fabric underwear and may improve the condition.[17][38]
The barrier function of the epidermis can be restored and maintained with the frequent application of bland, unperfumed emollient creams or ointments to moisturise the skin, and this should be done by all patients. The most efficacious time to apply an emollient is immediately after showering while the skin is still moist. Emollients should be used at least twice a day and more frequently if the patient is able.[2]
Treatment of any underlying dermatosis, systemic condition, or psychiatric disorder
Any underlying dermatosis including atopic dermatitis, allergic contact dermatitis, stasis dermatitis, superficial fungal (tinea and candidiasis) and dermatophyte infections, lichen sclerosis, viral warts, scabies, lice, an arthropod bite, and a cutaneous neoplasia or systemic condition causing pruritus such as renal failure, obstructive biliary disease (primary biliary cirrhosis and primary sclerosing cholangitis), Hodgkin's lymphoma, hyper- or hypothyroidism, and polycythaemia rubra vera should be identified and treated in the presence of secondary LSC in all patients to prevent re-establishment of the itch-scratch cycle following resolution of the acute episode.[1][2]
A flare of atopic dermatitis is a common cause of secondary LSC in children.
Underlying depression, anxiety disorder, obsessive-compulsive disorder, and a prominent itch-scratch cycle with intractable daytime pruritus should be treated with psychopharmacology and psychological therapy.
The tricyclic antidepressant clomipramine or an appropriate selective serotonin-reuptake inhibitor (SSRI; fluoxetine, paroxetine, sertraline) should be prescribed following specialist psychiatry advice.[2][39][40][41]
Cognitive behavioural therapy has also been found to be effective in the treatment of LSC.[42][43][44]
Sedating agents
LSC is associated with significant nocturnal pruritus that occurs only in the lighter stages of sleep.[18] Sedatives increase the ratio of deep to light sleep and are therefore the preferred treatment for nocturnal pruritus.[2] Because of the possible risk of habituation with conventional sedatives such as benzodiazepines, older-generation sedating antihistamines such as hydroxyzine (in both adults and children) and tricyclic antidepressants such as doxepin (in adults only) are the preferred agents.[2][17] Doxepin has the benefit of a longer half-life and is thus more useful for patients who are woken during the night with pruritus, as it helps patients to stay asleep throughout the night.[45]
These drugs should be given 2 hours before going to bed to reduce the risk of a morning 'hangover' with sedation, a dry mouth, and blurred vision.[2] Lower doses should be considered in older patients, as they are more likely to experience central nervous system depressive adverse effects, including confusion.
Topical calcineurin inhibitors
When long-term use of topical corticosteroids is indicated, as in the presence of an underlying chronic dermatosis, topical calcineurin inhibitors may be used as corticosteroid-sparing agents in both adults and children to reduce the risk of topical corticosteroid-associated adverse effects, particularly atrophy and striae.[29][30][31] Topical calcineurin inhibitors are prescribed in conjunction with pulsed topical corticosteroids in a regimen involving the use of topical calcineurin inhibitors on weekdays and topical corticosteroids on weekends.
These drugs can also be used on facial, intertriginous, and genital lesions in both adults and children, as the application of topical corticosteroids should be avoided in these areas where possible.[31]
Adverse effects of topical calcineurin inhibitors include transient skin burning, which can limit their use in some patients, and increased risk of local skin infections at the site of application. While cases of malignancy have been reported in patients who have used topical calcineurin inhibitors, there is no clinical evidence to establish that treatment with these drugs increases the risk of malignancy.[46]
Topical antipruritics
Topical capsaicin (in both adults and children >2 years of age) or topical doxepin (in adults only) can be added to the treatment regimen of LSC for relief of breakthrough pruritus despite treatment with topical corticosteroids.[47][48] The adverse effects of burning and stinging after application of capsaicin may limit its use in some patients, and doxepin may cause allergic contact dermatitis, especially when used on inflamed skin.[49]
Cryosurgery
Cryosurgery is an effective adjunct to high-potency topical corticosteroids for small localised lesions of LSC in adults and children >12 years of age.[50] It is typically performed with liquid nitrogen using either a cotton-tipped applicator or hand-held spray delivery device.
Complications include blister formation, haemorrhage, infection, excessive granulation tissue formation, pigmentation abnormalities, and altered sensation. Avoiding freeze cycles of >30 seconds and deep freezing over nerve bundles can reduce many of its complications. As pigmentation abnormalities are very common with the use of cryosurgery in dark-skinned people, consideration of an alternative form of treatment in these patients is warranted.
Light therapy
UV light therapy with UV-A and psoralen (PUVA) or UV-B (narrow or broadband) can be used in adults and children >12 years of age in LSC lesions resistant to treatment with high-potency topical corticosteroids and intra-lesional corticosteroid injections or as an adjunct to high-potency topical corticosteroids in diffuse disease.[1][39]
PUVA may be more efficacious than broadband UV-B, but narrow-band UV-B (NBUVB) has equal efficacy to PUVA, is safer with a lower incidence of adverse effects, and does not require the patient to wear UV-A blocking eye protection after the procedure, as it does not involve the ingestion of a photosensitising agent such as psoralen. NBUVB is therefore the preferred form of light therapy.
PUVA and UV-B are carried out by a dermatologist 2 and 3 times per week, respectively.
Adverse effects of UV light therapy include the risk of sunburn, cataracts (with PUVA) and increased risk of skin cancer, especially with prolonged PUVA therapy. The risk of developing cataracts with PUVA therapy can be avoided by wearing UV-A blocking eye protection for 24 hours following ingestion of the psoralen-sensitising agent if any sunlight exposure is expected.[51]
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