Pelvic floor physical therapist Dr. Alexandra DiGrado and sex & couples therapist Dr. Rebecca Howard Eudy get real about sexual health, intimacy, and the stuff we didn't learn about our body in school. From the clitoral hood to parenthood, no topic is off-limits. Each episode blends a combined 30 years of clinical experience with compassionate advice and humor, giving you trusted knowledge, practical tools, and the confidence to take charge of your health and relationships.
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If you’ve been told a genital rash or intense itching is “just a yeast infection,” but the typical treatment hasn’t worked, this episode is for you. Pelvic floor physical therapist Dr. Alexandra DiGrado and relationship & sex therapist Dr. Rebecca Howard Eudy sit down to talk about lichen sclerosus, a chronic inflammatory skin condition that causes patches of skin to become thin, white, crinkled, or scarred. It most commonly affects the genital and anal areas, but can also appear on other parts of the body. Lichen sclerosus is often misdiagnosed and mistreated because its symptoms can look and feel a lot like a yeast infection. This is a shorter episode, but an important PSA if you’ve been dealing with symptoms that won’t clear up, especially if they’re affecting your body image, sex life, and day-to-day comfort.
What you'll learn:
The autoimmune connection: Lichen sclerosus frequently overlaps with conditions like Hashimoto's, Graves' disease, and vitiligo.
Who it impacts most: The average age of diagnosis is 51, most often in people with vulvas, although it can affect people of all ages and sexes.
Impact on intimacy: How muscle guarding and scarring can affect sexual health, and tips to get relief.
Finding the right care: Where to locate knowledgeable providers and support networks if your primary doctor lacks experience with the condition.
Tune in if you've ever thought:
"This itching and burning feels like a yeast infection, but Monistat isn't doing anything.”
"Am I going crazy, or is my skin down there actually changing?”
"I’m so self-conscious about how I look there - I can’t even imagine having sex right now.”
Helpful resources
The Lost Labia Chronicles: Your one-stop shop for all things lichen sclerosus - Education and support resources for all your needs.
If you enjoyed this episode, please follow the show, share it with a friend, and leave a quick rating or review. It takes just 30 seconds, but it's one of the best ways to help our show grow and reach even more people. Thank you for listening!
SPEAKER_00
Welcome to Under the Hood. I'm Dr. Alex DeGrotto, your pelvic floor physical therapist. And I'm Dr. Rebecca Howard Uti, your sex and relationship therapist. Hi, Alex. Hey, good morning. Good morning. It's been a while. I know. It's nice to be back. Yeah, I know. We've both been on conflicting vacations, school schedules and stuff and so on. Yeah. Yeah. Okay. So today we have a listener request. Yep. And I don't know much about it, but I know that you do. So I'm excited to learn more. So we're talking about lichen sclerosis. That's correct. Yep. Did I pronounce that? You did, yeah. Okay. As far as I know. Okay, good. So tell me, what is lichen sclerosis?
SPEAKER_01
Yeah. So this is a, it's actually more common than people even realize. And it's a skin condition that typically affects the vulva, which for people who are still learning their anatomy down there is the outer part. So the vagina is on the inside and the vulva is on the outside. So it's the labia, which are the lips. And it can even affect the anus. It's more common in people with a vulva, but it also can, men can get it as well. People with a penis can also get it, but typically involving people with a vulva and a vagina. And it's thought to be an autoimmune disorder. So it can go in tandem with hypothyroid, Hashimoto's, graves, and different autoimmune diseases like that. Vitaligo is another one that they can go together. And the way that you would be able to tell that you have it is through either a biopsy or clinical presentation. So typically there's these white, patchy, really uncomfortable, scarring, rash type presentation, but it can also cause thickening of that area and a decrease in size of the labia menorah. And so there's an incredible blog called The Lost Labia Chronicles, which is exactly what it sounds like. And so that's one of the ways that people suddenly realize that they have this and can get treatment for it. And it causes a lot of inflammation and itching. It's so uncomfortable. And it can cause fissures, which are like the little tears. Pain with sex. It's really, it can be really hard for folks. And it it's important to get diagnosed so you can get treatment.
SPEAKER_00
And so does it affect just the labia?
SPEAKER_01
It goes, yeah, so it goes, it can go all the way to the anus and it and it goes to the seventh layer of the skin. So it gets deep in there. And so that is when we start talking about the treatment, that's one of the reasons why it's so important to do the treatment correctly.
SPEAKER_00
So then it doesn't go all the way.
SPEAKER_01
Well, because it already is all the way. Oh, I see. We want to make sure that the treatment is getting all the way in there. I see, I see, I see. Okay.
SPEAKER_00
And so but so when you say it's on the labia and it can spread to the anus, like all sort of in the external. But does it go internal? Like can it go into the vaginal?
SPEAKER_01
That's right. Okay. So no, it's primarily in the labia. Yeah, exactly. And the the outer part of the the um peridium and the anus out in there. Yeah.
SPEAKER_00
Okay.
SPEAKER_01
I know. It's really tough. Sounds really painful. And it can affect people of all ages. So you could be, you know, young, you can be old, definitely more toward people who are estrogen deficient. So when you're postmenopausal and your estrogen levels decline, more likely, but we've seen it in young people, we've seen it in postpartum people, perimenopausal.
SPEAKER_00
Wow. Okay. So you it sounds like this would be something that would be tough to miss. It's not only is it very uncomfortable, but visually you would notice or feel a difference. It's like a big change in the skin.
SPEAKER_01
And I wish that I could say that that's true, but a lot of times it's misdiagnosed as a yeast infection. And so, you know, if somebody isn't super familiar with this, I think you actually can miss it. And so it's important to go to the providers that that are familiar with it. Sometimes people will see a specialist.
SPEAKER_00
And I guess that makes sense because if it's presenting with itching, with burning, with pain, it would be easy to think that it was a yeast infection. And you're not usually seen at the doctor for a yeast infection.
SPEAKER_01
And so, and and the the white patches, you could think, oh, that's yeast, you know, but it's not. It's actually the melanocytes change in color because essentially your body is identifying that seventh layer as not itself, you know. So it's sort of attacking that layer. And so that's the challenge because it's very inflammatory. And so the skin will actually scar. Yes. So Okay.
SPEAKER_00
So what is the treatment for this?
SPEAKER_01
Well, clebatazole is really strong steroid. That is the typical treatment. When people use clebatazole, they want to do a sitz bath or a long soak ahead of time so that it softens that thick scar tissue so that the clebatazole can get all the way into the layer that needs it the most. So typically they do a strong steroid for it. And that is part of the treatment, but there's a lot of maintenance that goes along with it. So people often do find that sitz baths in general and soaking can be really helpful for it. And our mutual friend who has it has said that that has really helped with theirs. And so the other thing is addressing the symptoms that come along with it. So people have pain with sex, you know, they have pain with orgasm. So dilator training and using the pelvic wand and helping the muscles to come down from the hypertonic state that they've been in because of the discomfort is a big part of the treatment as well.
SPEAKER_00
I can imagine that when, you know, like we talked about before, when people have chronic pain or they're afraid that there's going to be pain, it would be tempting to avoid being sexual at all. Not only that, but I could imagine also if it's changing the way that the labia looks or something.
SPEAKER_01
Oh, yeah, you feel self-conscious totally. Yeah, and not interested. You're not turned on because you're so uncomfortable. Yeah, absolutely. So probably sex therapy is is another good. Once the treatment is underway and you start to kind of undo the pain and discomfort, then I think, yeah, trying to sort of reestablish that aspect of your life can be tricky. You know, because there's a lot of fear. And as we've talked about with pain in the past, once your brain associates something with pain, then it's trying to avoid the pain. So that's very natural to kind of feel like, oh gosh, I better not do that.
SPEAKER_00
Yeah. Yeah. Yeah. And I think that people can feel, you know, it's like with anything where you end up feeling less attractive, you know, if you're self-conscious about something, so much of desire and sex and pleasure is so mental. Totally. That it is only natural that when you you know your body's literally attacking itself, yeah. That could really put a damper on any desire.
SPEAKER_01
Definitely. Yeah. And I think, you know, we start the vaginal estrogen, perhaps. And maybe sometimes people get surgery for the scarring and the adhesions and they get their treatments underway and they do the sits, the sits baths and the soaks, and they start to feel better. And then then we slowly introduce just re reducing the tension and kind of helping with the scar tissue with manual therapy. And then, you know, we start to slowly, slowly reintroduce. So it's a process, you know, and it can be a lengthy process. And there's certainly some treatments that aren't as research-based that people will try because you're kind of desperate at that point. There's something called an O shot and there's like laser therapies and stuff like that. But we still need a lot more clinical research to say, you know, whether or not those are actually truly effective. Yeah.
SPEAKER_00
It sounds like the early diagnosis and treatment so that you don't end up getting that scar tissue ends up making a big difference.
SPEAKER_01
Definitely. Yeah. And I think just knowing the signs. So if you're seeing that white patchy rash, if you're feeling intense itching, if you're getting fissures, if you're having bruising, if you're having, and then you start to just maybe take a mirror and separate your labia and look, and you just find out, you know, okay, this sounds like what maybe what I'm experiencing, and then bring it, whether it's to a vulvar dermatologist or bring it to a urogynecologist who are more specialized in pain conditions, then hopefully get the right treatment.
SPEAKER_00
Yeah. Yeah, that that makes so much sense. And the it's like again, the shame. Oh, totally. And also that the hassle. Yeah. The hassle of, you know, having a go and find a specialist or getting the right person to treat you is a barrier.
SPEAKER_01
It's a barrier. And also knowing how to use the clebatas all correctly. So it's really important when you do see the provider to really understand how to do it. Because I think if if we're dealing with the deeper layers here, we want to make sure that we're actually getting to the problem, you know, with the treatment. So this is one of those sort of quick talks, but mostly as a PSA, you know, so that if someone's experiencing these symptoms, they know where to look. And I mentioned the lost labia chronicles, which is a great support. But there is actually also lichen sclerosis networks where you can look up the doctors. And there's a doctor who has a free webinar on lichen sclerosis, and her last name is K-R-A-P-F Jill is her first name. And so we'll link it because I think sometimes you just need to find support. Yeah. And so there is a lichen support network that people can use to just to get some resources to hear what other people are doing to help. And then certainly a pelvic floor physical therapist who's familiar with it can help with the down training. Yeah. In conjunction with treatment.
SPEAKER_00
Right. So it sounds like this is something that if you get the right diagnosis, hopefully get treatment early, ideally, but even if not, it's it's very manageable.
SPEAKER_01
Yes, it can be. And I think sometimes the management is long-term. Sure, right.
SPEAKER_00
Well, it's an autoimmune disease. That's right. It's not curable. Totally. But it is manageable. Yeah, exactly. Yeah.
SPEAKER_01
Yeah. Okay, cool. You're very welcome. Thank you for listening to Under the Hood. If you liked this episode, please take a minute and leave us a review. And we'd love to hear from you. If you have any ideas for future episodes, please let us know.
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