Lichen Sclerosus or STD: How to Tell the Difference from Visual Symptoms

If you have noticed something unusual ‘down there’ and unsure what it means, you are not alone. When it comes to sensitive skin changes in the genital area, it is easy to jump to conclusions. Especially with the internet offering a million possibilities. Two such often-confused conditions are lichen sclerosus and sexually transmitted diseases (STDs).

While both can cause noticeable skin changes, their causes, treatments, and implications are very different. However, close inspection is all it takes to differentiate these two conditions from each other, and we are ready to teach you all you need to know.

What is Lichen Sclerosus?

Lichen sclerosus is a long lasting immune mediated skin condition characterized by inflammation. The first sign of lichen sclerosus is reddened thinning skin with well-defined boarders, that later turns to a pale ivory-white colour.^[1] Itching is one of the major symptoms of this condition, and it is often worse at night. With repeated scratching skin becomes thick and plaque like, with other symptoms like burning, pain, cracks, ulcers and swelling.^[1] While lichen sclerosus is commoner in the genital area than any other body part, it is not a sexually transmitted disease (STD).^[1] However, it may look like a STD to an inexperienced eye.

Why Confusion Happens: Visual Similarities and Differences

The appearance of lichen sclerosus when it involves the genital area is quite deceiving. In women, it usually starts near the clitoral area and spreads to the vulva, perineum, and anus, sometimes forming a shape called the “keyhole sign.”^[1] Vagina and cervix, which are located internally, are usually not involved. In men, it mainly involves glans penis and foreskin, leading to complications like tight foreskin (phimosis).

A variety of STDs can give rise to a similar picture, including genital herpes, syphilis, genital warts and yeast infections. Itching, ulcer formation, skin colour changes and patchy lesions are common symptoms shared by these conditions. However, a close look reveals a wide array of subtle differences that help you in correctly identifying the skin condition.

Lichen Sclerosus vs. Common STDs: Quick Visual Guide

Other STDs such as chlamydia, gonorrhea and trichomonas have other characteristic features like oozing pus, bad smell and discomfort when passing urine, so you will not misidentify them for lichen sclerosus.

When Differentiation is Essential

Scenario 1: Persistent painless White Patch vs. Genital Ulcer

A 40-year-old female has noticed an itchy patch of skin in her vulva which has been there for a month. While there was no ulceration or pain initially, scratching has made the skin excoriated and now there is pain. She is worried about syphilis.

• Painless itchy genital lesion can be either lichen sclerosus or syphilis.
• The chronicity of the condition makes it more likely to be lichen sclerosus. If the skin went from nothing to an ulcer within a few weeks, then completely disappear on its own within another couple of weeks, it is very likely to be syphilis. This case, on the other hand, has been going on for a month without any change of symptoms.
• The colour and texture of the lesion is the other clue to fully differentiate the 2 conditions. Lichen sclerosus makes the skin pale, thin and wrinkled, and it does not get ulcerated on its own. Excoriation has occurred in this case due to itching. Unlike lichen sclerosus, syphilis give rise to a round ulcer that spontaneously occurs and spontaneously disappears.

Scenario 2: Persistently Itchy, Thinning Skin vs. Painful Blisters

A 20-year-old male noticed a fleshy blisters in the groin area that become itchy sometimes. It spread to the surrounding skin over a few weeks and now he has multiple similar skin coloured raised lesions. He feels some pain due to the lesions. He is wondering if he should go to the doctor immediately.

• Lichen sclerosus usually presents as pale whitish wrinkled skin that is persistently intensely itchy, and subsequently easily get torn. Unless torn, lichen sclerosus causes minimal discomfort.
• Painful blisters that suddenly appear and rapidly spread are more likely to be STD than lichen sclerosus. Lichen sclerosus is a long-lasting condition that hardly undergo any rapid changes. Painful lesions could be herpes or warts. If there are sores or ulceration, there is a high chance of it being herpes.

The appearance of fleshy skin coloured lesions point more towards genital warts, especially since there is no ulceration or skin thinning. They can have a cauliflower like appearance.

Scenario 3: chronic vs sudden onset and course of the lesion

A 53-year-old female suddenly noticed a funny patch of wrinkled skin on her inner thigh. On further inquiry, she stated “actually, I’ve been having on-and-off itching down there for a long time and the white patch of skin has been slowly expanding,”. She is worried about STD.

• The timeline gives a clue whether it is lichen sclerosus or STD. Lichen sclerosus is a long-lasting condition, as opposed to STDs which are typically observed out of nowhere after a new sexual partner. Some STDs like herpes can keep recurring, but symptomatic episodes come and go, and you would not have any itching, pain or discomfort during the time in between episodes.
• Further, STDs typically have an identifiable starting point. A patient would say “I was completely well until after that night…” And proceed to describe a risky sexual encounter. Lichen sclerosus on the other hand evolves more gradually with no identifiable starting point. The lesion does not occur over night and does not undergo transformation within a matter of hours or days.
• In this scenario even though the lesion was noticed recently, she has experienced the symptoms over several months. The chronicity and slow transformation are suggestive of lichen sclerosus.

Diagnosis: How Do Doctors Tell Them Apart

Doctors use medical history, visual examination and some investigations to diagnose the condition properly.

• Medical history: lichen sclerosus has a history of chronicity. Lesions gradually appear and transform very slowly. Itchiness and other symptoms are there for a long time, from months to years. In contrast, STD come with a history of risky sexual encounter followed by sudden appearance and rapid spread of the symptoms.
• Visual examination: As described above, each type of disease has its own characteristic features. Doctors have a trained eye to correctly identify those features and come to a proper diagnosis.

Investigations: If the doctor is still uncertain after talking to you and looking at the lesion, they will suggest some tests. Skin biopsy (a piece of skin from the affected area is taken and examined under the microscope) is used to diagnose lichen sclerosus, while various swab tests, blister fluid tests and biopsy are used for STDs.

When to Seek Medical Advice

Despite all the differences between lichen sclerosus and STDs, it can be hard to differentiate the two conditions to an untrained person. Furthermore, having a proper medical diagnosis is essential to be sure what you are dealing with. In case of STD, an early visit to a doctor would help to get the right treatment and cure the disease, saving you a lot of discomfort, social isolation and intimacy issues. In case of lichen sclerosus, it will help you minimize complications like severe scarring and disfiguration of the genital area leading to sexual dysfunction. And remember, chronic lichen sclerosus in the genital and anal regions has a potential to turn into squamous cell carcinoma.^[1] So, it is essential to be on follow up with a medical professional once you are diagnosed with lichen sclerosus.

Generally speaking, you need to see a doctor whenever you notice an unexplained suspicious lesion in the genital area or around the anus. Both lichen sclerosus and STDs can be sensitive and embarrassing topics, which often leads people to seek advice from unreliable or unqualified sources. However, understand that doctors are professional who will give you an expert diagnosis without judgment, while protecting confidentiality.

An early visit to your doctor will save you from a lot of unnecessary worry and put you on the fast track to healing. Do not hesitate to seek help, prioritize your skin health for a secure life.

Noticed Unusual Skin Changes in the Genital Area? Itching, redness, or lesions could be signs of lichen sclerosus, a sexually transmitted infection (STI), or another skin condition.

Concerned about privacy or discomfort discussing intimate issues? First Derm offers fully anonymous online consultations. Ask a board-certified dermatologist online. Get peace of mind within hours! No scheduling. No appointments.

Treatment

Disclaimer:
This article is for educational purposes only and is not a substitute for professional medical advice or evaluation. If you are experiencing symptoms, consult a board-certified dermatologist or qualified healthcare provider. Do not use this information to delay or disregard professional medical attention.

Conclusion

While visual symptoms can offer useful clues, distinguishing between lichen sclerosus and STDs based on appearance alone is not always straightforward. Many conditions share similar signs like irritation, discoloration, or ulcers, making self-diagnosis unreliable and misleading. A doctor’s opinion is the only way to identify the condition without doubt. For discreet, fast, and confidential help, consider using First Derm’s online consultation service, which is a reliable way to get peace of mind and professional input without the wait or the stigma. Say goodbye to anxiety and get answers today! your peace of mind starts with a simple doctor’s visit.