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Patient Information Leaflets (PILs)

LICHEN SIMPLEX

What are the aims of this leaflet?

This leaflet has been written to help you understand more about lichen simplex, what it is, what causes it and the treatment options.

What is lichen simplex?

The term ‘lichen’ is Latin and means a plant-like moss covering trees. Lichen simplex describes a response to the skin being repeatedly scratched or rubbed over a long period of time (also called lichen simplex chronicus). A single or multiple plaque (thickened area of skin) of rough skin forms, with increased markings and sometimes little bumps around the hair follicles.

Lichen simplex can affect any age group, but is most common in adults and is unusual in children.

What causes lichen simplex?

Different skin complaints, itchy infections and persistent scratching can lead to the development of lichen simplex. Itchy skin conditions include, for example, eczema, irritant or allergic dermatitis and psoriasis. Lichen simplex can also form in response to the itching of dry skin or a persistently scratched insect bite. Itching due to conditions such as fungal skin infections and varicose veins can lead to lichen simplex. Lichen simplex is more common in people who feel anxious or stressed. Damage to the nerves, e.g. due to back injury, herpes zoster infection (shingles) or stroke can lead to lichen simplex. Sometimes, no cause can be identified.

Is lichen simplex hereditary?

Lichen simplex itself does not run in families, but some of the skin diseases leading to lichen simplex do, such as eczema or psoriasis.

What are the symptoms of lichen simplex?

Lichen simplex can be sore, but is more often very itchy. This itch usually comes in bursts, may be worse at times of rest and at night. The itch then prompts scratching, which in turn aggravates the skin (called itch-scratch cycle) and may lead to superficial skin infection (impetigo).

What does lichen simplex look like?

Lichen simplex has increased skin markings called lichenification and can show little bumps around hair follicles. The skin may feel dry, thickened and rough to the touch. The affected skin often looks scaly, red and over time can become more pigmented than the surrounding skin, especially in darker skin types.

Areas more commonly affected by lichen simplex are those within easy reach of scratching, for example the nape of the neck (lichen ‘nuchae’, Latin for neck), the front of the legs, outer arms and genitals.

How is lichen simplex diagnosed?

Lichen simplex is diagnosed by taking a history of the symptoms and examining the skin. Skin scrapings may be taken to exclude a fungal infection (such as ring-worm).

If a contact allergy is suspected, a patch-test may be given to find out if there is an allergic reaction to anything coming in contact with the skin. If the diagnosis is not clear, a skin sample (biopsy) may need to be taken under local anaesthetic for examination under a microscope.

Is lichen simplex serious?

Although lichen simplex is not infectious or serious, the itching can affect sleep and quality of life. Depending on the affected area, a plaque of lichen simplex may be found unsightly or embarrassing.

Can lichen simplex be cured?

Lichen simplex will settle with the appropriate treatment but may come back when this is stopped, unless an underlying cause can be found and treated.

How can lichen simplex be treated?

The itch-scratch cycle needs to be broken in lichen simplex. Any specific underlying problem,e.g. a fungal infection or contact allergy,needs to be treated.

Treatment of lichen simplex may require a combination of ointments, creams and antihistamine tablets. Soap, shower gel or bubble bath should be avoided. A soap substitute (any bland cream orointment) should be applied prior to a bath or shower and then washed off to clean the skin. Frequent application of moisturizers is helpful.

Covering the affected skin with a dressing, plaster or bandage (occlusion) may help relieve the itchingand reduce the damage caused by scratching. This can also be achieved with frequent application of bland ointments.

Treatment of skin inflammation:

Repeated coursesof strong (e.g. betamethasone) or super-strong (e.g. clobetasol propionate) steroid ointment or cream, applied once a day,areoften required. Steroid impregnated tape can be useful, as it also covers the affected area. Sometimes, steroid injections (e.g. triamcinolone) into the plaque of lichen simplex reduce both the itch and thickness.

Tacrolimus and pimecrolimus (calcineurin inhibitors) are licensed as creams / ointments to treat eczema and may reduceskin inflammation andthe itch.

Coal tar creams or ointments may also be useful as maintenance treatment, because they have anti-inflammatory properties. Tar bandages may be helpful as they cover the area.

Treatment of infection:

If the skin is broken or infected, an antibiotic or antiseptic cream or ointment can be used alone or incombination with a steroid cream or ointment. Antibiotics cream or ointment should only be applied short-term to avoid the development of antibiotic resistance. Antiseptic creams or lotions may also be used under the supervision of a healthcare professional, in the form of a wash to prevent and treat infection of the skin.

Treatment of itch:

Cooling creams containing menthol can be applied whenever itching is felt and are available in concentrations ranging from 0.5% to 5%, butmaysting if the skin is broken.

Doxepin (antihistamine) cream can be applied 3 to 4 times a day, butmay cause sleepiness, in particular if used too often. As a guide, one 30g tube should last at least 3 days.

Capsaicin cream is derived from chilli peppers and may be applied 3 to 4 times a day for localised pain, but may also help the itch. It can initially result in a burning sensation. Lidocaine 5% ointment applied 10-15 minutes beforehand can prevent the burning sensation.

Trans-cutaneous electrical nerve stimulation (TENS) has been described as helpful in improving the localised itch.

Antihistamine tabletscan be relatively non-sedating,e.g. cetirizine, loratadine or sedating: chlorpheniramine, hydroxyzine, low-dose doxepin (anti-depressant in higher doses). Antidepressants such as amitriptyline and selective serotonin re-uptake inhibitors, as well as mood stabilisers such as gabapentin and pregabalin are used as second-line treatments.

These medications can be useful for up to a few weeks to break the itch-scratch cycle and aid sleep if taken before bedtime. Care must be taken when used during the day, as they may cause drowsiness and interfere with the ability to drive or operate machinery.

Many people with lichen simplex are helped by psychological therapy to change the scratching behaviour (habit reversal therapy) or to reduce tension and stress.

Some people with chronic widespread lichen simplex benefit from ultraviolet light treatment, which is usually given in a specialist hospital department (see Patient Information Leaflet on Phototherapy) or immunosuppressive tablets such as ciclosporin or methotrexate.

Self-care (What can I do?)

Avoid anything which may irritate the area. This can be contact with clothing made from wool or synthetic fibre – cotton and silk are best. Nails should be kept short to avoid accidental damage of the skin. Make a conscious effort not to scratch. Whenever the skin feels itchy, apply a moisturizer instead of scratching.

Where can I get more information about lichen simplex?

Web links to detailed leaflets:

http://www.dermnetnz.org/dermatitis/lichen-simplex.html

http://emedicine.medscape.com/article/1123423-overview

http://patient.info/doctor/lichen-simplex-chronicus

A list of skin-related charities and support groups can be found at:

http://www.bad.org.uk/for-the-public/patient-support-groups

For details of source materials used please contact the Clinical Standards Unit (clinicalstandards@bad.org.uk).

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel

BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED DECEMBER 2015
UPDATED OCTOBER 2019

REVIEW DATE OCTOBER 2022

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