Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

adults and children ≥12 years

1st line – topical or intra-lesional corticosteroids

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adults and children ≥12 years
1st line – 

topical or intra-lesional corticosteroids

Potent (class I or II) topical corticosteroids are prescribed for a maximum of 2 weeks' continuous use on any one lesion, avoiding the face and intertriginous areas.

Any class II or I drug may be used, with class I more effective for thicker lesions of LSC.

Creams and ointments are appropriate for the body, solutions and gels for hairy areas (e.g., scalp), and ointments for eroded skin to avoid stinging and burning.

To minimise risk of topical corticosteroid-associated adverse effects, application frequency or potency should be decreased as the condition improves.

When long-term use of topical corticosteroids is indicated, as with an underlying chronic dermatosis, a corticosteroid-sparing agent (e.g., topical calcineurin inhibitor) may be used in both adults and children.[29][30][31]

Occlusion overlying a topical corticosteroid is appropriate in thickened lesions of LSC and when the topical corticosteroid alone is not optimally effective, as it increases its efficacy.[35] It also increases topical corticosteroid adverse effects, so should be restricted to several hours per day for a maximum of 1 to 2 weeks at a time.[37]

Intra-lesional corticosteroids at weekly intervals for 6 to 8 weeks at a time are an alternative to high-potency topical corticosteroids if these prove ineffective, particularly for very thick plaques.[7][17]​​[32]

Primary options

fluocinonide topical: (0.05%) apply sparingly to the affected area(s) twice daily

OR

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily for a maximum of 2 weeks, maximum 50 g/week

Secondary options

triamcinolone acetonide: 1-3 mg intra-lesionally once weekly, maximum 5 mg per injection site or 30 mg in total

Plus – emollients, lifestyle modification, and sedating agents

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adults and children ≥12 years
Plus – 

emollients, lifestyle modification, and sedating agents

Treatment recommended for ALL patients in selected patient group

Twice-daily application of emollient creams or ointments to moisturise the skin while it is still wet (e.g., after showering) restores and maintains the epidermal barrier function.[2]

Environmental triggering/exacerbating factors such as dry or excessively moist skin, chronic friction from tight or rough clothing, and harsh skincare products should be eliminated. 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]​​

Occlusion is an effective physical barrier against scratching.

Nocturnal pruritus is treated with sedating agents taken 2 hours before going to bed to reduce the risk of sedation, a dry mouth, and blurred vision in the morning.

Doxepin has a longer half-life and is thus useful for patients woken during the night with pruritus, as it helps them stay asleep throughout the night.[45]

Primary options

doxepin: 10-25 mg orally once daily at bedtime initially, increase by 10-25 mg every 7 days according to response, maximum 75 mg/day

OR

hydroxyzine: 10-25 mg orally once daily at bedtime initially, increase gradually according to response, maximum 100 mg/day

Plus – treatment of underlying dermatological, systemic, or psychiatric condition

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ONGOING
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adults and children ≥12 years
Plus – 

treatment of underlying dermatological, systemic, or psychiatric condition

Treatment recommended for ALL patients in selected patient group

Any underlying dermatosis or systemic condition causing pruritus should be identified and treated in secondary LSC to prevent re-establishment of the itch-scratch cycle following resolution of the acute episode.[1][2]

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]

Consider – topical calcineurin inhibitors

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ONGOING
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adults and children ≥12 years
Consider – 

topical calcineurin inhibitors

Additional treatment recommended for SOME patients in selected patient group

When long-term use of topical corticosteroids is indicated (e.g., with an underlying chronic dermatosis), a topical calcineurin inhibitor may be prescribed in conjunction with pulsed topical corticosteroids in a regimen involving the use of topical calcineurin inhibitors on weekdays and topical corticosteroids on weekends.[29][30][31]

Also used on facial, intertriginous, and genital lesions, as the application of topical corticosteroids should be avoided in these areas where possible.[31]

Tacrolimus 0.1% ointment should only be given to children >16 years of age.

Adverse effects include transient skin burning, which can limit their use in some patients, and increased risk of local skin infections at the site of application.

Primary options

pimecrolimus topical: (1%) apply to the affected area(s) twice daily

OR

tacrolimus topical: (0.03% or 0.1%) apply to the affected area(s) twice daily

Consider – topical antipruritics

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ONGOING
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adults and children ≥12 years
Consider – 

topical antipruritics

Additional treatment recommended for SOME patients in selected patient group

Topical capsaicin or doxepin 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. Doxepin may cause allergic contact dermatitis, especially when used on inflamed skin.[49]

Primary options

capsaicin topical: (0.025%) apply to the affected area(s) twice to three times daily

OR

doxepin topical: (5%) apply to the affected area(s) twice to four times daily

Consider – cryosurgery

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ONGOING
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adults and children ≥12 years
Consider – 

cryosurgery

Additional treatment recommended for SOME patients in selected patient group

Effective adjunct to high-potency topical corticosteroids for small localised lesions of LSC.[50]

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.

Consider – light therapy

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ONGOING
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adults and children ≥12 years
Consider – 

light therapy

Additional treatment recommended for SOME patients in selected patient group

UV light therapy with UV-A and psoralen (PUVA) or UV-B (narrow or broadband) can be used 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]

Narrow-band UV-B is the preferred form of light therapy, as it 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.

PUVA and UV-B are carried out 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 cataracts 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]

children <12 years

1st line – low- to mid-potency topical corticosteroids

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children <12 years
1st line – 

low- to mid-potency topical corticosteroids

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 should be used.[2] The preferred low- and mid-potency topical corticosteroids are hydrocortisone valerate and triamcinolone (0.1%), respectively.

When long-term use of topical corticosteroids is indicated, as with an underlying chronic dermatosis, a corticosteroid-sparing agent (e.g., topical calcineurin inhibitor) may be used.[29][30][31]

Occlusion overlying a topical corticosteroid is appropriate in thickened lesions of LSC and when the topical corticosteroid alone is not optimally effective, as it increases their efficacy.[35] It also increases topical corticosteroid adverse effects, so should be restricted to several hours per day for a maximum of 1 to 2 weeks at a time.[37]

Primary options

hydrocortisone topical: (0.25%) apply sparingly to the affected area(s) twice daily

OR

triamcinolone topical: (0.1%) apply sparingly to the affected area(s) twice daily

Plus – emollients, lifestyle modification, and sedating antihistamine

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ONGOING
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children <12 years
Plus – 

emollients, lifestyle modification, and sedating antihistamine

Treatment recommended for ALL patients in selected patient group

Twice-daily application of emollient creams or ointments to moisturise the skin while it is still wet (e.g., after showering) restores and maintains the epidermal barrier function.[2]

Environmental triggering/exacerbating factors such as dry or excessively moist skin, chronic friction from tight or rough clothing, and harsh skincare products should be eliminated.

Occlusion is an effective physical barrier against scratching.

Nocturnal pruritus is treated with an older-generation sedating antihistamine.[2]

Primary options

hydroxyzine: children ≤40 kg: 0.5 to 1 mg/kg orally once daily at bedtime initially, increase gradually according to response, maximum 2 mg/kg/day; children >40 kg: 10-25 mg orally once daily at bedtime initially, increase gradually according to response, maximum 100 mg/day

Plus – treatment of underlying dermatological condition

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ONGOING
|
children <12 years
Plus – 

treatment of underlying dermatological condition

Treatment recommended for ALL patients in selected patient group

Any underlying dermatosis should be identified and treated in secondary LSC 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.

Consider – topical calcineurin inhibitors

Back
ONGOING
|
children <12 years
Consider – 

topical calcineurin inhibitors

Additional treatment recommended for SOME patients in selected patient group

When long-term use of topical corticosteroids is indicated (e.g., with an underlying chronic dermatosis), a topical calcineurin inhibitor may be prescribed in conjunction with pulsed topical corticosteroids in a regimen involving the use of topical calcineurin inhibitors on weekdays and topical corticosteroids on weekends.[29][30][31]

Also used on facial and intertriginous lesions, as the application of topical corticosteroids should be avoided in these areas where possible.

Tacrolimus and pimecrolimus should not be given to children <1 and <2 years of age, respectively.

Adverse effects include transient skin burning, which can limit their use in some patients, and increased risk of local skin infections at the site of application.

Primary options

tacrolimus topical: (0.03%) apply to the affected area(s) twice daily

OR

pimecrolimus topical: (1%) apply to the affected area(s) twice daily

Consider – topical antipruritic

Back
ONGOING
|
children <12 years
Consider – 

topical antipruritic

Additional treatment recommended for SOME patients in selected patient group

Topical capsaicin can be added to the treatment regimen of LSC for relief of breakthrough pruritus despite treatment with topical corticosteroids.[47][48] It should not be given to children <2 years of age.

The adverse effects of burning and stinging after application of capsaicin may limit its use in some patients.[49]

Primary options

capsaicin topical: (0.025% cream) apply to the affected area(s) twice daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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