Follow up to previous post - recurrent perianal cut/fissure

[someqs17]

Hello,

I have been plagued with a relatively frequent (once every 3-4 weeks on average) recurrent cut on the same side, and in around the same location of my perianal area for the past 3-4 years.

2 years ago they did a biopsy of the cut. Biopsy came back as dermatitis which I knew was just not correct -- too vague and clearly didn't explain my problem. However, 1 week ago, I got this cut in my perianal area and this time the obgyn did a biopsy of the cut which came back as "Lichen Sclerosis et atrophicus." I thought "wow -- this sounsd like a real diagnosis of my problem -- finally!" But I am questioning it because based on what I have read about LS and symptoms, it doesn't sound completely like my recurrent cut.Can I be certain that the biopsy is correct? I mean, could they have misread it or can i be SURE that this cut is LS based on the punch biopsy?

I appreciate your help.

Thank you.

[someqs17]

Yeah, I don't think anyone was thinking Lichen Sclerosus when they saw my fissure either, but the one NP who saw me thought it was possible, and that's what the biopsy said. I have having the biopsy slides re-examined by a really good dermapathologist at Penn Medicine. If they tell me it's LS too, I think that is what it is.

[maatson]

This is a condition easily missed ,not in as much due to rarity but due to the fact that it is not thought of. The clinical appearence of Lichen sclerosis et atropicus is typical enough and as I mentioned above visual diagnosis just about nails the diagnosis.

[maatson]

Obstruction of the outlet of the apocrine duct adjacent to the skin surface, with subsequent rupture into the intradermal plane, initiates the inflammatory condition termed "hidradenitis suppurativa." The chronic manifestations of the process, indicated by recurrent abscess formation, draining sinuses, skin fistulas, and an intense cicatricial response, usually affect the distal two thirds of the anatomic anal canal because the proximal portion is devoid of hair follicles and accessory glands.
Dis Colon Rectum. 1983 Oct;26(10):669-76.

Chronic hidradenitis suppurativa of the anal canal. A surgical skin disease.
Culp CE.

[someqs17]

So you don't think a biopsy nails the diagnosis? I looked up what you said, the Hidradentitis, and that apparently affects sweat glands...I don't see how that explains a recurrent anal fissure...

[maatson]

I would have given a diagnosis of 'Hidradenitis Suppurativa' as a differential diagnosis, The diagnosis of 'Lichen sclerosis' would much depend on the clinical inspection of the lesion.

[someqs17]

Hi,

Thank you for following up with me. I am unsure what this statement means, "However any anal fissure should also be ruled out because lichen scelrosus is usually found in elderly women." Are you saying an anal fissure is unlikely LS or that it should be re-examined? My plan was to have the biopsy slides sent to my dermatologist, where they do dermapathology, to get a second opinion. If they say its LS, then I guess I will proceed from there. Does that sound like a good plan? How likely is it that the diagnosis is wrong? I'm not actually hoping it's wrong, because I thought it was herpes, and I'd rather have this...

[Bhupinder Kaur, MD]

Hello,
It is very unlikely for the biopsy report to be wrong. However any anal fissure should also be ruled out because lichen scelrosus is usually found in elderly women. Lichen sclerosus is a chronic disease which effects usually the genital areas in postmenopausal women. The exact cause is not known and can be too active immune system and hormone problems.

Some people have also proposed a genetic and hereditary basis of disease. Treatment consists of strong cortisone cream or ointment on the skin. Other treatment  options include Retinoids, vitamin A-like drugs, Tacrolimus ointment and Ultraviolet light treatment.

It is very difficult to precisely confirm a diagnosis without examination and investigations and the answer is based on the medical information provided. For exact diagnosis, you are requested to consult your doctor. I sincerely hope that helps. Take care and please do keep me posted on how you are doing.