Synopsis
Recognise lichenification as the product of repeated rubbing, identify the initiating itch and psychosocial amplifiers, and break the itch-scratch cycle without missing infection or malignancy.
- Lichen simplex is a thick leathery plaque with exaggerated skin markings caused and maintained by repeated rubbing or scratching.
- Common accessible sites include nape, forearms, ankles, lower legs, scalp and anogenital skin; one person may have several plaques.
- Find the itch source: eczema, contact allergy, tinea, scabies, venous disease, neuropathy and systemic pruritus may initiate the cycle.
- Break scratching with explanation, nail care, night barriers, emollient and a short adequately potent topical corticosteroid matched to site.
- Address stress and automatic behaviour respectfully; behavioural techniques complement physical treatment and do not imply the itch is imagined.
- Biopsy a persistent atypical, ulcerated or indurated plaque and sample a fungal edge when tinea remains plausible.
- For Lichen simplex chronicus, document body sites, severity, sleep and function, recent treatment, infection features and what the patient can realistically apply each day.
- In Lichen simplex chronicus, reassess the diagnosis when a well-used, correctly potent regimen fails rather than repeatedly intensifying treatment without examining adherence, exposure and mimics.
Key red flags
Non-healing ulcer, bleeding induration, widespread severe pruritus with systemic symptoms, genital scarring, neuropathic deficit, child safeguarding concern or treatment-resistant focal disease requires specialist evaluation.
Progressive induration, ulceration, bleeding or non-response despite verified treatment requires biopsy assessment.
Investigation priorities
Identify the primary itch disorder and other plaques beyond the presenting site.
Management branches
A stable accessible lichenified plaque lacks infection, tumour features or a clear untreated mimic.
- Explain the reinforcement cycle, agree a non-shaming strategy such as short nails, covering at night and substituting pressure or cooling for scratching.
- Apply a potent topical corticosteroid thinly for a defined short course and use generous emollient to reduce dryness and friction.
- Review itch, thickness and actual scratching triggers within two to four weeks, then step down anti-inflammatory exposure.
Key medicines
Betamethasone valerate 0.1% creamApply thinly to an active body-site plaque once or twice daily for up to four weeks, then reduce or stop as skin flattens and itch settles.Avoid face, genitals, folds, infection and unplanned occlusion; monitor atrophy and systemic exposure and biopsy rather than extending ineffective use.
Clobetasol propionate 0.05% ointmentAdults apply thinly once or twice daily only to severe resistant thick plaques under specialist direction, not exceeding four weeks or 50 g weekly.Never use on thin anogenital or facial skin without specialist instruction; avoid untreated infection and prolonged occlusion and step down as soon as control permits.