British Journal of Dermatology 2002; 147: 640–649.

GUIDELINES
Guidelines for the management of lichen sclerosus
S.M.NEILL, F.M.TATNALL* AND N.H.COX†
St Peter’s Hospital, Chertsey, Surrey, St John’s Dermatology Centre, St Thomas’ Hospital, London and Chelsea and Westminster
Hospital, London, U.K.
*Watford General Hospital, Vicarage Road, Watford WD1 8HB, U.K.
†Cumberland Infirmary, Carlisle CA2 7HY, U.K.

Accepted for publication 10 June 2002

Summary These guidelines for the management of lichen sclerosus have been prepared for dermatologists on
behalf of the British Association of Dermatologists. They present evidence-based guidance for
treatment, with identification of the strength of evidence available at the time of preparation of the
guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.
Key words: guidelines, lichen sclerosus

using as much evidence-based data as possible. There

Disclaimer are few published randomized controlled trials to
These guidelines have been prepared for dermatologists support the following guidelines for the management
on behalf of the British Association of Dermatologists of lichen sclerosus (LS); the recommendations made are
and reflect the best data available at the time the report those that are currently considered best practice but will
was prepared. Caution should be exercised in interpre- be modified at intervals in the light of new evidence.
ting the data; the results of future studies may require Levels of evidence to support the guidelines are quoted
alteration of the conclusions or recommendations in according to the criteria stated in Appendix 1. Apprais-
this report. It may be necessary or even desirable to ing and grading the evidence for the treatment of LS is
depart from the guidelines in the interests of specific not easy, particularly as it is a disorder in which many
patients and special circumstances. Just as adherence treatments have a large placebo effect; additionally,
to the guidelines may not constitute defence against a disease definition has been unreliable or unclear in
claim of negligence, so deviation from them should not some of the reports so it is possible that
therapy-
necessarily be deemed negligent. resistant cases may have had some atypical features.

Introduction Definition
The aim of the British Association of Dermatologists is to LS is a lymphocyte-mediated dermatosis that has a
provide guidelines for the management of skin diseases predilection for the genital skin in both sexes and was
first formally described at the end of the nineteenth
Correspondence: Dr N.H.Cox. century by Hallopeau and Darier as a variant of lichen
E-mail: [email protected] planus (LP).1–3 Use of the terms leucoplakia and
These guidelines were prepared for the British Association of Der- kraurosis vulvae4 in older literature is a source of
matologists Therapy Guidelines and Audit subcommittee. Members of confusion. Balanitis xerotica obliterans, a term used for
the committee are: N.H.Cox (Chairman), A.V.Anstey, C.B.Bunker,
LS of the penis, was only recently coded as part of LS in
M.J.D.Goodfield, A.S.Highet, D.Mehta, R.H.Meyrick Thomas, A.D.
Ormerod, J.K.Schofield and C.H.Smith. These guidelines have been literature search tools such as Medline. Not all LS is
endorsed by the Clinical Effectiveness Group of the Association for histologically atrophic, and the term
lichen sclerosus et
Genitourinary Medicine and the Medical Society for the Study of atrophicus has now been replaced with LS alone.
Venereal Diseases (Chair: Dr K.W.Radcliffe). We are grateful for
Currently, LS is considered as a separate entity from
additional input from the Royal College of Obstetricians and Gynae-
cologists. LP on the basis of its specific distinguishing clinical and
Conflict of interest: none. histological features. However, it is recognized that

640
2002 British Association of Dermatologists

 GUIDELINES FOR THE MANAGEMENT OF LS 641

some cases of LS may represent an overlap syndrome, interlabial sulci, labia minora, clitoral hood, clitoris and
sharing features of both LS and LP, and perhaps the perineal body. Genital mucosal involvement does not
two conditions represent different parts of a spectrum of occur, the vagina and cervix always being spared (by
the same process. Such overlap cases are often associ- contrast with LP). However, there may be some
ated histologically with squamous cell hyperplasia, and mucosal involvement at the edge of mucocutaneous
are best categorized as
complicated LS, as response to junctions, which may lead to introital narrowing.
a topical ultrapotent corticosteroid is often poorer.5 Perianal lesions occur in women in 30% of cases. Itch
These guidelines are in the main for uncomplicated is the main symptom but pain occurs if there are
LS with the classical histological features of the erosions or fissures. The itch is worse at nights and
disorder. may be so severe as to disturb sleep. Dyspareunia
occurs in the presence of erosions, fissures or introital
narrowing.
Pathogenesis
Some women are asymptomatic and the LS is only
The aetiology of LS is uncertain but there is mounting discovered when they are being examined for another
evidence to suggest that autoimmune mechanisms are reason. Most of these patients have inactive disease,
involved in its pathogenesis;6–8 there is an increased which may have occurred in childhood, and the
incidence of tissue-specific antibodies9 and associations changes seen are the long-standing atrophic changes
with other autoimmune diseases in patients with that persist. However, some of these individuals have
LS,10,11 as well as positive associations with HLA class changes of active disease with hyperkeratosis and
II antigens.12–14 There is still controversy regarding the ecchymosis, and should therefore receive treatment.
implication of Borrelia infection as an aetiological
agent; although several studies have shown that this
Female anogenital: child
association does not occur in the U.S.A., some doubt
still remains in Europe.15,16 The lesions are similar to those in adult women but
ecchymosis may be very striking and potentially
mistaken as evidence of sexual abuse.20 There has
Incidence
been a tendency to exclude a diagnosis of sexual abuse
It is clear from the number of patients attending a if LS has been confirmed; however, as LS exhibits the
vulval clinic that LS is a common disease. LS in females Koebner phenomenon at sites of trauma, some cases of
has two peak ages of presentation. The first of these LS may in fact be caused or aggravated by sexual
occurs in prepubertal girls17 and may resolve or abuse.21 Suspicious features include LS in older prepu-
continue beyond the menarche.18 The other peak of bertal girls, the presence of associated infection (espe-
incidence is in postmenopausal women;17 although cially infections that are characteristically sexually
this suggests a hormonal influence, hormone replace- transmitted), or other symptoms or signs of abuse.
ment therapy neither improves existing disease nor Perianal LS with or without vulval involvement
provides any protection against its development. Inter- occurs in young girls, who commonly present with
estingly, pregnancy seems to improve the symptoms constipation because of painful fissuring in this area.
and signs, and a normal vaginal delivery is usually
possible.
Male genital: adult
The incidence of LS in males is lower than in females
but there is also a bimodal onset, with peaks of disease The lesions appear most commonly on the prepuce,
presentation occurring in young boys and then again coronal sulcus and glans penis. More rarely lesions
in adults.19 may be found on the shaft of the penis. The presenting
complaint is usually tightening of the foreskin, which
may lead to phimosis and painful erections. One report
Clinical features documented that 40% of phimosis occurring in adults
was due to LS,22 although another study of 75 subjects
Female anogenital: adult
with severe phimosis only identified LS in eight
The typical lesions are porcelain-white papules and (11%).23 In contrast to women, men commonly
plaques, often with areas of ecchymosis. Follicular present with the consequences of scarring. The perim-
delling may be prominent. The lesions occur in the eatal area may be involved and postinflammatory

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642 S . M . N E I L L et al.

scarring may lead to stenosis and obstruction causing

Histology
dysuria and poor urinary stream.
Other presenting complaints are due to the appear- The classical histological features of uncomplicated
ance of lesions, decreased penile sensitivity and LS include a thinned epidermis with hyperkeratosis, a
soreness rather than itch. Circumcision does not neces- wide band of homogenized collagen below the der-
sarily ensure protection against further flares of the moepidermal junction and a lymphocytic infiltrate
disease and one series showed that 50% of men beneath the homogenized area. There may be small
requiring circumcision continued to have lesions of focal areas where the inflammatory infiltrate is close to
LS.19 Perianal disease is extremely rare in males. the dermoepidermal junction, similar to LP.27 A few
patients may have a thickened epidermis; these patients
tend to have complicated disease that is not so
Male genital: child
responsive to treatment and may have a higher risk
The disease usually affects the prepuce and can lead to in the long term of developing an associated squamous
phimosis. The incidence of phimosis caused by LS in cell carcinoma (SCC).
children is difficult to determine as not all surgical The length of time that LS has been present cannot be
specimens are assessed histologically. One study docu- determined accurately using histological parameters.28
mented the presence of LS in 14 of 100 prepubertal
boys having elective circumcision for disease of the
Other investigations
foreskin;24 a similar figure of 14% was recorded in a
French series.22 A more recent study of 100 children Other investigations that might be indicated include a
with phimosis documented that all of them had LS.25 screen for other autoimmune diseases, in particular
Perianal involvement occurs rarely, if ever. thyroid disease in women.

Extragenital
Complications
The classical extragenital sites are the upper trunk,
Malignancy
axillae, buttocks and lateral thighs. Extragenital
lesions in men are uncommon and usually do not SCC, discussed below, is the commonest malignancy
occur in association with genital lesions. The face and described in association with anogenital LS. Interest-
scalp in both sexes are other sites that may rarely be ingly, SCC has not been recorded in LS at sites other
involved. than the anogenital area. Verrucous carcinomas also
Oral lesions of LS are extremely rare and many of the appear to occur on a background of LS.29,30 There have
cases reported in the literature have not been substan- also been reports of basal cell carcinoma31 and
tiated with histological evidence and may well have melanoma occurring in cases of vulval LS.32,33
been examples of LP or morphoea.26 In the rare
instances of oral LS these are recorded at sites in the Squamous cell carcinoma in women with genital lichen
mouth where there is cornified stratified squamous sclerosus. SCC arising within LS only occurs in lesions
epithelium, i.e. tongue, gingiva and hard palate. affecting the anogenital area; in practice, this risk is
extremely small. Two studies each of over 200 women
with LS under regular review have shown a small but
Investigations
definite increased incidence of invasive SCC.17,34 The
The diagnosis in most patients is usually made clinic- magnitude of this risk is about 5% or less lifelong in
ally, but a confirmatory biopsy is helpful in cases where known patients with LS17,30 (and is therefore probably
there is some clinical doubt about the diagnosis and to a significant overestimate in view of the likely high
document any atypical features. The main differential prevalence of undiagnosed cases of LS). However,
diagnoses include LP, mucous membrane pemphigoid histopathological examination of vulval SCCs indicates
and genital psoriasis. A skin biopsy is not always that about 60% occur on a background of LS.35–38 A
practical in children and it is preferable to initiate their clinical study of anogenital SCC presenting to a vulval
treatment without histological confirmation. A biopsy clinic demonstrated that 14 of 23 cases occurred on a
is essential in all cases that fail to respond to adequate background of LS.30 The role of human papilloma-
treatment. virus (HPV) as a possible aetiological agent in the

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 GUIDELINES FOR THE MANAGEMENT OF LS 643

progression to malignancy in LS has not been clearly Pseudocyst of the clitoris. Occasionally, clitoral hood
established, although recent evidence suggests that adhesions seal over the clitoris and keratinous debris
there may be two distinct aetiologies for vulval SCC. builds up underneath, forming a painful pseudocyst.
One type occurs in older women with a chronic This requires a subtotal or total circumcision.50
dermatosis such as LS, the other in younger women
without LS but with evidence of the same oncogenic Phimosis. The most common complication in males is
HPV types that are linked to cervical SCC.39 Although secondary phimosis, which may require circumcision if
evidence for an important role of HPV in LS-associated medical treatment fails. If the disease is still active at
SCC is scanty, there is a remote theoretical risk that the time of surgery it is important to continue topical
topical corticosteroid use might induce oncogenic HPV corticosteroids following the surgery to prevent Koeb-
types that may be cause for concern because, as found nerization and further scarring, particularly around the
in the normal population, up to 20% of cases of LS may coronal sulcus.
incidentally carry the oncogenic HPV 16.40
SCC of the vulva should be managed by gynaecol- Meatal stenosis. LS of the glans may cause meatal
ogists experienced in this field as surgery has to be stenosis, which is manifest as an altered urinary
individualized according to the tumour size and loca- stream, less commonly progressing to cause frank
tion, particularly in early invasive disease.41 obstruction to urinary flow.

Squamous cell carcinoma of the penis associated with

Sensory abnormalities: dysaesthesia
lichen sclerosus. An association between LS and penile
SCC has also been reported.42,43 The magnitude of Vestibulodynia and vulvodynia. These conditions may
this association is probably less than 4%, which was occur after an inflammatory condition of the vulva
the case in a retrospective series of 86 histologically and ⁄ or vestibule. The patient remains symptomatic
confirmed cases of LS.44 There is probably poor despite clinical improvement or resolution of the skin
recognition of the association, as a review of LS in lesions. This is neuropathic pain and will not respond
1995 was only able to document nine reported to topical corticosteroids, so treatment must be aimed
cases.44 The role of HPV in inducing malignant at the eradication of the neuronal sensitization. Xylo-
change is again unproven, but there is documenta- caine 5% ointment should be tried first, with progres-
tion in the literature showing a high incidence of sion to amitriptyline in unresponsive cases.
HPV 6 (in six of 23 patients) using polymerase chain
reaction (PCR) technology in childhood penile LS and
Penile dysaesthesia
another four of 23 patients with HPV 16 or 18.45
Another recent therapeutic study suggested that Men may develop a similar problem, with an abnormal
three of 22 men had evidence of HPV after use of burning sensation on the glans or around the urethral
corticosteroids for LS46 (in one case by penoscopy, meatus.
and in the other two on histological criteria), and
studies also using PCR documented HPV in one of
Psychosexual problems
2547 and none of 2448 patients. Oncogenic HPV
types do not appear to be commonly associated with Men and women who have any chronic genital
penile LS.48 disorder will often lose their interest in sexual activity,
leading to problems with sexual dysfunction.51,52 It is
important to give patients the opportunity to express
Scarring
their concerns on their sexual function and to offer a
Introital narrowing. Infrequently, some women may referral to someone with the necessary expertise to
have narrowing of the introitus. This can present address these problems.
problems with dyspareunia and ⁄ or difficulties mictur-
ating. If surgery has to be considered to widen the
Management
introitus it is important to use part of the posterior
vaginal wall in the reconstruction to prevent further An extensive historical overview of treatment of LS is
adhesions and stenosis due to Koebnerization.49 provided in the review by Meffert et al.44

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644 S . M . N E I L L et al.

Child anogenital lichen sclerosus. There is one report of

Topical corticosteroids
betamethasone dipropionate being used with success
Adult female anogenital lichen sclerosus. Ideally, all for vulval LS in children; all patients had improvement
women with symptomatic or active anogenital LS and eight of 11 had complete remission.57 No main-
should be seen at least once by a dermatologist; difficult tenance therapy was required. A subsequent study of
cases with complications may be best managed in a 10 girls treated with clobetasol propionate twice daily
vulval clinic with a multidisciplinary team, including a for 6–8 weeks documented similar results and lack of
dermatologist and a gynaecologist. adverse effects during treatment or prolonged follow-
The recommended and accepted treatment is the up58 (Strength of recommendation A, Quality of evidence
ultrapotent topical corticosteroid ointment clobetasol II-ii).
propionate53,54 (Strength of recommendation A, Quality In boys, phimosis is commonly due to LS (see above),
of evidence II-ii). There are no randomized controlled but studies of the use of corticosteroids have not always
trials providing evidence for any specific corticosteroid distinguished those with LS. A prospective study of 139
being the most effective or documenting that one boys with phimosis treated with betamethasone for
regimen is superior to another. The regimen recom- 1 month documented that 80% of the 111 who
mended by the authors for a newly diagnosed case is completed the study had normal retractability of the
clobetasol propionate initially once a night for 4 weeks, foreskin after this time; 10% proceeded to circumcision
then on alternate nights for 4 weeks and, for the final as treatment failures and 10% were having ongoing
third month, twice weekly. The rationale for once daily topical treatment59 (Strength of recommendation A,
application is based on pharmacodynamic studies Quality of evidence II-ii).
showing that an ultrapotent corticosteroid needs a An ultrapotent topical corticosteroid may avoid a
once daily application only.55 circumcision in some cases of preputial phimosis.60,61
If the patients’ symptoms return with a drop in the
schedule they are instructed to go back up to the Extragenital lichen sclerosus. Clobetasol propionate, with
frequency that was effective. A 30-g tube of clobetasol or without occlusion, is the first-line treatment. This is
propionate should last 12 weeks and the patient is then used once daily, as and when required. In general,
reviewed. If the treatment has been successful the extragenital lesions are not as responsive as genital
hyperkeratosis, ecchymoses, fissuring and erosions disease to the potent topical corticosteroid (Strength of
should have resolved but the atrophy and colour recommendation A, Quality of evidence III).
change will remain.
The clobetasol propionate is then continued and used
Testosterone and other hormones
as and when required. Most patients seem to require
30–60 g annually. Some patients go into complete Adult female anogenital lichen sclerosus. Older studies
remission, requiring no further treatment. Others will have documented benefit from use of topical testoster-
continue to have flares and remissions and they are one in vulval dystrophy (presumably some of these
advised to use clobetasol propionate as required. cases were LS),62,63 including one controlled study in LS
A soap substitute is also recommended, and the that documented greater benefit in the active treatment
patient is given an information sheet on LS with group.64 However, more recent research has documen-
instructions for the safe use of the topical corticosteroid, ted that it is not as effective as clobetasol propionate65
to try to ensure compliance. and is no more effective than an emollient.66 In the
maintenance of remission after topical corticosteroid it
Male genital lichen sclerosus. A retrospective study of 22 was actually worse than an emollient control67
men treated with clobetasol propionate documented (Strength of recommendation D, Quality of evidence II-i).
this to be safe and effective, with significant improve- Topical testosterone is expensive and with overuse can
ment in discomfort, skin tightness, and also in urinary lead to virilization. This discrepancy between studies is
flow in the nine patients in whom this was affected46 difficult to explain, and some authors still suggest that
(Strength of recommendation A, Quality of evidence II-ii). some patients will respond; one explanation is that
The theoretical possibility of provoking latent HPV there may be changes in the expression of androgen
infection is discussed above. The use of a potent topical receptors with disease progression, which may in turn
corticosteroid often avoids the need for circumcision.56 alter the hormonal responsiveness.68

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 GUIDELINES FOR THE MANAGEMENT OF LS 645

Topical progesterone has also been reported to be Extragenital lichen sclerosus. Shave (tangential) excision
effective69 (Strength of evidence C, Quality of evidence IV). has been used,78 and carbon dioxide laser has been
reported to produce an improvement in symptoms and
Male genital lichen sclerosus. Testosterone has also appearance of lesions.76
been used topically (2Æ5% ointment) for male genital A case of extragenital LS in a child has been
LS70 (Strength of recommendation C, Quality of evidence successfully treated with low-dose ultraviolet (UV) A1
IV). phototherapy.79

Child anogenital lichen sclerosus. Topical oestrogen was

Other treatments
reported to be beneficial in four girls, improving the
histological features and itch (in the three who had this Ciclosporin. A pilot trial of topical ciclosporin failed to
symptom).71 However, the magnitude of benefit is have any beneficial effect clinically or histologically on
uncertain as this report stated that the overall clinical five cases of vulval LS80 (Strength of recommendation D,
improvement was 20%, and no comparative trials are Quality of evidence III).
available.
Retinoids. There is no evidence that these are partic-
ularly effective in uncomplicated LS but there is some
Surgery, laser, photodynamic therapy and cryotherapy
evidence that they may have a role in complicated
Adult female anogenital lichen sclerosus. There is no disease that does not respond to an ultrapotent
indication for removal of vulval tissue in the manage- corticosteroid,81–83 including one long-term placebo-
ment of uncomplicated LS, and surgery should be controlled study. However, this study only documented
used exclusively for malignancy and postinflammatory benefit in 14 of 22 evaluable patients as well as in six of
sequelae. 24 controls, and only 46 of 78 patients could be
In one study, nine of 12 patients with severe itch due evaluated. Use of topical retinoids is accompanied by
to vulval LS unresponsive to topical treatment respon- the problem of irritancy (Strength of recommendation C,
ded to cryotherapy, 50% for 3 years72 (Strength of Quality of evidence I).
recommendation C, Quality of evidence III).
In an open study of photodynamic therapy for vulval Potassium para-aminobenzoate. A report of five patients
LS (topical 5-aminolaevulinic acid, argon laser light, with LS at various sites, and resistant to numerous
one to three treatments), 10 of 12 patients had other therapies, documented good improvement in all
significant improvement.73 Laser treatment has also five (dose 4–24 g daily in divided doses)84 (Strength of
been used with some success74 (Strength of recommen- recommendation C, Quality of evidence III).
dation C, Quality of evidence III).
Others. There are reports of benefits from psoralen
Male genital lichen sclerosus. The role of surgery is better plus UVA treatment, stanozolol,85 antimalarials,
documented for penile LS, either to improve symptoms antipruritic and antihistamine agents such as oxato-
due to phimosis, which has failed to respond to a trial of mide, and various antibiotics (for which the main
an ultrapotent topical corticosteroid, or symptoms due rationale is the uncertain link with Borrelia infec-
to meatal stenosis. Two reviews (52 patients in total) tion). These and others are summarized elsewhere,44
document satisfactory results from circumcision for LS of but must all be viewed as less well proven or as
the foreskin, and meatal dilatation, meatotomy or anecdotal.
meatoplasty for meatal stenosis.75,76
Laser treatment has generally employed the carbon
Treatment failure
dioxide laser, and may have a role in the treatment of
meatal stenosis74,77 (Strength of recommendation B, If treatment with topical corticosteroids fails to bring LS
Quality of evidence III). under control then it is important to consider the
following:
Child anogenital lichen sclerosus. Surgical treatment of 1 Non-compliance. Sometimes patients may be
childhood phimosis by circumcision has demonstrated alarmed at the warnings on the package insert warn-
the presence of LS in a high proportion of cases, but ing against the use of a topical corticosteroid in the
topical corticosteroids should be used first. anogenital area and they will then not use the

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646 S . M . N E I L L et al.

preparation. Also, very elderly patients disabled with runs a relentless course despite trials of various
poor eyesight and limited mobility may not be able to therapies, and a small percentage does go on to develop
apply the medication appropriately. one or more SCCs.
2 Is the diagnosis correct, or is there an added problem It is important to biopsy persistent ulcers, erosions,
such as the development of a contact allergy to the hyperkeratosis and erythematous zones, whether pre-
medication or is there another superimposed condition, sent at initial presentation or subsequently, to exclude
e.g. secondary candidiasis, intraepithelial neoplasia, intraepithelial neoplasia or invasive SCC.
malignancy, psoriasis or mucous membrane pemphig-
oid?
Recommendations and conclusions
3 Is the LS in fact treated, but the patient is still
symptomatic because they have developed a secon- An ultrapotent topical corticosteroid is the first-line
dary sensory problem, dysaesthetic vulvodynia or are treatment for LS in either sex at any site, but there are
experiencing problems with intercourse that they may no randomized controlled trials comparing corticoster-
feel too shy to discuss? oid potency, frequency of application and duration of
4 Is the problem mechanical due to scarring, e.g. treatment.
severe phimosis or meatal stenosis in males, in which Asymptomatic patients with evidence of clinically
case surgery may be indicated? active LS, i.e. ecchymosis, hyperkeratosis and progress-
ing atrophy, should be treated.
Anogenital LS is associated with SCC but the
Follow-up
development of this complication is rare in clinical
The risk of malignancy in uncomplicated genital LS practice (5% or less). It is not yet known whether
that has been diagnosed and treated appropriately is treatment will lessen the long-term risk of malignant
very small. If malignancy occurs it does so rapidly. change.
Early detection would require 3-monthly follow-up Long-term follow up in a specialized clinic is unnec-
consultations; this is generally impossible in the U.K. essary for uncomplicated disease that is well controlled
due to the constraints of the National Health Service clinically using small amounts of a topical corticoster-
system. oid, and follow up should be reserved for patients with
The authors suggest two follow-up visits after the complicated LS that is unresponsive to treatment and
initial consultation: (i) at 3 months to assess response those patients who have persistent disease with history
to treatment and to ensure that the patient is using the of a previous SCC.
topical corticosteroid appropriately and judiciously, Surgical intervention is indicated only for the com-
and (ii) if response has been satisfactory, a final plications of scarring or the development of malignancy.
assessment 6 months later to ensure that the patient Any psychosexual issues should be addressed if
is confident in treating their problem and to take the appropriate and referral made to practitioners experi-
opportunity to discuss any residual problems that the enced in this field if indicated.
patient might have before discharge back to the care of
their primary physician. If patients continue to use a
Audit points
topical corticosteroid it is suggested that they see their
primary care physician once yearly. Instruction should • Has a biopsy been performed in patients with
be given to the patient at the time of their discharge clinically active disease that is unresponsive to ad-
from the clinic warning them that any persistent equate treatment with an ultrapotent topical cortico-
ulceration or new growth must be reported to their steroid?
family practitioner who will then make an urgent • Are follow-up arrangements in place for patients
referral back to an appropriate specialist. with ongoing symptomatic disease?
Long-term follow up is, however, required for • Are patients with genital LS aware that any persist-
patients with LS that continues to be poorly controlled. ent ulcer, erosion or new growth within the affected
These patients usually have LS with a histological skin needs to be reported?
pattern that has features of both LS and LP with • Has a topical corticosteroid of adequate potency and
squamous cell hyperplasia. Clinically, these patients duration been used prior to surgery in males with
seem to have an overlap syndrome and their disease symptomatic preputial tightening?

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 GUIDELINES FOR THE MANAGEMENT OF LS 647

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 GUIDELINES FOR THE MANAGEMENT OF LS 649

Appendix 1 Quality of evidence

The consultation process for British Association of I Evidence obtained from at least one properly
Dermatologists (BAD) guidelines has been published designed, randomized controlled trial.
elsewhere.86 Evidence is searched from Medline and II-i Evidence obtained from well-designed controlled
other medical databases, from reviews and references trials without randomization.
in publications. There is a 3-month consultation II-ii Evidence obtained from well-designed cohort or
process with the entire BAD membership. Updates are case–control analytical studies, preferably from
made at intervals according to new evidence and will more than one centre or research group.
appear on the BAD website and as single-sheet sum- II-iii Evidence obtained from multiple time series with
mary documents. or without the intervention. Dramatic results in
uncontrolled experiments (such as the results of
the introduction of penicillin treatment in the
Strength of recommendations
1940s) could also be regarded as this type of
A There is good evidence to support the use of the evidence.
procedure. III Opinions of respected authorities based on clinical
B There is fair evidence to support the use of the experience, descriptive studies or reports of expert
procedure. committees.
C There is poor evidence to support the use of the IV Evidence inadequate owing to problems of meth-
procedure. odology (e.g. sample size, or length of compre-
D There is fair evidence to support the rejection of the hensiveness of follow-up or conflicts in evidence).
use of the procedure.
E There is good evidence to support the rejection of the
use of the procedure.

2002 British Association of Dermatologists, British Journal of Dermatology, 147, 640–649