Lichen Simplex Chronicus | Visual Dermatology Atlas

Illustration of the main clinical features of lichen simplex chronicus, including a thickened, lichenified plaque, hyperpigmentation, and accentuation of normal skin markings. The self-perpetuating itch-scratch cycle maintains the condition and may produc

General info +

AKA: Neurodermatitis / Circumscribed neurodermatitis

• Chronic inflammatory skin disorder characterized by localized lichenification caused by repeated scratching or rubbing.
• Typically presents as one or more well-demarcated, thickened plaques.
• Results from a self-perpetuating itch → scratch → inflammation → increased itch cycle.
• Chronic mechanical trauma causes epidermal hyperplasia and skin thickening.
• May develop on previously normal skin or secondary to an underlying pruritic dermatosis.
• Atopic dermatitis or an atopic background may be associated.

Symptoms / presentation +

• Chronic, intense pruritus is the predominant symptom.
• Itching may be intermittent or paroxysmal and is sometimes worse at night or during periods of inactivity.
• Repeated scratching or rubbing may eventually become habitual or unconscious.
• Scratching provides temporary relief but perpetuates the itch–scratch cycle.
• Assess for underlying causes of pruritus, including atopic dermatitis, contact dermatitis, xerosis, and dermatophytosis.

Clinical exam +

• Thickened, indurated, lichenified plaque, usually well demarcated.
• Prominent accentuation of normal skin markings = characteristic finding.
• Dry, rough ± scaly surface.
• Excoriations and crusting may occur from scratching.
• Brown, gray, or violaceous hyperpigmentation may occur.
• Scaling is usually mild.
• In darker skin tones, lesions may show prominent hyperpigmentation ± follicular papules.

Distribution +

• Characteristically affects areas readily accessible to scratching.
• Posterior neck/nape, classically common in women.
• Scalp.
• Ankles and lower legs.
• Upper thighs.
• Extensor aspects of the forearms.
• Anogenital region.
• Usually consists of one or a few localized plaques.

Dermoscopy +

• Prominent skin markings and furrows.
• Variable white scaling.
• Areas of brown or gray pigmentation.
• Excoriations, erosions, and crusts may be visible.
• No pathognomonic dermoscopic pattern; dermoscopy is mainly helpful in evaluating alternative diagnoses.

Diagnostic +

• Primarily a clinical diagnosis based on chronic pruritus, repeated scratching, and characteristic lichenification.
• Evaluate for an underlying cause of pruritus.
• KOH preparation/fungal culture if dermatophytosis is suspected.
• Patch testing if allergic contact dermatitis is suspected.
• Skin biopsy may be considered for atypical or persistent lesions or when the diagnosis is uncertain.
• Histology typically demonstrates hyperkeratosis, acanthosis/epidermal hyperplasia, and superficial chronic dermal inflammation.

Differential diagnosis +

• Plaque psoriasis
• Allergic contact dermatitis
• Irritant contact dermatitis
• Atopic dermatitis
• Dermatophytosis (tinea corporis)
• Prurigo nodularis
• Hypertrophic lichen planus
• Mycosis fungoides in selected atypical or persistent presentations

Treatment plan +

• Primary goal: break the itch–scratch cycle.
• Identify and treat any underlying pruritic skin disorder.
• Minimize scratching and rubbing; occlusive dressings may help protect selected lesions.
• Regular emollients to restore the skin barrier.
• Potent to superpotent topical corticosteroids for appropriately located thick plaques.
• E.g., clobetasol propionate 0.05% once or twice daily for 1–2 weeks, followed by reassessment.
• For sensitive or thin-skinned areas, consider a lower-potency corticosteroid or topical calcineurin inhibitor, depending on location.
• Refractory thick plaques: intralesional triamcinolone may be considered by a dermatologist; concentration and volume depend on lesion size and location.
• A sedating antihistamine, such as hydroxyzine, may occasionally be considered short-term when nocturnal pruritus significantly interferes with sleep, with attention to adverse effects.
• Address behavioral or psychological factors when they contribute to repetitive scratching.

References +

DermNet — Lichen simplex chronicus.
UpToDate — Lichen simplex chronicus.
Merck Manual Professional — Lichen simplex chronicus.
Bolognia JL, Schaffer JV, Cerroni L. Dermatology. Elsevier.