Lichen simplex (lichen simplex chronicus)

What is lichen simplex?

Lichen simplex is the name given to an itchy persistent rash caused by repeatedly scratching or rubbing the skin over a long period of time. Lichen simplex can affect any age group but is most common in adults. It is more common in women. It is unusual in children.

What does lichen simplex look and feel like?

• Lichen simplex is intensely itchy; the itch may be worse at night
  
• There may be single or multiple areas of skin affected
  
• Lichen simplex affects areas of the body which can be easily reached and scratched, including the backs of forearms, elbows, lower legs and ankles. The head, neck and genitalia may also be affected
• The skin may appear red or darker, with white/grey scale to the surface
• The skin feels rough and dry and over time becomes thickened (lichenified) and may also develop small bumps. Sometime the surface can become almost wart-like
• Ulcers and cracks may form, which can increase the risk of skin infections

What causes lichen simplex?

Lichen simplex arises as a result of long-term (chronic) scratching. Any itchy skin condition (e.g. eczema, psoriasis, and skin infections ) can lead to lichen simplex. As lichen simplex is intensely itchy, the skin is then scratched more (so called the ‘itch-scratch cycle’). Lichen simplex is more common in individuals who are stressed or anxious and who are prone to scratching.

It is not infectious (cannot be passed from one person to another) and is not hereditary (does not run in families).

Things you can do to help yourself

There are several things you can do at home to help lichen simplex:

• Try and keep stress to a minimum

• Reduce scratching. The itch-scratch cycle needs to be broken; the more you scratch or rub the skin, the worse the lichen simplex will be and the more intense the itching. If you feel like you want to scratch your skin find something for your hands to do until the itch passes (e.g. a job around the house or use a stress ball). If you must touch your skin, try patting rather than scratching or rubbing

• Keep nails short and clean to minimise damage to the skin from unintentional scratching

• Protect your skin by avoiding irritants such as soaps, bubble baths, detergents, and contact with other chemicals

• Do not wash (bath or shower) more than once a day, for no more than 10-15 minutes, keeping the water lukewarm - our skin does not like water. Avoid soaps and anything that makes a lather as this may damage the skin; instead, apply an emollient onto your skin before you get into the bath/shower, and then wash off in the water. Take care not to slip - using an emollient in this way is best avoided in people with poor balance and/or those who are more at risk of breaking a bone

• Apply regular emollient moisturisers – these come in the form of creams, gels, and ointments; ointments are more effective if the skin is very dry. Aim to use twice a day as a minimum, your pharmacist can advise on suitable preparations

• Cooling creams (moisturisers with menthol) may also reduce itch; these can be applied as often as needed

• Certain materials worn next to the skin such as wool and synthetic fabrics can also aggravate itching; stick to soft, fine-weave clothing or natural materials such as cotton and silk
  

Make an appointment at your GP surgery

There are no specific tests to diagnose lichen simplex. Your healthcare professional might take a skin scraping to send a small sample to the laboratory to test for evidence of fungal infection.

Alongside the use of regular emollients, treatment options provided by your healthcare professional may include:

• Topical steroid creams or ointments – strong steroid preparations are likely to be required and need to be applied thinly once or twice a day for as long as directed by your healthcare professional. It can be useful to cover the area once the treatment has been applied – e.g. using Clingfilm or tubular bandages

• Topical steroids under medicated bandages e.g. ZIPZOC ® or Viscopaste may also be advised for some patients; the bandages should be replaced once or twice a week and the treatment continued until the thickened areas flatten and the itch settles. There is a useful video showing how to apply these bandages on the PCDS website (https://www.pcds.org.uk/zinc-o...)

• For small areas, steroid-containing tape or plasters may be tried in some cases

• Sedating anti-histamines may be used for up to a few weeks in order to reduce the itching, as well as aid sleep. Care must be taken as these can cause drowsiness and affect your ability to drive or operate machinery so these are not suitable for everyone

Your mental health

Lichen simplex can have a significant psychological impact and may affect many areas of daily life including work and personal relationships. The intense itch may affect your sleep. If your mental health is affected and having an impact on your quality of life, then you should discuss this with a health professional.

Referral to a specialist

If the diagnosis is uncertain, or your symptoms are not controlled by treatments offered by your GP surgery, you may be referred to see a specialist. This may be a GPwER/GPwSI (a GP who has been trained in relevant areas of dermatology) or a dermatologist.

What will happen when you are referred?

Occasionally, if the diagnosis is not certain, some patients may require a skin biopsy (a small sample of skin is taken under local anaesthetic, i.e. you are awake for the procedure).

Other treatments occasionally used by a specialist may include steroid injections into the affected areas of skin, as well as light treatment (phototherapy) or tablets which suppress the immune system.

Can lichen simplex be cured?

Lichen simplex can be successfully treated, but can recur. Using moisturisers once to twice every day will reduce the likelihood of it returning.  

Habit reversal therapy

Itchy skin conditions can understandably lead to behaviours such as scratching, rubbing, and/or picking as ways to try and cope. Eventually the behaviours can become habits. Habit reversal therapy is a treatment programme that offers a solution to the behaviour that has developed. Unfortunately, therapy is not widely available, however, if you have developed such a habit then ask a health professional to see if there are any local services providing habit reversal therapy; alternatively you can do a Google search. Patient information leaflet on habit reversal therapy can be found at https://www.atopicskindisease.com/categories/HR

CAUTION

This leaflet mentions ‘emollients’ (moisturisers). Pure petroleum emollients are flammable and should never be used near a naked flame. Non-paraffin-based emollients may also act as accelerants if they have a high oil content, so caution is advised with all topical treatments. Your hands may be slippery after applying a greasy moisturiser, so allow time for them to soak in before driving or operating machinery.

Helping with other skin conditions

If you, a family member, or friend have an undiagnosed skin condition; or you want to learn more about how to treat skin conditions, please view our short video on how to get the best from this website.