vulvar lichen sclerosus

I haven't ever treated this myself, but I am familiar with the Chinese discussions of this condition. The white skin is a local lack of blood. You have to determine whether this local lack of blood is part of a systemic blood vacuity or whether there is some evil qi blocking the blood from getting to this area. This second option is the more common one according to the Chinese literature. The types of evil qi which may be preventing the blood form nourishing the local area include, wind, cold, damp heat, qi stagnation, and/or blood stasis. In this case, there is, at the very least, wind due to blood not mothering the qi. Hiowever, there may also be externally contracted wind evils as well. Also, from your description, I would say there is blood stasis, either as part of the original pathomechanisms or as a result of the scratching causing bleeding causing stasis.

Hope some of these ideas help in parsing out your patient's presenting patterns. Also, besides any systemic internal treatment, you will also need some local treatment as well. For these, look under local treatments for scleroderma. "Different diseases, same treatment."

Good luck.

Since Vulvar Lichen Sclerosus can co-exist with or be preceded by lichen simplex and can have a very similar appearances, I would probably approach the dx and treatment as if I was treating Lichen simplex. My dermatology teacher, Mazin Al Khafaji treated lots of Lichen simplex cases with good results. He shared the following thinking with me:

The two main patterns for lichen simplex are:

1) Blood heat generating wind

2) Blood Xu generating wind

The first pattern usually only lasts for up to 6 months or so before turning into the second pattern. So since it is possible that the sclerosus may evolved from a lichen simplex pattern (which would take time), I am thinking that her main pattern would be that of blood xu generating wind. The description above seems to fit the idea of blood xu with the pale skin that is lacking nourishment. I would still cool blood, because of the bleeding that occurs when scratched, and as well invigorate blood because of the purplish color and recalcitrant nature of this lesion. Because the lesion is in the groin, dampness is very typical, and I would think it wise to add some medicinals to treat it.

A formula I may start with would look like:

To nourish, invigorate, and clear heat from the blood:

Shou Di Huang 15 Dan Shen 12

Xuan Shen 12 Qian Cao Gen 12

Hong hua 9 Dang Gui 9

Bai Shao

To scatter wind, drain damp and stop itch:

Fang Feng 9 Cang Er Zi 9

Bai Xian Pi 12 Ku Shen 9

She Chuang Zi 12

Add Gan Cao to harmonize.

If this is not strong enough to stop the itch then look at:

Chan Tui, Bai Jiang Can, Wu Shao She

Of course nourish the yin more if it is very depleted.

This type of treatment does demand patience, for both the practitioner and client!! It can take many weeks or months.

A topical wash of She CHuang Zi and Ku Shen decoction would be good. Adding a little peppermint oil would also help stop the itch.

Good luck,

Trevor Erikson

http://skin.health-info.org/

dabtcm

This is a situation and condition I have seen and treated in clinic numerous times, and generally present in women who are peri-menopausal or even post-menopausal, although it can also randomly occur in younger women as well.

Lichen Scleosis is a localized thinning of the tissues in the external genitalia that may even extend to the perineum. Western medicine usually offers one or two managements for this condition, the topical administration of topical cortico-steroid based creams or the topical administation of hormone-based gels/topicals as well. Neither of which is a favourable choice as cortico-steroid based creams may well further thin an already thinned (sclerotic) area, and hormone-based topicals may well initiate unfavorable cellular change in the area leading to a potentially more serious condition than what the patient already has.

From a TCM view point this condition is characterized as a form of 'senile vaginitis'. It is usually related to s Deficiency of Liver-Kidney Yin and Blood unable to adequately nourish the area Leading to atrophy and sclerosis. Loss of adequate Yin and Blood is witnessed both by the pale thinning tissue as well as localized Blood Stasis as seen by the areas of purple and subcutaneous hemorrhaging (petechiae). Deficiency of Yin and Blood causes Dryness and may well lead to Wind formation locally as witnessed by the itch. With this in mind it is important to use this as a basis for local treatment (washes) or internal treatment that address Yin/ Deficiency of Blood and enrich fluids as well as dispel local Wind related to Deficincy.

With this in mind it is important to enrich Yin and Fluids as well as invigorate flow to dispel the localized Blood Stasis which can interfere with normal nourishment of the tissue(s) locally. In employing either topical washes or internal treatment it is important to use 'clean' and not 'cloying' Yin/Blood enriching medicinals, as this can/may lead to the formation if Damp-Heat, which would be a more uncomfotable and difficult condition for the patient to manage as well as for you as a practitioner to treat.

Lichen sclerosis is one of atrophy and the concept of supplementation as mentioned is important as well as treating any other accompanying pattern(s) that the patient is presenting with in clinic. Also. consider that you must elicit her cooperation to be more forthcoming with information in order to gather as much information to treat her completely. This condition, although similar in some regards to scleroderma (an auto-immune condition) is not related. If you wish, I would be more than willing to post both topical as well as internal treatment(s) if you are able to provide more information as well as any other accompanying signs and symptoms as well as other pattern(s) as well if you are able to elicit this from the patient.....it helps us help you to help her !

Wishing the best of success in your care and management of this patient.

Thanks for the feedback and info in these replies - very helpful! I will be chatting with my patient again next week and will probe further with questions around the common patterns you have described for this condition. Fine tuning and estabishing a proper differential diagnosis is certainly a must. Thanks again - I'll keep you posted on how this case is unfolding over the coming weeks.

Steph

I was reading this subject with interest as I have a client with a very longstanding condition, similar symptoms to Stephanie's patient.

She's 84 now, but has experienced periodic but ongoing itching since her 50s! She's quite healthy for her age in other respects, except for this one nagging condition...which tends to come on at night. It's gotten so bad that she just has to look at the bed and starts to feel the itch!

I feel that for her now, esp at this age, blood stasis is implicated, as well as yin and fluid deficiency. There is a damp/heat component as well, because she often feels hot and sweaty "down there", and of course wind as it comes and goes, seemingly without a connection.

Stephanie, I'd love to hear what happened with your patient and any results, protocols? And the last poster offered to post suggested internal treatment...and a wash...the latter most appreciated, as I've finally convinced my patient to obtain a sitz bath with which to use a TCM external wash.

Thanks!

I\'m glad to have found a discussion about treating this terrible disease. I have just seen a 49 yo woman who has an advanced case of vulvar lichen sclerosis, and I am confounding by also having to negotiate her severe multiple chemical sensitivities. She is quite hesitant to take any herbs at this point or add anything topical, since *everything* triggers a reaction for her. I even have to see her at her own home since she is primarily house bound due to her sensitivities. She was diagnosed after years of simply thinking she had an itchy vulva, and now she is experiencing significant atrophying of her labia minora. Her gyn has warned her that she may soon lose the use of her urethra if the degeneration continues at this pace. Needless to say, she is quite anxious and stressed.

Here is her presentation. I would appreciate any thoughts as to how any of you might proceed. For her first treatment, I primarily treated her for calm shen, clear blood heat, and stop itching. This was her first acupuncture experience, so I used minimal needles for this first treatment.

--severe vulvar itching, worse before and during menstrual cycle. \"feels raw and burning\"

--dry eyes, thinning skin on much of body, spider veins on chest - not dry hair or nails or lips

--hx joint problems, esp hypermobility, repetitive stress injuries, difficult to heal

--hx constant postnasal drip and sinus/ear clogging

--digestion: bloating, tends to loose stools (on rotation diet now)

--sleep: difficult, wakes at 3-4am, up 2-3x night to urinate

--generally feels cold, esp hands and feet, but also core

--rarely sweats, even with vigorous exercise - recent hot flashes with mild sweating, esp during day

--hx of headaches and palpitations

--tongue: pale, scanty coat, sli red at very tip with crack at tip. center crack with swelling on either side (crack does not run entire length of tongue), slightly deviated to right, moderate bilateral sublingual stagnation

--pulses: moderate, weak and deep at both KID, but especially deep on left side, thin at LIV and HRT. Thin LU, sli wiry SP (I am a newbie practitioner, so I am not an expert pulse taker yet)

--menstrual cycle: 14-40 days apart, usu bleeds for 7 days with clots. severe cramps, occ brst tenderness prior

--meds: chlorthalidone for hypercalciuria; potassium to compensate for diuretic; etodolac for menstrual cramps; occ trazadone for insomnia; claritin for seasonal allergies; and the following supplements: glutathione, 5-HTP, lithium, magnanese, Co-QH, vit C, mulit-vit; cod liver oil, digestive enzymes.

whew! She is also just beginning to work with an ND and is considering homeopathy, although she remains quite skeptical of anything alternative. I guess what I really need is to hear that I can offer her some relief (besides simply stress relief), especially without the possibility of dispensing herbs at this point. So any advice on how to proceed would be greatly appreciated.

Thanks!

best,

Julia Carpenter, LAc

Berkeley, CA