Diagnosis and treatment of lichen sclerosus: an update

The SWIFT Model for Lichen Sclerosus Among Premenarchal Girls

OBJECTIVE/PURPOSE

Delay in diagnosis of childhood lichen sclerosus (LS) can be ameliorated with an efficient evaluation tool. We sought to create a useful prognostic tool for rapid and accurate risk stratification for LS in premenarchal girls.

METHOD

We conducted a retrospective chart review at a single institution of premenarchal girls presenting with vulvovaginal complaints at a specialty pediatric and adolescent gynecology clinic at a major academic center. Sixty-nine patients seen between July 2019 and September 2020 were used as a pilot study to create a model for LS based on 18 signs and symptoms. Accuracy of the pilot model was confirmed in a larger data set (additional 105 patients, seen between January 2017 and December 2020), and model parameters were refined through cluster-based analytics.

RESULTS

Pilot study yielded 5 predictors for LS: soreness (S), whitening (W), urinary incontinence (I), fissures (F), and thickening of the clitoral hood (T)-SWIFT. The final refined model is given as log odds (LS) = -7 + 3·S + 17·W + 3·I + 3·F + 18·T. This model yielded a >97% accuracy in predicting LS among 174 unique patients (LS prevalence = 18%).

CONCLUSIONS

The SWIFT model accurately predicts clinical diagnosis of LS in premenarchal girls. Replication in other patient populations is highly encouraged. Awareness of LS is paramount, and an efficient, accurate evaluation tool will prove invaluable in assuring timely diagnosis and treatment for premenarchal patients.

Urologic dermatology: a comprehensive foray into the noninfectious etiologies of balanitis

Balanitis is classically defined as inflammation of the glans penis, often also encompassing the prepuce (balanoposthitis). Several investigations have found that a sizable proportion of urology clinic visits are due to balanitis or related complaints. Balanitis can have numerous complications, including severe pain, urethral stenosis, phimosis, sexual dysfunction, and if untreated, malignancy. Unfortunately, there is no recent or comprehensive review that describes the various etiologies, clinical workup, and treatments for balanitis. Herein this review, we attempt to provide the reader with a complete and updated guide to balanitis in an attempt to improve clinical outcomes.

Photodynamic Therapy in the Treatment of Vulvar Lichen Sclerosus: A Systematic Review of the Literature

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disease involving the genital skin and mucous membrane. Patients exhibit focal atrophy and destructive scarring, with an increased risk of malignant transformation. Due to objective symptoms as well as subjective complaints, patients with VLS experience emotional distress, lowered mood, and sexual dysfunction, which is reflected in impaired health-related quality of life. Thus, the necessity of implementing appropriate therapy at the earliest possible stage of the disease in order to avoid serious complications is highlighted. We presented the systematic review of available literature, performed with MEDLINE, Cinahl, Central, Scopus, and Web of Science databases. We identified a total of twenty relevant studies which indicate that photodynamic therapy (PDT) is a valuable therapeutic modality in the treatment of VLS.

Cancer of the vulva: 2021 update

Vulvar cancer is an uncommon gynecological malignancy primarily affecting postmenopausal women. There is no specific screening and the most effective strategy to reduce vulvar cancer incidence is the opportune treatment of predisposing and preneoplastic lesions associated with its development. While vulvar cancer may be asymptomatic, most women present with vulvar pruritus or pain, or have noticed a lump or ulcer. Therefore, any suspicious vulvar lesion should be biopsied to exclude invasion. Once established, the most common subtype is squamous cell carcinoma. Treatment of vulvar cancer depends primarily on histology and surgical staging. Treatment is predominantly surgical, particularly for squamous cell carcinoma, although concurrent chemoradiation is an effective alternative, particularly for advanced tumors. Management should be individualized and carried out by a multidisciplinary team in a cancer center experienced in the treatment of these tumors.

A useful update for trainees and specialists regarding the diagnosis, staging, treatment, and some controversies in the management of vulvar neoplasms.

Fractional Micro-ablative CO2 Laser as Therapy in Penile Lichen Sclerosus

Introduction: Topical steroids remain the first-line therapy to treat lichen sclerosus (LS), but circumcision may be curative in most cases. Positive results have been obtained by using a fractional micro-ablative CO2 laser to treat genital LS. This study aims to assess the safety and efficacy of the fractional micro-ablative CO2 laser in the treatment of penile LS. Case Presentation: Five treatments with the fractional CO2 laser were performed on one 69-year-old man affected by penile LS. A significant improvement in symptomatology was noted after the first treatment session. Complete clinical remission was achieved 14 weeks after the last treatment. Conclusion: The fractional micro-ablative CO2 laser may represent a practical therapeutic approach in penile LS.

Fractional CO2 laser treatment as adjunctive therapy to topical steroids for managing vulvar lichen sclerosus

Objectives

Uncontrolled vulvar lichen sclerosus (VLS) is often associated with distressful symptoms of genital itch, irritation, and pain and can lead to a pathological process including anatomical changes, scarring, and an elevated risk of cancer in the genital area. First‐line topical corticosteroid as monotherapy is frequently not adequate to fully suppress disease activity and control symptoms. This study evaluated the efficacy of fractional CO₂ laser treatments as adjunctive therapy where recalcitrant VLS had been improved, but not adequately controlled, with topical corticosteroid treatment. Outcomes were evaluated up to 12 months after a series of CO₂ laser treatments delivered via a fractional handpiece.

Materials and Methods

Women with a diagnosis of VLS supported by histologic findings on biopsy and/or clinical signs on physical examination received up to five monthly laser treatments. Subjects maintained existing topical corticosteroid and any exogenous hormone treatment during the study. Investigators assessed severity (0 = not present, 1 = mild, 2 = moderate, or 3 = severe) of clinical signs and architectural changes present before adjunctive study interventions and at follow‐up visits. Subjects reported the presence of clinical symptoms and impact on quality of life on 4‐ or 5‐point Likert scales. The validated Female Sexual Function Index (FSFI) was used to assess changes in sexual function. Four subjects were biopsied before adjunctive laser treatment and at follow‐up.

Results

Twelve females, 11 postmenopausal, with a mean age of 57 ± 10 years received three to five monthly CO₂ laser treatments. Significant improvement in all prominent clinical signs and architectural changes were reported at the 3‐ and 6‐month follow‐ups after the treatment series. Significant improvement was maintained at the 12‐month follow‐up, with 89% of subjects showing at least one‐point improvement in elasticity compared to baseline; 86% in lichenification; 88% in sclerosis; and 80% in whitening and parchment‐like skin. Labial fusion and the extent of disease improved in 50% of patients. Ulcerations present in three subjects at baseline resolved after treatment. Subjects reported 86% improvement in dyspareunia and 83% in skin tearing. Quality of life improved significantly after treatment (p < 0.01). The 6‐month follow‐up FSFI showed significant improvement in sexual function compared to baseline (p < 0.05), with a mean point improvement of 4.5. Histology findings after treatment showed some positive improvement, as a decrease in dermal hyalinized zone thickness. There were no treatment complications or adverse events related to the treatment.

Conclusions

Fractional CO₂ laser treatment outcomes showed improvement in predominant clinical signs and architectural changes in VLS recalcitrant to topical corticosteroid treatment. Adjunctive laser treatment relieved symptoms and improved quality of life as well as sexual function. Fractional CO₂ laser treatment may provide an advanced treatment modality for the management of recalcitrant VLS with improved patient care and sustainable outcomes. Further study in a larger population and with CO₂ laser treatment to both vulvar tissue and the vaginal canal should be explored.

Differentially Regulated miRNAs and Their Related Molecular Pathways in Lichen Sclerosus

Lichen sclerosus (LS) is a chronic inflammatory skin disorder with unknown pathogenesis. The aberrant expression of microRNAs (miRNAs) is considered to exert a crucial role in LS. We used the next-generation sequencing technology (RNASeq) for miRNA profiling and Ingenuity Pathway Analysis (IPA) for molecular network analysis. We performed qRT-PCR, miRNA transfection and Matrigel assays for functional studies. We identified a total of 170 differentially expressed miRNAs between female LS and matched adjacent normal tissue using RNASeq, with 119 upregulated and 51 downregulated. Bioinformatics analysis revealed molecular networks that may shed light on the pathogenesis of LS. We verified the expression of a set of miRNAs that are related to autoimmunity, such as upregulated miR-326, miR-142-5p, miR-155 and downregulated miR-664a-3p and miR-181a-3p in LS tissue compared to the matched adjacent normal tissue. The differentially expressed miRNAs were also verified in blood samples from LS patients compared to healthy female volunteers. Functional studies demonstrated that a forced expression of miR-142-5p in human dermal fibroblast PCS-201-010 cells resulted in decreased cell proliferation and migration. These findings suggest that differentially expressed miRNAs may play an important role in LS pathogenesis; therefore, they could serve as biomarkers for LS management.

What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review

PURPOSE

The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given.

MATERIALS AND METHODS

To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed.

RESULTS

Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL.

CONCLUSIONS

The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.

Human beta defensin levels and vaginal microbiome composition in post-menopausal women diagnosed with lichen sclerosus

Human beta defensins (hBDs) may play an important role in the progression of lichen sclerosus (LS), due to their ability to induce excessive stimulation of extracellular matrix synthesis and fibroblast activation. The genetic ability of the individual to produce defensins, the presence of microbes influencing defensin production, and the sensitivity of microbes to defensins together regulate the formation of an ever-changing balance between defensin levels and microbiome composition. We investigated the potential differences in postmenopausal vaginal microbiome composition and vaginal hBD levels in LS patients compared to non-LS controls. LS patients exhibited significantly lower levels of hBD1 (p = 0.0003), and significantly higher levels of hBD2 (p = 0.0359) and hBD3 (p = 0.0002), compared to the control group. The microbiome of the LS patients was dominated by possibly harmful bacteria including Lactobacillus iners, Streptococcus anginosus or Gardnerella vaginalis known to initiate direct or indirect damage by increasing defensin level production. Our observations highlight that correcting the composition of the microbiome may be applicable in supplementary LS therapy by targeting the restoration of the beneficial flora that does not increase hBD2-3 production.

Vulvar Lichen Sclerosus from Pathophysiology to Therapeutic Approaches: Evidence and Prospects

Vulvar lichen sclerosus (VLS) is a chronic, distressing, inflammatory disease with an enormous impact on quality of life. Treatment goals are relieving symptoms, reversing signs and preventing anatomical changes. Despite the availability of numerous therapeutic options, treatment outcome may not be entirely satisfactory and a definitive cure does not exist. This may be due to the fact that the exact VLS etiopathogenesis remains unknown. The objectives of this paper were to review the most up-to-date knowledge on VLS etiopathogenesis and to consider the available therapies through the lens of a plausible pathogenetic model. An electronic search on both VLS etiopathogenesis and its treatment was performed using the National Library of Medicine PubMed database. Based on current knowledge, it is conceivable that various, heterogeneous environmental factors acting on a genetic background trigger an autoimmune, Th-1 response, which leads to a chronic inflammatory state. This, in turn, can determine both tissue and micro-vascular injury and activation of signaling pathways involved in fibroblast and collagen metabolism. This pathogenetic sequence may explain the effectiveness of anti-inflammatory treatments, mostly topical corticosteroids, in improving VLS clinical-pathological changes. Further deepening of the disease pathways will presumably allow key mediators to become new therapeutic targets and optimize the available treatments.

Lichen sclerosus of the vulva

Lichen sclerosus of the vulva (LSV) is seen frequently enough to warrant knowing how to diagnose it and institute appropriate treatment strategies. LSV is a chronic skin disorder, very likely of autoimmune origin, which may affect various areas of the perineum, although some women may be affected in extragenital areas. The disease has significant adverse impact on quality of life and sexual activity and may undergo malignant transformation. History of symptomatology and clinical examination is sufficient to make the diagnosis. Skin biopsy is only necessary in specific scenarios. Topical corticosteroids are still the mainstay of therapy, initially to institute remission and then for maintenance. Long-term therapy and surveillance are invariably necessary. Surgery does have a role, but only in specific associated conditions. A number of alternative treatment options have been mooted, especially if the disease is resistant to topical corticosteroids, but these options are still being assessed and studied.

Circumcision versus preputioplasty for balanitis xerotica obliterans: a randomised controlled feasibility trial

OBJECTIVES

To determine: (i) feasibility for a randomised controlled trial (RCT) comparing circumcision to preputioplasty and intralesional triamcinolone (PIT) to treat balanitis xerotica obliterans (BXO) and (ii) patient outcomes to inform future study design.

PATIENTS AND METHODS

Approval was obtained from the UK Health Research Authority and local Research Ethics Committee (Reference 16/NW/0364) and the trial protocol registered with ClinicalTrials.gov (NCT02854995). A total of 20 boys (aged 2-16 years) with BXO were randomised to either circumcision or PIT (online parallel group 1:1 allocation, non-blinded). Exclusion criteria were: (i) previous penile surgery and (ii) contraindication for either treatment. Follow-up (including satisfaction questionnaire) was at 6 weeks, 3 and 12 months. Data are presented as median (interquartile range [IQR]), continuous variables were compared by t-test.

RESULTS

A total of 54 boys were approached over 18 months: 23 (45%) were recruited and randomised. The commonest reason for non-entry was treatment preference: 12 preferred circumcision, 18 preferred PIT. Four patients withdrew after randomisation, three did not want circumcision and one did not want PIT. The groups were similar in terms of age (median [IQR] 11 [6-12] vs 8 [7-10] years, P = 0.53) and duration of symptoms (median [IQR] 6 [6-15] vs 6 [2-24] months, P = 0.77). There were no protocol breaches, serious adverse events or postoperative meatal stenosis. There was one self-resolving haematoma after PIT and one suture granuloma after circumcision. Two boys went on to have a circumcision after PIT. Overall, satisfaction levels were high for both groups.

CONCLUSION

A definitive RCT of circumcision vs PIT for BXO appears feasible, with 39% of those approached completing the trial. More families preferred PIT. A robust comparison in the form of a multicentred RCT is required.

Treatment with Theresienöl - a new option in the management of vulvar leukoplakia

Introduction

The term vulvar leukoplakia encompasses a variety of non-inflammatory diseases that lead to skin discoloration of the external genitalia and white colouration. Most commonly, these are vulvar lichen sclerosus (VLS) and squamous cell hyperplasia of the vulva (SCHV). They have similar aetiology, clinical presentation, and treatment but different anatomical pathology.

Aim of the study

The study aims to determine the effect of Theresienöl herbal oil treatment in patients with clinically proven diagnosis of VLS and SCHV.

Material and methods

This prospective study includes 17 patients with a diagnosis of VLS and SCHV, who underwent a 3-month treatment course with Theresienöl herbal oil. All patients were followed up for 1 year after therapy initiation, and the effect of treatment was reported using a visual analogue scale (VAS) for genital itching.

Results

The median age of patients enrolled was 60.6 years (range 42–74); 2 patients dropped out due to failure to attend follow-up visits. The mean score of the VAS taken at the beginning of treatment was 1.65 (0–5); at the 3^rd month the mean score was 9 (8–10) and it remained similar at the 12^th month – 8.67 (7–10).

Conclusions

Theresienöl herbal oil treatment of vulvar leukoplakia is effective and safe, but studies should be continued.

Diagnosis and management of cutaneous and anogenital lichen sclerosus: recommendations from the Italian Society of Dermatology (SIDeMaST)

Lichen sclerosus (LS) is a disabling chronic inflammatory disease of skin and genital mucous membrane causing itch, pain, dysuria and restriction of micturition, and significant sexual dysfunction and dyspareunia both in women and men. If left untreated, LS is associated with a high degree of sclerosis and scarring, as well as with an elevated risk of cancer in the genital area. Although a central role of autoimmunity is suggested, the pathogenesis of LS is still not clearly understood and the disease remains difficult to treat. The goals of treatment of LS are to alleviate symptoms and discomfort, prevent anatomical changes and prevent malignant transformation. This guideline has been developed by an Italian group of experts. It summarizes evidence-based and expert- based recommendations. The highest level of evidence favors the use of topical high potency corticosteroids; second and third lines' treatments include topical calcineurin inhibitors and topical retinoids, respectively. Surgical treatment has become the treatment of choice in male genital LS with persistent phimosis not responsive to medical treatment. The aim of this paper is to offer evidencebased and easily applicable recommendations for the management of LS.

Study of melanocyte density and epidermal thickness in vulvar lichen sclerosus lesions

OBJECTIVE

This study aimed to analyze changes in melanocyte density and epidermal thickness in vulvar lichen sclerosus (VLS).

METHODS

Vulvar skin tissues were collected from 15 VLS female patients in Beijing Hospital, classified into early (n = 7) and late VLS (n = 8) groups according to pathological manifestations. Melanocyte density and full epidermal and cell-layer (from the bottom of the stratum corneum to that of the basal layer) thickness were calculated using an image analysis software. The control group was normal vulvar skin tissues from 15 females after plastic surgery.

RESULTS

The early VLS (0.170 ± 0.071 µm) and late VLS (0.110 ± 0.035 µm) groups had significantly lower densities of epidermal melanocytes than the control group (0.275 ± 0.036) (F = 36.426, P < 0.001). The cell-layer thickness did not differ between the early VLS (154.603 ± 121.984 µm) and control (176.974 ± 80.296 µm) groups (P = 0.899) but significantly decreased in the late VLS group (83.455 ± 37.129 µm) compared to the control group (P = 0.003).

CONCLUSIONS

Melanocyte density decreased in early and late VLS. The full epidermal and cell-layer thickness did not significantly change in early VLS, but the cell-layer thickness decreased in late VLS.

Applying limiting entropy to quantify the alignment of collagen fibers by polarized light imaging

Collagen alignment has shown clinical significance in a variety of diseases. For instance, vulvar lichen sclerosus (VLS) is characterized by homogenization of collagen fibers with increasing risk of malignant transformation. To date, a variety of imaging techniques have been developed to visualize collagen fibers. However, few works focused on quantifying the alignment quality of collagen fiber. To assess the level of disorder of local fiber orientation, the homogeneity index (HI) based on limiting entropy is proposed as an indicator of disorder. Our proposed methods are validated by verification experiments on Poly Lactic Acid (PLA) filament phantoms with controlled alignment quality of fibers. A case study on 20 VLS tissue biopsies and 14 normal tissue biopsies shows that HI can effectively characterize VLS tissue from normal tissue (P < 0.01). The classification results are very promising with a sensitivity of 93% and a specificity of 95%, which indicated that our method can provide quantitative assessment for the alignment quality of collagen fibers in VLS tissue and aid in improving histopathological examination of VLS.

Proposition of a severity scale for lichen sclerosus: The "Clinical Lichen Sclerosus Score"

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin disease of the anogenitalarea leading to itch, burning, sexual dysfunction and impaired quality of life. An unmet need in the context of LS is a practical, easily assessable grading scale to classify disease severity and to allow intra- and interindividual comparisons. The objectives of this study were i) to assess the prevalence and severity of 23 items proposed by a recent Delphi consensus group in patients with adult VLS. ii) to develop a clinical severity scale and, iii) to test the interrater reliability of this novel severity scale. A retrospective assessment of the prevalence and severity of 23 items in 143 patients was performed by using patient records and photo documentation to develop a novel clinical severity scale (i.e. the "Clinical Lichen Sclerosus Score" = CLISSCO) for VLS. Thereafter, the CLISSCO was validated by 16 raters. We found that the items proposed by the consensus group vary markedly in frequency and severity. Following selection of the most relevant items, the CLISSCO was developed consisting of 3 "Symptoms", 3 "Signs" and 6 "Architectural changes" rated on a 0-4 point Likert-scale. The intraclass correlation coefficient was excellent for each item, the applicability of the CLISSCO considered user-friendly by the raters. We conclude that the CLISSCO proved to be a user-friendly, reliable tool to assess disease severity in VLS. However, further studies are needed to validate its applicability and value in daily practice and clinical research.

Efficacy of 5-Aminolevulinic Acid (ALA)-Photodynamic Therapy (PDT) in Refractory Vulvar Lichen Sclerosus: Preliminary Results

Background

As a chronic inflammatory skin disease of unknown etiology, vulvar lichen sclerosus (VLS) mainly affects postmenopausal and perimenopausal women. The main clinical manifestations of VLS include itching, burning pain, and sexual dysfunction, which can lead to a decline in quality of life. The existing treatment options include topical corticosteroid ointment, estrogen, and traditional Chinese medicine; however, their therapeutic effects on VLS remain unsatisfactory.

Material/Methods

Thirty patients with VLS and routine treatment failure were treated with 5-aminolevulinic acid (ALA)-photodynamic therapy (PDT). A 20% ALA water-in-oil emulsion was applied to the vulvar lesions and sealed with plastic film for 3 h. Patients were irradiated at a power density of 60 to 90 mW/cm² with a red light at a wavelength of 635±15 nm for 20 min, delivering a total dose of 100 to 150 J/cm² per session. The treatment was repeated 3 times every 2 weeks. The objective parameters, female sexual function index (FSFI) and quality of life (QoL) scores, were used before and after treatment to evaluate the clinical curative effect.

Results

All patients completed 3 treatment cycles of ALA-PDT and follow-up visits. The clinical symptoms of pruritus completely disappeared in 27 cases, and itching improved from severe to mild in 3 cases. The pathological changes of all patients were objectively improved. FSFI score decreased significantly after treatment (P<0.001). The main adverse effects of ALA-PDT were pain, erythema, and swelling. These adverse effects were temporary and tolerable. The QoL score was significantly improved after treatment (P<0.001).

Conclusions

ALA-PDT is an effective and safe approach for the treatment of VLS.

Koebnerization of Lichen Sclerosus Et Atrophicus at Insulin Injection Sites - A Rare Case with Dermoscopic Features

Lichen sclerosus et atrophicus (LSEA), also known as lichen sclerosus (LS), is a disabling, cosmetically disfiguring condition predominantly affecting the anogenital region of pre- and postmenopausal females. Extragenital LS is relatively less common and occurs predominantly on the trunk and neck. Koebnerization or isomorphic phenomenon is reported occasionally in LS after trauma like radiotherapy. A few case reports describe koebnerization of LS at injection sites. We describe the first such case in India of LS koebnerizing at insulin injection sites with dermoscopic features.

Microablative fractional radiofrequency as a therapeutic option for vulvar lichen sclerosus: a pilot study

OBJECTIVES

To assess the clinical response to and the histomorphometric effects of microablative fractional radiofrequency (MFR) in women with symptomatic vulvar lichen sclerosus (VLS).

METHODS

This was a pilot study on the use of MFR for the treatment of VLS. Upon recruitment and at each treatment session, all participants were examined and each of their symptoms were rated on a visual analog scale. After the procedure, the participants completed a satisfaction questionnaire. We compared the morphometric findings of vulvar biopsies performed at enrollment and after the last treatment session. The participants were divided into three groups according to previous treatment with corticosteroids: G1, no previous treatment; G2, treated for up to 5 years; and G3, treated for >5 years.

RESULTS

This study included 26 women. After two to three sessions, most participants in all groups became either "asymptomatic" or "much better" than before treatment and were "very satisfied" or "satisfied" with the intervention. Pruritus and burning sensation were the most frequently reported symptoms. Nearly 40% of the participants in all groups reported complete remission of symptoms. The improvement was rated as moderate or higher by 80%, 76%, and 66% of the women in groups 1, 2, and 3, respectively. The improvement of symptoms persisted for 11 months (range, 7-16 months), on average, after the treatment. Type III collagen concentration significantly increased and was associated with important symptom improvement. Tissue trophism and vascularization also increased but did not reach statistical significance, probably because of the small number of cases.

CONCLUSIONS

MFR may be an effective and safe treatment for symptomatic VLS.

Histopathological Coexistence of Extragenital Lichen Sclerosus and Morphea in a Single Lesion

Lichen sclerosus (LS) and morphea are two infrequent inflammatory dermatoses of unknown etiology. LS is characterized by, polygonal, bluish-white, slightly elevated papules that coalesce into plaques, which become increasingly atrophic overtime.it mostly affects genitals, however, it can affect any site on the skin and mucosa. Morphea characterized by, erythematous to violaceous patches or plaque with a white, sclerotic center, and the outer edge of the lesions take on the characteristic violaceous ring. The overlapping clinical and histopathologic features of both LS and morphea in the same patient have led some to speculate that they may have a common pathologic link or that both conditions represent the same disease spectrum. The coexistence of LS and morphea in the same lesion is a rare finding. We present a patient, who was diagnosed with what appeared clinically to be extragenital LS, but with histopathologic features of both LS and morphea.

5-ALA-photodynamic therapy in refractory vulvar lichen sclerosus et atrophicus

OBJECTIVE

As a chronic inflammatory skin disease of unknown etiology, vulvar leukoplakia mainly affects postmenopausal and peri-menopausal females. The main clinical manifestations of vulvar lichen sclerosus et atrophicus (VLSA) include itching, burning pain, and sexual dysfunction, which can lead to a decline in the quality of life. The existing treatment options include topical corticosteroid ointment, estrogen, and traditional Chinese medicine. However, their therapeutic effects on VLSA remain unsatisfactory. In the present study, we aimed to investigate the clinical efficacy and safety of photodynamic therapy (PDT) in combination with 5-aminoketovaleric acid (ALA) for the treatment of vulvar leukoplakia.

METHODS

A total of 30 patients with VLSA who failed routine treatment were treated with ALA-PDT. The patients were irradiated at a power density of 60-90 mW/cm² with a red light at a wavelength of 635±15 nm for 20 min. Twenty percent of ALA water-in-oil emulsion was applied to the lesion and sealed with plastic film for 3 h. The treatment was repeated three times every 2 weeks. The objective and subjective symptoms and signs of vulvar lesions based on the horizontal visual analogue scale were recorded at 6 months after each treatment and the last treatment.

RESULTS

All patients completed three cycles of ALA-PDT and follow-up. The clinical symptoms of pruritus completely disappeared in 27 cases. Itching changed from severe to mild in three cases. The pathological changes of all subjects were improved. The main side effects of ALA-PDT were pain, erythema, and swelling. The side effects were temporary and tolerable. All patients reported their results as "satisfied" or "very satisfied".

CONCLUSIONS

ALA-PDT was an effective and safe approach for the treatment of VLSA.

Morphea patients with mucocutaneous involvement: A cross-sectional study from the Morphea in Adults and Children (MAC) cohort

BACKGROUND

Demographic and clinical findings of patients with mucocutaneous morphea have not been well characterized, to our knowledge.

OBJECTIVE

To determine the demographic and clinical characteristics of morphea patients with mucocutaneous lesions who were enrolled in the Morphea in Adults and Children cohort.

METHODS

Cross-sectional study of 735 patients in the Morphea in Adults and Children cohort from 2007 to 2018.

RESULTS

A total of 4.6% of linear morphea patients had oral involvement versus 2.4% among the entire cohort, whereas 10.3% of generalized morphea patients had genital involvement versus 3.7% among the entire cohort. Patients with genital lesions were older at disease onset than those with oral morphea (57 versus 11.5 years; P < .001) and had more frequent extragenital lichen sclerosus et atrophicus (59.2% versus 5.6%; P = .004).

LIMITATIONS

Selection bias and limited number of affected subjects.

CONCLUSION

Oral morphea lesions predominate in younger patients with facial linear morphea, whereas genital lesions predominate in postmenopausal women with overlying extragenital lichen sclerosus et atrophicus.

Female Sexual Dysfunction: Pharmacologic and Therapeutic Interventions

Female sexual dysfunction is associated with personal distress and includes female sexual interest and arousal disorder (including former hypoactive sexual desire disorder), female orgasmic disorder, genitopelvic pain and penetration disorder, and substance- or medication-induced sexual dysfunction. These disorders are remarkably common among women, with an estimated prevalence of 20-40%. It is our responsibility as obstetrician-gynecologists to identify risk factors and screen for female sexual dysfunction. Appropriate screening allows for further exploration into sexual function and dysfunction and, ultimately, determination of associated distress. Treatment often involves addressing the underlying issue through therapy or medical management. For female sexual interest and arousal disorder, treatment generally includes cognitive behavioral therapy, often with a mindfulness focus, and consideration of pharmaceutical management. Female orgasmic disorder is treated with education and awareness, as well as therapy. Evaluation for underlying etiology is particularly critical for genitopelvic pain and penetration disorder to allow treatment of an underlying condition. Finally, substance- or medication-induced sexual dysfunction is best managed by cessation of the implicated substance and consideration of adjunctive therapy if dysfunction is related to antidepressants. Female sexual dysfunction is often overlooked in clinical practice; however, there are effective medical and psychological options for management.

Development of Extragenital Lichen Sclerosus in Malignant Melanoma Patients Treated With Ipilimumab in Combination With Nivolumab

The immune checkpoint inhibitors opened a new era for the treatment of melanoma. Nowadays, combined immune checkpoint inhibitors are administered to provide additive or synergistic effects on anti-melanoma immunity. The use of these drugs comes with serious adverse events related to excessive immune activation. Here, we present development of extragenital lichen sclerosus in a patient with metastatic malignant melanoma, during the combined therapy with checkpoint inhibitors.

Adipose tissue stromal vascular fraction and adipose tissue stromal vascular fraction plus platelet-rich plasma grafting: New regenerative perspectives in genital lichen sclerosus

Lichen sclerosus (LS) is a chronic relapsing, inflammatory skin disorder usually involving the anogenital region of both sexes lacking a resolutive therapy. This study compared adipose tissue derived-stromal vascular fraction (AD-SVF) and AD-SVF-enriched platelet-rich plasma (PRP) therapy in the management of genital LS patients. Additionally, in vitro evaluation of cells and growth factors contained in the injected SVF has been evaluated as possible predictive factors for treatment outcome. The study population was 40 patients diagnosed with LS who were symptomatic despite medical treatment. Patients (age 43-78 years) randomized into two groups using a 1:1 allocation ratio, were evaluated clinically and assessing dermatology life quality index (DLQI) before and 6 months after treatment. Both procedures demonstrated a strong safety profile with no complications linked to the therapy. After 6 months, both treatments allowed for a significant improvement respect to baseline. Combinatory therapy demonstrated decreased efficacy in late stage patients. No correlations have been found between clinical and biological findings. AD-SVF and AD-SVF plus PRP are safe and effective regenerative approaches for genital LS patients. Clinical results support the preferential use of combinatory therapy for early stage patients confirming a synergic effect of AD-SVF and PRP. In contrast, AD-SVF plus PRP is discouraged for late stage patients.

Lichenoid dermatoses involving the vulva: A clinical-pathologic correlation✰

The lichenoid tissue reaction pattern generally signifies cytotoxic damage to the epithelium. When such reaction pattern occurs on vulvar skin or mucosa, the effects can result in considerable morbidity. None of the entities discussed in this review are entirely unique to the vulva, however, some entities may classically occur at this site, while others tend to be widespread diseases that may incidentally affect vulvar skin and mucosa. Given the complex anatomy of the vulva and the bridging of a site showing both keratinizing squamous epithelium and non-keratinizing squamous mucosa, histopathologic features may display variation in presentation. Although identification of a "lichenoid reaction pattern" alone may provide insight into the disease process, understanding of clinical presentation and specific sites of involvement, along with recognition of the nuanced features of the disease entities can help establish a specific diagnosis. Accurate histopathologic diagnoses by pathologists can improve the ability for treating clinicians to implement timely and effective treatment.

Vulvar leukoplakia: therapeutic options

Vulvar leukoplakia is not a histological diagnosis and involves several diseases. Most commonly, these are vulvar lichen sclerosus and squamous cell hyperplasia of the vulva. These two conditions have similar aetiology, clinical presentation and treatment but different histopathological changes. They both lead to significant impairment of quality of life, risk of malignancy, as well as recurrence after treatment. Treatment of these conditions includes topical corticosteroids as a first-line therapy, but they have their side effects and not all patients are receptive to this therapy. This requires the use of alternative therapeutic options such as topical calcineurin inhibitors, topical and systemic retinoids, other steroid creams, various destructive techniques and, as a last resort, surgical removal of affected tissues. Surgical treatment should be avoided, despite the malignant potential, because of recurrence risk in both diseases New therapeutic approaches are coming into effect in gynaecological practice due to potential risks of the above-mentioned methods. Platelet-rich plasma therapy, ablative and non-ablative laser treatment, and new topical medicines, are some of the new options applied to improve the efficacy of treatment avoiding the side effects of conventional medications. A number of them are still in their initial phase of application and time will tell their effectiveness.

Frontal fibrosing alopecia and genital Lichen sclerosus: Single-center experience

BACKGROUND

Despite the incidence of Frontal fibrosing alopecia (FFA) has been increasing in last two decades, the pathophysiology and trigger factors of FFA have not been yet fully understood.

AIMS

The aim of this study was to describe epidemiology, clinical and trichoscopic features and comorbidities of FFA patients, in order to improve the understanding of this disease.

PATIENTS/METHODS

A retrospective, observational monocentric study was conducted from 2003 to 2019. Data concerning epidemiology (age, gender, age of menopause, and age of FFA onset), comorbidities, current therapies, localization of FFA (such as frontotemporal hairline, occipital, eyebrow, eyelash, beard, sideburns, and body hair), presence of papules and sign of Lichen planus (LP) at skin, mucosae and/or nail were collected for each patient included.

RESULTS

A total of 119 Caucasian, adult patients (8 men and 111 female) with FFA were enrolled in the study. Cutaneous, mucosal, or nail localization of LP were found in 16% of our subjects. Interestingly, 15 out of 119 subjects (10.61%) were affected by concomitant genital Lichen sclerosus (LS) and 5 out of these 15 patients (4.38%) presented both LS and LP in association with FFA.

CONCLUSION

Considering the high prevalence of LS in FFA patients in our case series, and the frequency of autoimmune comorbidities in both LS and FFA, it is possible to hypothesize an autoimmune process in both conditions. Further studies are needed for a better understanding of the nature of the association between LS and FFA.

Photodynamic therapy in dermatology: Beyond current indications

Photodynamic therapy (PDT) has long been used in dermatology as a therapeutic strategy for several malignant and premalignant conditions. Currently, it is approved in Europe for the treatment of actinic keratosis, squamous cell carcinoma in situ, and some forms of basal cell carcinoma, with favorable clearance rates associated with satisfying aesthetic results. Nonetheless, in the past few years, PDT has also demonstrated efficacy in many other conditions, including inflammatory and infectious dermatoses. These results, probably explained by its immunomodulatory, anti-inflammatory, and bactericidal effects, may lead to an expansion of PDT indications in the upcoming years. In this article, conditions where PDT may be useful are reviewed, thus highlighting the potential of this therapeutic modality for the dermatologist.

A Case of Generalized Lichen Sclerosus et Atrophicus

A 62-year-old female, with previous history of asthma and hypertension, presented with generalized hyperpigmented skin lesion, found a year ago. Physical examination revealed brown colored lichenified and sclerotic patches on the lower abdomen and flexural areas of extremities. Punch biopsy was performed and histopathological examination revealed hyperkeratosis, follicular plugging and thinning in epidermis. In dermoepidermal junction, cleft like space separating atrophic epidermis and dermis was seen. Also, lichenoid lymphocytic infiltration was observed in mid-dermis. Based on clinical and histopathological findings, a diagnosis of generlaized lichen sclerosus et atrophicus (LSA) was made. Other laboratory examinations were unremarkable. As there is no standard treatment for LSA, the patient received various treatments including topical steroid, tacrolimus and narrow-band ultraviolet B therapy. The skin lesion has softened and its color improved after treatment. LSA is defined as infrequent chronic inflammatory dermatosis with anogenital and extragenital manifestations. Generalized type is rare and genital involvement is the most frequent and often the only site of involvement. We report this case as it is an uncommon type of LSA with generalized hyperpigmented and sclerotic skin lesion in a postmenopausal female patient.

Elastophagocytosis and interstitial granulomatous infiltrate are more common in extragenital vs genital lichen sclerosus

BACKGROUND

Genital and extragenital lichen sclerosus (LS) share similar histopathologic features. A recent small series documented elastophagocytosis uniquely in extragenital LS. We evaluated a larger series of LS for elastophagocytosis, elastic fiber loss, and other histopathologic features. We evaluated matrix metalloproteinase (MMP) expression to determine if these proteins play an etiologic role.

METHODS

Genital (n = 42) and extragenital (n = 41) LS biopsies were examined for histopathologic features, elastic fiber alteration (Verhoeff van Gieson staining), and MMP-2 and MMP-9 expression (immunohistochemistry).

RESULTS

Elastophagocytosis and an interstitial granulomatous pattern were significantly more common in extragenital LS than genital LS (43.9% vs 4.7% and 56.1% vs 9.5%). Extragenital LS had mild/focal elastic fiber loss (43.9%), while genital LS had moderate (61.9%) or marked (19%) loss. MMP-9 was diffusely expressed in histiocytes in both types of LS (genital 97.5%; extragenital 100%). Weak MMP-2 expression was seen in genital (58%) and extragenital (55%) LS.

CONCLUSIONS

Extragenital LS, but not genital LS, frequently exhibits elastophagocytosis and interstitial granulomatous infiltrate, and these patterns could contribute to elastic fiber destruction in extragenital LS. While MMP-2 and MMP-9 expression are common in LS, expression did not significantly differ depending on anatomic site and thus is unlikely to explain observed histopathologic differences.

Proposition of standardized protocol for photodynamic therapy for vulvar lichen sclerosus

Background: Photodynamic therapy (PDT) is an alternative treatment modality for vulvar lichen sclerosus (VLS) which is a chronic inflammatory mucosal condition. In literature, no consensus of optimal parameters of PDT for VLS is reached so far.Objectives: The aim of this narrative review is to develop a standardized treatment protocol for PDT in VLS.Methods: A systematic literature search was conducted to identify studies reporting on PDT in VLS and used treatment parameters, side-effects, and clinical outcomes were summarized.Results: Thirteen studies used 5-aminolevulinic acid (5-ALA) with concentrations of 20%, 10%, 5% and three studies used methyl aminolevulinate (MAL). Generally, the light source was red light (median 630 nm). Light dose varied between 9 and 180 J/cm² and light intensity between 40 and 700 mW/cm². Incubation period with the photosensitizer ranged from 2 to 6 h. All studies showed a substantial improvement in VLS-related pruritus, burning and pain.Conclusions: Based on a literature review, we suggest the following protocol for PDT in VLS: 5% 5-ALA as a photosensitizer applied for 3 h under occlusion before irradiation at the dose of 120 J/cm² with red light (590-760 nm) and intensity of 204 mW/cm².

Lichen sclerosus among women in the United States

Background

Vulvar lichen sclerosus (LS) is a chronic dermatosis for which the true prevalence is not well established. LS remains an underrecognized and undertreated disease, and treatment patterns and differences among various specialties that care for patients with LS are largely unknown.

Objective

This study sought to determine the prevalence of diagnosed vulvar LS, demographic characteristics, and diagnostic and treatment patterns in the United States.

Methods

A database comprising >21.7 million women with commercial insurance in the United States was analyzed, and the largest cohort of patients with LS in the United States to date was identified.

Results

We found that obstetricians/gynecologists are diagnosing and managing approximately half of women with LS, and regardless of specialty, the majority of providers are appropriately prescribing high-potency topical steroids.

Conclusion

Our results suggest that LS may truly be underrecognized and underdiagnosed, especially in younger women.

Benign dermatoses of the male genital areas: A review of the literature

The male genitalia are a common site of dermatoses. Patients with penile diseases often delay or avoid medical care due to anxiety and embarrassment. In this narrative review, we describe some of the main benign dermatoses localized to male genital, focusing on their epidemiology, clinical and dermoscopic features, as well as available therapies.

Ultrasound evidence of bladder outlet obstruction secondary to lichen sclerosus et atrophicus in boys (balanitis xerotica obliterans)

BACKGROUND

Lichen sclerosus (LS), (balanitis xerotica obliterans), causes pathological phimosis. Many boys present with obstructive symptoms, the cause is usually obvious on examination so ultrasound scans (USS) of the urinary tract are not routinely indicated. We review a series of abnormal USS in boys with LS.

METHODS

Retrospective note review for boys undergoing surgical treatment for LS between 2000 and 2017. Seventy-eight boys had a USS prior to surgery, those with abnormal USS form the study population. Boys with neuropathic bladder or congenital urinary tract abnormalities were excluded.

RESULTS

Nineteen of 78 boys (24%), mean age 9 years, were included. Seventeen had obstructive symptoms, 13 had culture proven UTIs, 12 had new onset incontinence. On USS 3 (17%) had acute retention, 8 (78%) had an isolated post-void residual volume (PVR) >10% of estimated bladder capacity (EBC); 3 had bladder wall thickening +/- PVR >10%, 5 had upper tract changes. Symptoms resolved with successful treatment of LS. Six boys had post treatment USS, abnormalities resolved in 5.

CONCLUSIONS

Clinicians should consider LS in boys presenting with UTIs, new onset incontinence and obstructive urinary tract symptoms. Routine USS are not indicated though should be considered in those with an atypical history or examination.

TYPE OF STUDY

Case Series.

LEVEL OF EVIDENCE

Level 4.

Anogenital lichen sclerosus

Lichen sclerosus (LS) was first described by Hallopeau in 1887. It is a chronic inflammatory condition most commonly involving the anogenital region with a relapsing course and a potential for destruction, functional impairment, atrophy, and malignant changes. LS affects both sexes with a female preponderance of 5:1. The exact prevalence of the disease is difficult to predict as the lesions are asymptomatic in the initial phase and later when the complications arise patients might visit the surgeon, pediatrician, gynecologist, or urologist. The etiology of LS has a complex interplay of genetic factors, autoimmunity, infections, and trauma. Physical examination to assess the extent of the disease and decide the line of management is the most crucial step in the management. Corticosteroids, calcineurin inhibitor, retinoids, phototherapy, and surgery can be helpful. Self-examination and long-term follow-up are necessary.

Balanitis xerotica obliterans: an update for clinicians

Lichen sclerosus (LS) is a severe, chronic, dermatosis characterised by inflammatory, sclerotic, pruritic lesions that causes significant morbidity in patients of all genders and ages. In boys, the lesions typically affect the foreskin and glans (termed balanitis xerotica obliterans (BXO)), leading to phimosis and potentially meatal stenosis. The incidence of the disease is not well reported but the average age of affected boys is 8 years (range 1-16). Diagnosis can often be made clinically, although histological study remains important to rule out important differential diagnoses. Complications include genital scarring, urinary and sexual dysfunction as well as the development of carcinomas in adult life. Circumcision has been regarded as definitive management of BXO in boys, but this may be supplemented with medical therapies such as topical steroids, immune modulators, intralesional triamcinolone and ozonated olive oil. Supportive measures including emollients, avoidance of irritants, surveillance of complications and recurrence as well as education and counselling remain important.Conclusion: BXO remains an important cause of phimosis in boys. The frequency of this condition appears unclear but seems likely to be less than 1% of males. Treatment generally involves circumcision, with some evidence that topical steroids or immunomodulators may decrease the incidence of recurrent meatal stenosis.What is Known:• Surgical circumcision is considered the definitive management of BXO• Many aspects of BXO are still in contention or require further study including the epidemiology and aetiology.What is New:• There is increasing awareness of non-surgical modalities that may be used in adjunct to surgery including topical corticosteroids, immune modulators, intralesional triamcinolone and ozonated olive oil• Awareness of meatal stenosis-related BXO has led to the development of surgical techniques such as preputioplasty as well as buccal mucosal inlay grafts.