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Lichen Simplex
Appearance
Lichen simplex, sometimes called neurodermatitis, 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, shin, behind the neck, and genitalia (vulva or scrotum) [1,
2] . Plaques are usually greater than 5 cm in diameter [3] .
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Aetiology
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.

Epidemiology
The condition has been estimated to occur in 12% of the population [4] . 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 [5] . The condition is aggravated by periods of inactivity (presumably
because there are no distractions to the itching) and stress [6] . One study found that people with lichen simplex
chronicus had different personality profiles from those who did not [7] .

Differential diagnosis
Usually the unilateral nature of the lesion, on the shin or dorsum of the foot, coupled with the history of an
enlarging, very itchy skin thickening are enough to make the diagnosis clinically.

However, there are some dermatological conditions that 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 (not as thickened as lichen simplex and usually on the back of the neck).
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 years), leading to hair loss.
Amyloidosis (of the primary localised cutaneous type)
Atopic dermatitis.
Contact dermatitis.
Cutaneous T-cell lymphoma.
Dermatitis herpetiformis.
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Discoid (nummular) dermatitis, also known as discoid eczema. (Usually more lesions, scattered up a
limb).
Pretibial myxoedema (usually bilateral).
Plaque psoriasis (more widespread than lichen simplex and bilateral).
Seborrhoeic dermatitis (usually bilateral).
Stasis dermatitis.
Tinea cruris.

Investigations
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

Once the lesion is covered over and the patient cannot scratch it, it usually resolves. Resolution once
a firm occlusive dressing is applied (and hopefully not removed by the patient, to scratch) is therefore
diagnostic of lichen simplex.
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.
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. [8, 9] . Topical
tacrolimus may be particularly helpful for cases resistant to other treatment and promote long-lasting
benefit [10] .
Gabapentin has also been used to good effect in cases resistant to topical treatments [11] .

Prognosis
The condition often improves well with treatment but occasional cases may become persistent, especially on the
genitalia.

Further reading & references

1. 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.
2. European guideline for the management of vulval conditions; International Union against Sexually Transmitted Infections,
2016
3. Lichen simplex chronicus on the back; Medline Plus, 2013
4. An JG et al; Quality Of Life of Patients with Neurodermatitis. Int J Med Sci 2013; 10(5):593-598.
5. Cahill S, Chronic pruritic vulva lesion, Journal of Family Practice, Vol. 62, No. 02: 97-99, 2013.
6. 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.
7. Martin-Brufau R, Corbalan-Berna J, Ramirez-Andreo A, et al; Personality differences between patients with lichen simplex
chronicus and normal population: Astudy of pruritus. Eur J Dermatol. 2010 May-Jun;20(3):359-63. doi:
10.1684/ejd.2010.0961. Epub 2010 Apr 13.
8. 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.
9. 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.
10. Aschoff R, Wozel G; Topical tacrolimus for the treatment of lichen simplex chronicus. J Dermatolog Treat. 2007;18(2):115-
7.
11. Gencoglan G, Inanir I, Gunduz K; Therapeutic hotline: Treatment of prurigo nodularis and lichen simplex chronicus with
gabapentin. Dermatol Ther. 2010 Mar-Apr;23(2):194-8.
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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 makes no warranty as to its
accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions.
For details see our conditions.

Original Author: Current Version: Peer Reviewer:

Dr Laurence Knott Dr Oliver Starr Dr Laurence Knott
Document ID: Last Checked: Next Review:
4056 (v23) 30/11/2016 29/11/2021

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