Lichen Simplex Chronicus Is Scratching With Eczema

photo showing lichen simplex chronicus on a persons elbow
What is lichen simplex chronicus, what causes it, and how is it treated?. Istockphoto.com/Stock Photo©PositiveFocus

If your dermatologist has told you that you have lichen simplex chronicus (also called neurodermatitis) you may be wondering exactly what this is. Why does this occur for some people with eczema and other skin conditions, and how can it be treated?

What is Lichen Simplex Chronicus? - Definition

Lichen Simplex Chronicus (LSC), or "neurodermatitis" is actually more of a symptom than a specific disease itself.

The skin eruption is created by constantly (habitually) scratching a certain area of skin over a long period of time. This scratching causes characteristic changes such as thickening and darkening of the skin, and an accentuation of normal skin line.

These skin changes are referred to as "lichenification" as the appearance can look much like the lichen which grows on trees and rocks in a forest.

Lichen Simplex Chronicus Related to Eczema and Other Skin Diseases

Lichen Simplex Chronicus is seen most commonly in people with eczema. Although eczema can affect the whole body, however, the eruption of LSC in usually found in one area. The nerve endings in this area are irritable and trigger an itch-scratch-itch cycle. The more the eruption is scratched or rubbed, the more it itches, continuing the cycle.

Conditions which may lead to lichen simplex chronicus include most any condition which can cause itching and may include:

Appearance of Lichen Simplex Chronicus

For those who are familiar with lichen on rocks, lichen simplex chronicus has much this same appearance, but on the skin.

It usually appears as a solitary patch or plaque with a round or oval pattern. The surface often appears dry and scaly and the surrounding skin can feel thick and leathery. The rash is often red, with discoloration that is often irregular and pigmented. There may be associated scratch marks near the rash.

Where Lichen Simplex Chronicus Occurs

The areas most commonly affected by lichen simplex chronicus are listed below in the order of frequency:

  • Outer lower portion of lower leg
  • Wrists and ankles
  • Back and side of neck (lichen simplex nuchae)
  • Forearm portion of elbow
  • Scrotum, vulva, anal area, pubis
  • Upper eyelids
  • Opening of the ear
  • Fold behind the ear

Who Gets Lichen Simplex Chronicus

Lichen simplex chronicus is more common in adults and is fairly uncommon in children. It occurs more frequently in women than in men and is often seen between the ages of 30 and 50. The rash is sometimes associated with anxiety disorders such as obsessive-compulsive disorder and with depression. It may also be associated with a condition which leads to neuropathy, such as disc disease in the spine.

What Else Could it Be? Differential Diagnosis

There are several conditions which can look very similar to lichen simplex chronicus.

Some of these include:

Diagnosis

The diagnosis of lichen simplex chronicus is often made by a combination of findings such as a history of eczema and the telltale scratch marks. A skin scraping may need to be done to rule out conditions such as fungal infections (a KOH test) or scabies. Sometimes a skin biopsy is done to confirm the diagnosis and rule out other causes.

Treatment of Lichen Simplex Chronicus

The treatment of lichen simplex chronicus is best accomplished with a combination of treatments designed to heal the rash and treat the underlying condition. Treatment approaches include:

Stopping scratching - The most important part of treatment is understanding that all itching, rubbing, and even touching of the rash must stop. Since many people scratch in their sleep, the area may have to be covered. Another option for some people is wearing cotton gloves at night and making sure nails are filed down to minimize damage when scratching does occur. When severe, a person may require a medication to help with the itch temporarily while getting the itch under control.

Treating eczema - Lichen simplex chronicus is treated like chronic eczema by decreasing water and soap contact and applying emollients.

Topical steroid creams - Topical steroids are almost always needed to control the symptoms. Since the strength of the steroids required is pretty strong, a health care provider needs to prescribe them and monitor their use. 

A hydrocortisone cream obtained over-the-counter can be used until an appointment is made. Even with the use of these creams, however, scratching needs to be controlled. In some cases, a steroid injection directly into the plaque may be used. Long-term use, especially of the stronger prescription steroid preparations, can cause thinning of the skin leading to other problems. 

Coal tar - Coal tar products have been around for a hundred years but may still offer help in the treatment of LSC.

For comfort - The itching may be severe, and this can be treated with anti-itch creams, lotions, cooling and methylated creams.

Clothing - Reducing itching may be made easier with some types of clothing than others. For vulvar lichen simplex chronicus there is some evidence that wearing silk underwear may help.

Associations and Impact on Quality of Life

Lichen simplex chronicus does not only affect people physically but can have a significant impact psychologically and socially as well. This underlines the importance of treating the rash.

Prognosis and Complications of Lichen Simplex Chronicus

Over time, lichen simplex chronicus may lead to complications. The most common are scarring and changes in pigmentation in the affected area. There is also the risk of secondary bacterial infections, especially in those who have decreased immune function. Secondary infection most often requires antibiotics, and can, in rare cases, lead to severe systemic infections (sepsis.)

Sources:

Corazza, M., Borghi, A., MInghetti, S., Toni, G., and A. Virgili. Effectiveness of Silk Fabric Underwear as an Adjuvant Tool in the Management of Vulvar Lichen Simplex Chronicus: Results of a Double-Blind Randomized Trial. Menopause. 2015. 22(8):850-6.

Kouris, A., Christodoulou C., Efstathiou, V. et al. Comparative Study of Quality of Life and Obsessive-Compulsive Tendencies in Patients with Chronic Hand Eczema and Lichen Simplex Chronicus. Dermatitis. 2016. 27(3):127-30.

Wick, M. Psoriasiform Dermatitides: A Brief Review. Seminars in Diagnostic Pathology. 2016 Dec 14. (Epub ahead of print).

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