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Chapter 2: Lichen Simplex Chronicus

Shanthi Narla; Jonathan I. Silverberg

LICHEN SIMPLEX CHRONICUS

Therapeutic Approach

Lichen simplex chronicus (LSC) is a chronic, severely pruritic disorder characterized by one or more lichenified plaques. LSC most commonly affects the scalp, nape of neck, extensor aspects of extremities, ankles, and anogenital area. Therapy should be aimed at interrupting the itch–scratch cycle.1 Systemic causes of itch should also be identified and addressed. In the authors’ experience, first-line treatment is topical high-potency corticosteroids. The literature also supports use of topical doxepin. In patients with a small number of lesions, intralesional triamcinolone may be considered. While the literature does not strongly support it, gabapentin may be utilized as a systemic treatment. See Table 2-1.

Table 2-1Lichen Simplex Chronicus Treatment Table
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Table 2-1 Lichen Simplex Chronicus Treatment Table
MEDICATION NAME MECHANISM OF ACTION DOSING ADVERSE EFFECTS RECOMMENDED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy          
Corticosteroids Anti-inflammatory

  • Fluprednylidene-21-acetate (QD)

  • Betamethasone 17-valerate (thrice daily)

  • Diflucortolone valerate 0.3% (without occlusion BID)

  • Halobetasol propionate 0.05% (BID for 21 d)

  • Clobetasol 17-propionate 0.05%

  • BID for 21 d

 Burning and erythema, pustular lesions and hyperpigmentation (with occlusion), vesiculation, oozing, pruritus, dryness, telangiectasia, numbness in finger tips, skin irritation None IB2-5
Doxepin Anti-itch

  • Doxepin Hydrochloride 5% Cream QID

 Transient stinging, drowsiness, dry mouth, burning None IB6,7
Aspirin Anti-itch

  • 5 mL of 3% aspirin dissolved in dichloromethane BID for 2 wk

 Burning None IIB8
Calcineurin inhibitors Anti-inflammatory

  • Pimecrolimus 1% cream BID

  • Tacrolimus 0.1% ointment BID

 Burning None IV9-11
Ketamine-amitryptyline-lidocaine Anti-itch

  • 10% ketamine, 5% amitriptyline, and 5% lidocaine compounded in a lidoderm cream: apply sparingly to areas that were the most severe, limiting to less than 30% of total body surface area up to 3 times daily

  • 5% ketamine, 5% amitriptyline, and 5% lidocaine compounded in a lidoderm cream: apply sparingly to areas that were the most severe, limiting to less than 30% of total body surface area up to 3 times daily

 Burning, redness, itching, raw/sloughing skin sensation, dizziness, numbness, encephalopathy if applied to a large body surface area None IV12
Intralesional Therapy
Triamcinolone acetonide Anti-inflammatory

  • 10 mg/mL at weekly intervals

 None None IV13
Botulinum toxin type A Anti-itch

  • 100 U/mL BoNT/A spaced 2 cm apart

 None None IV14
Systemic Therapy
Antidepressant Antidepressant

  • Imipramine 25 mg in increasing doses weekly

 Not reported Not reported IIB1,15
Gabapentin Anti-itch

  • Gabapentin 300 mg/d gradually increased to 900 mg/d

 Sedation None IV16
Procedural therapy
Narrowband UVB Anti-inflammatory

  • 2-3 times/week; mean number of sessions: 29; mean cumulative dose: 23.7 J/cm2

 Erythema None IV17
Focused ultrasound Unknown

  • 3.5 W, 10 MHx, 100 Hz pulse

 Transient hyperemia and edema, superficial skin burn None IV18
Transcutaneous electrical nerve stimulation Anti-itch

  • 3x/wk, 50-100 Hz, 40-75 microsecond pulse width

 Transient local erythema, irritation, numbness None IV19-21
Liquid nitrogen cryotherapy Unknown

  • Applying a cotton ...

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