Ultrapotent topical corticosteroid treatment of childhood genital lichen sclerosus

Does compliance to topical corticosteroid therapy reduce the risk of development of permanent vulvar structural abnormalities in pediatric vulvar lichen sclerosus? A retrospective cohort study

BACKGROUND

Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis of the genital skin, with up to 20% of cases in the pediatric age group. Limited data exist concerning the prognosis of pediatric VLS, particularly the likelihood of permanent architectural change and whether this can be prevented by compliance with topical corticosteroid treatment (TCS).

OBJECTIVE

To evaluate the extent to which compliance to TCS treatment influences the risk of developing vulvar structural abnormalities, including clitoral phimosis and diminutive or fused labia minora.

METHODS

A retrospective chart review of case records of pediatric-age females with VLS between January 31, 2004 and January 31, 2021.

RESULTS

One hundred eighteen cases of VLS were identified, with a mean age at diagnosis of 7.25 years and a mean follow-up period of 42.7 months. Thirty-four girls were "partially compliant," whereas 84 were "compliant." The risk ratio (RR) of developing any vulvar structural abnormality or clitoral phimosis was 5.76 (95% CI 2.96-11.3) and 21.2 (95%CI 5.23-85.9) times higher, respectively, in partially compliant compared with compliant subjects. The RR of a partially compliant female with pre-pubertal onset VLS having a vulvar structural abnormality persisting beyond menarche was increased 3.54-fold relative to compliant females (95% CI 1.75-7.17).

LIMITATIONS

The retrospective nature of our data, lack of a control group, wide variability in follow-up duration, and nonstandardized method of stratifying compliance.

CONCLUSION

Vulvar structural abnormalities are common in prepubertal onset VLS. Compliance to TCS appears to be critical in the prognosis of pediatric VLS although attitudes underpinning noncompliance to TCS treatment require further elucidation.

Vulvar vitiligo and lichen sclerosus in children: A clinical challenge

Vulvar vitiligo (VV) and vulvar lichen sclerosus (VLS), both feature skin and mucosal hypo-/depigmentation. The aim of this study was to describe the clinical and dermoscopic features of VV and VLS in the pediatric population, providing diagnostic clues, and to define their association. We performed a systematic literature review of the clinical and dermoscopic features of pediatric VV and VLS. An observational study was conducted on children affected by VLS associated with VV, referred to the Dermatology Unit of the Sant'Orsola Polyclinic in Bologna, Italy. Medical history, age at diagnosis, ethnicity, clinical and dermoscopic features, and symptoms were recorded for all patients. 124 cases of VLS and 10 cases of VV were reviewed. Clinical manifestations included hypo-/depigmented patches in both conditions, while ecchymosis/purpura and fissures/erosion were observed in VLS. Symptoms including pruritus, pain, or burning were reported only by VLS patients. In our study five patients with VLS associated with VV were retrieved. Clinical features included well-demarcated depigmented patches in VV and translucent areas, erythema, ecchymoses/purpura, and labial fusion in VLS. Dermoscopy showed white structureless areas with a whipped cream-like appearance, linear or dotted vessels, white chrysalis-like structures, erosion and red-purpuric blotches in VLS and reduced pigment network or pigment absence, intralesional spots of residual pigmentation and telangiectasias in VV. Symptoms were present in all patients. Both VV and VLS show hypo-/depigmented patches. In the presence of associated symptoms, possible VLS should be investigated with clinical and dermoscopic examination to achieve a prompt diagnosis.

Topical Corticosteroids in the Treatment of Vulvar Lichen Sclerosus: A Review of Pharmacokinetics and Recommended Dosing Frequencies

Topical corticosteroids are often utilized as the first-line treatment for vulvar lichen sclerosus (VLS). However, there is wide variability in dosing regimens, as well as a lack of consensus on maintenance dosing. Available guidelines on dosing frequency and regimen continuation for VLS are based on clinical expert opinion and do not necessarily reflect the pharmacokinetics of topical corticosteroids. Over the past few decades, there have been many advances in the techniques used to measure the local and systemic absorption of topical corticosteroids. These techniques have led to a greater understanding of the pharmacokinetics and bioavailabilities of these medications. However, it is not clear how this new information has been applied in evaluating dosing regimens and commonly cited risks when considering short- and long-term use in different vulvar dermatoses. This purpose of this review is to evaluate the available evidence on pharmacokinetics, absorption rates, and concentration levels of topical corticosteroids in lesional and nonlesional skin. Additionally, the evidence regarding commonly cited risks of topical corticosteroid use, including dermal thinning, adrenal suppression, systemic immunosuppression, and tachyphylaxis are reviewed. Differences in the effects of topical corticosteroids on the varied tissues of the vulva are specifically explored. Finally, these considerations are applied to evaluate the current treatment guidelines for VLS to provide direction in determining an evidenced-based dosing regimen and to inform future research in this area. Mautz TT, Krapf JM, Goldstein AT. Topical Corticosteroids in the Treatment of Vulvar Lichen Sclerosus: A Review of Pharmacokinetics and Recommended Dosing Frequencies. Sex Med Rev 2021;XX:XXX-XXX.

Treatment Options in Vulvar Lichen Sclerosus: A Scoping Review

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. The aim of this review is to focus on first-line, second-line, and maintenance therapies as well as follow-up of women with VLS. With numerous controversies, we decided to conduct a scoping review on this subject. A review protocol was developed, and the Knowledge Resource Services website was used to run a search of articles pertaining to VLS with keywords “Vulvar,” “Vulval,” and “Lichen Sclerosus.” The search was limited to published data from the last 10 years, i.e., July 2009 onward, and researches published in English language. A total of 338 articles pertaining to VLS were obtained. Out of this, 62 were original articles related to management of VLS. Effective treatments such as high-potency topical steroids are now the standard of care and first-line treatment. Follow-up may be done every three to six months for the first two years and then at least yearly to ensure adequacy of treatment and encourage compliance. Long-term follow-up in specialist clinics is recommended for women who have persistent complaints, thickened skin, or history of neoplastic lesion. Monitoring young patients yearly is recommended as there are chances of recurrence.

Lichen Sclerosus in Prepubertal Girls: An Uncommon but Treatable Cause of Lower Urinary Tract Symptoms

Lichen sclerosus (LS) is a chronic inflammatory dermatosis commonly visualized in the anogenital region with porcelain-white atrophic patches that extend to the perianal region in a figure-of-eight configuration. While LS is known to increase lower urinary tract symptoms and incontinence in postmenopausal women, the age distribution is bimodal and literature on the LS impact in prepubertal girls remains limited. There is an association with autoimmune conditions and the pathogenesis is thought to be autoimmune with an underlying genetic predisposition. Lack of familiarity among pediatric urology providers may lead to a significant diagnostic and treatment delay, resulting irreversible genital skin changes.

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.

The long-term clinical consequences of juvenile vulvar lichen sclerosus: A systematic review

BACKGROUND

Vulvar lichen sclerosus (VLS) occurring in children and adolescents may have repercussions throughout life.

OBJECTIVE

We sought to assess the evidence available on the long-term consequences of juvenile VLS.

METHODS

Multiple databases were searched for studies containing long-term follow-up information on children or adolescents up to age 18 years with VLS. Articles were classified by level of evidence and the specific aspects of VLS studied.

RESULTS

In all, 37 studies met the inclusion criteria, giving information on the long-term consequences of VLS, of which 13 were cohort studies and 24 were case reports or series. These publications show that signs and symptoms persist after puberty and beyond, scarring and permanent architectural changes occur, treatment is effective with regard to symptoms, and long-term quality of life is affected. Findings suggest a possible relationship with risk of malignancy. The included publications had low-level evidence.

LIMITATIONS

Meta-analysis was not possible because the studies had different focuses. Very few patients were followed into adulthood.

CONCLUSIONS

There is low-level evidence suggesting long-term repercussions of juvenile VLS. Studies following children and adolescents with VLS into adulthood are needed to better understand the course of this disease and its repercussions on adult vulvar health.

Cushing Syndrome Induced by Topical Corticosteroids for the Treatment of Lichen Sclerosus

BACKGROUND

Lichen sclerosus is a chronic inflammatory dermatological condition with a predilection for the anogenital area.

CASE

We describe a case of iatrogenic Cushing syndrome from the administration of high-potency topical steroids for vulvar lichen sclerosus in a 6-year-old girl. Her symptoms resolved after the cessation of topical steroid treatment.

SUMMARY AND CONCLUSION

This case brings attention to iatrogenic Cushing syndrome as a potential complication when using high-potency topical corticosteroids in the anogenital region.

The treatment of vulval lichen sclerosus in prepubertal girls: a critically appraised topic

Lichen sclerosus is one of the dermatoses that specifically affects the anogenital skin. It has peaks of incidence in prepubertal girls and postmenopausal women. The objective of this critical appraisal was to review systematically the evidence for efficacy and safety of different treatments. There are no randomized controlled studies of treatment in prepubertal girls and most studies are small case series or case reports. There is little focus on quality of life.

Vulval Disease from the 1800s to the New Millennium

Background:

The study of vulval disease has become important over the last few decades. Although several inflammatory dermatoses were described at the end of the 19th century, vulval involvement in these conditions was only realized some time later. Indeed, the vulva may be a site of predilection of some inflammatory dermatoses such as lichen sclerosus.

Objective:

There are now groups of interested dermatologists, gynecologists, and genitourinary physicians that have cooperated to study patients with vulval disease. Hopefully, this will increase our knowledge over the next century.

Conclusion:

This review article examines vulval disease from an historical viewpoint and highlights important developments that have increased our understanding of the disorders that specifically affect the vulva.

[Vulvar diseases]

Vulvar diseases might cause problems in the differential diagnosis, because the clinical presentation of inflammatory, infectious and neoplastic disorders may be quite similar. Itching and pain as well as dysuria and dyspareunia are the most common symptoms of vulvar diseases. Inflammatory dermatoses like atopic and contact dermatitis, lichen planus, lichen sclerosus and atrophic vulvitis account for the majority of cases in specialized clinics. Furthermore, neoplastic conditions such as vulvar carcinoma, vulvar intraepithelial neoplasia (VIN) and vulvar Paget's disease have to be considered. Another frequent group are infections. Candida spp., herpes simplex viruses and human papilloma viruses are common pathogens. Additionally, vulvodynia is a typical problem that is sometimes difficult to treat. Because of the wide spectrum of clinical symptoms, cooperation with gynaecologists and psychosomatic specialists should be considered in difficult cases. The typical clinical presentations, their specific signs and symptoms, and pitfalls in the dermatological consultation are discussed.

Pediatric Lichen Sclerosus: A Review of the Epidemiology and Treatment Options

Lichen sclerosus (LS) is a rare, chronic, inflammatory disease of the skin that primarily affects postmenopausal women but may occur in men and children as well. Approximately 7% to 15% of cases are believed to occur in children. The epidemiologic data for LS have been limited and treatment options are not well studied, particularly in children. We reviewed new developments available in the current literature on the epidemiology and management of LS for children.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

Prepubertal-Onset Vulvar Lichen Sclerosus: The Importance of Maintenance Therapy in Long-Term Outcomes

BACKGROUND

There is sufficient published data on induction treatment with potent topical corticosteroid (TCS) in childhood vulvar lichen sclerosus (VLS) but limited data on long-term management. VLS has been shown to extend beyond menarche and repercussions of suboptimal long-term control may be devastating and permanent. This single-center retrospective study reviewed outcomes of long-term treatment using individualized regimens with target outcome of complete objective normality.

METHODS

Forty-six girls with prepubertal-onset VLS were studied for demographic data, previous treatment, induction and maintenance treatment, clinical response and compliance. Photographic records were available for all patients. The cohort was divided into two groups: adherent (using treatment all or most of the time) and non-adherent (using treatment some or less of the time).

RESULTS

Twenty-six patients (56%) had received prior treatment however only three had achieved disease control using daily potent TCS. Twelve patients (26%) had scarring on presentation. All achieved initial objective disease suppression with induction treatment using potent TCS. Thirty-one of 33 adherent patients (93.93%) sustained complete disease remission with no progression or scarring. In contrast, 1 of the 13 nonadherent patients (8%) achieved complete disease remission (p < 0.001), 9 of the 13 (69.23%) experienced disease progression (p < 0.001) and 3 of the 13 (23%) developed scarring during follow-up. Those with established scarring on presentation did not recover with treatment.

CONCLUSION

Our data support previous studies regarding initial treatment with potent TCS but additionally suggest maintenance treatment with individualized regimens that achieve objective normality in addition to symptom control provide optimal outcomes.

Treatment of vulvar lichen sclerosus with topical corticosteroids in children: a study of 72 children

Treatment of vulvar lichen sclerosus (VLS) in children by topical corticosteroids gives control of symptoms and some resolution of physical signs, but large studies are limited. We report the largest study of 72 prepubertal girls with VLS, 62 of whom were prospectively treated with daily application of an ultrapotent topical corticosteroid (UPTC), clobetasol propionate 0.05% ointment, for 3 months, with a follow-up period of 4-8 years [the remaining 10 patients responded to mild to moderate potency topical corticosteroids (MPTCs)]. The results were compared with a retrospective study of 31 prepubertal girls with VLS treated with MPTCs. MPTCs led to symptom clearance in 32.2% of patients, whereas UPTC led to symptom clearance in 72.6% of patients. Improvement in clinical signs following UPTC occurred in 90.3% of children at 3 months, with total resolution of clinical signs occurring in 29.2% at the 4-year follow-up or at puberty. No serious adverse effects occurred with UPTC treatment. In children with VLS, UPTCs relieve symptoms, resolve signs and possibly prevent scarring. UPTCs should therefore be the treatment of choice for VLS in children.

Diagnosis and treatment of lichen sclerosus: an update

Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of genital and extragenital skin. LS is a debilitating disease, causing itch, pain, dysuria and restriction of micturition, dyspareunia, and significant sexual dysfunction in women and men. Many findings obtained in recent years point more and more towards an autoimmune-induced disease in genetically predisposed patients and further away from an important impact of hormonal factors. Preceding infections may play a provocative part. The role for Borrelia is still controversial. Trauma and an occlusive moist environment may act as precipitating factors. Potent and ultrapotent topical corticosteroids still head the therapeutic armamentarium. Topical calcineurin inhibitors are discussed as alternatives in the treatment of LS in patients who have failed therapy with ultrapotent corticosteroids, or who have a contraindication for the use of corticosteroids. Topical and systemic retinoids may be useful in selected cases. Phototherapy for extragenital LS and photodynamic therapy for genital LS may be therapeutic options in rare cases refractory to the already mentioned treatment. Surgery is restricted to scarring processes leading to functional impairment. In men, circumcision is effective in the majority of cases, but recurrences are well described. Anogenital LS is associated with an increased risk for squamous cell carcinoma of the vulva or penis. This review updates the epidemiology, clinical presentation, histopathology, pathogenesis, and management of LS of the female and male genitals and extragenital LS in adults and children.

Pediatric vulvovaginal disorders: a diagnostic approach and review of the literature

Vulvovaginal complaints in the prepubertal child are a common reason for referral to the health care provider. The Cochrane Library and Medline databases were searched for articles published in English from 1980 to December 2004 relating to vulvovaginal conditions in girls. The following search terms were used: vulvovaginitis, prepubertal, pediatric, lichen sclerosis, labial fusion, labial adhesion, genital ulcers, urethral prolapse, psoriasis, and straddle injuries. The objectives of this article are to review the normal vulvovaginal anatomy, describe how to perform an age-appropriate examination, and discuss common vulvovaginal disorders and their management in young girls.

Anogenital pruritus: lichen sclerosus in children

Lichen sclerosus is a chronic mucocutaneous inflammatory condition affecting both adults and children in a bimodal age distribution. Children can present as young as 6 months of age but average around 5 years. Females present with vulvar itching, soreness, dysuria, or gastrointestinal complaints, while males tend to have difficulty retracting the foreskin leading to phimosis. On examination, white smooth atrophic plaques are found in the anogenital region with atrophy and possible distortion of anatomy. LS in children has been commonly misdiagnosed as sexual abuse, leading to delay in appropriate diagnosis and unnecessary turmoil for families. It is a chronic relapsing and remitting condition possibly due to autoimmunity. When evaluating patients, a complete history can help guide which patients may benefit from a systemic evaluation for autoimmune disease. Although some patients have spontaneous resolution during puberty, many do not. There is a significant risk of squamous cell carcinoma developing in genital LS in adults possibly from chronic inflammation, delay in diagnosis, and delay in appropriate treatment. The risk of squamous cell carcinoma in pediatric onset LS is undefined. It is also unclear if effective control of cutaneous inflammation can decrease the risk of malignant transformation. Treatment is aimed at decreasing symptoms and returning involved skin to its normal appearance. Relapses are common. Ultrapotent topical corticosteroids are first line for the treatment of LS and can be used intermittently for years for flares. Topical tacrolimus or pimecrolimus are also good treatment options at controlling inflammation. Patients need to be monitored every 6 to 12 months even when asymptomatic because of the potential for development of malignancy. Given the distressing nature of LS, support groups and a multidisciplinary approach are recommended.

Multicentre, phase II trial on the safety and efficacy of topical tacrolimus ointment for the treatment of lichen sclerosus

BACKGROUND

Lichen sclerosus is a chronic inflammatory autoimmune disease causing significant sclerosis, atrophy and pruritus. Treatment remains unsatisfactory, with potent corticosteroids being the most effective therapy.

OBJECTIVES

To conduct a multicentre, phase II trial to assess the safety and efficacy of tacrolimus ointment 0.1% for the treatment of lichen sclerosus with a follow-up period of 18 months at 10 university and teaching hospitals in Germany and Austria.

METHODS

Eighty-four patients (49 women, 32 men and three girls) aged between 5 and 85 years with long-standing, active lichen sclerosus (79 with anogenital and five with extragenital localization) were treated with topical tacrolimus ointment 0.1% twice daily for 16 weeks. Computerized analysis of the lesional area was performed. The primary endpoint was clearance of active lichen sclerosus. Secondary endpoints were time to optimal response, reduction of sclerosis and duration of remission.

RESULTS

The primary endpoint (clearance of active lichen sclerosus) was reached by 43% of patients at 24 weeks of treatment. Partial resolution was reached in 34% of patients. Maximal effects occurred between week 10 and 24 of therapy. Treatment led to a significant reduction of the total lesional area (P < 0.01) and to a significant decline in the total symptom score (P < 0.005). Symptoms (e.g. itching) and findings (erythema, erosions and induration) showed significant improvement. No serious adverse events were observed. There were three (9%) recurrences during the follow-up period.

CONCLUSIONS

Topical tacrolimus ointment 0.1% was safe and effective for the treatment of long-standing active lichen sclerosus.

Successful treatment of vulvar lichen sclerosus in a child with low-concentration topical tacrolimus ointment

Lichen sclerosus is a chronic inflammatory skin disorder that has a predilection for the anogenital area. Topical corticosteroid is occasionally effective; however, continuous treatment is often required and recurrence after its stoppage is frequent. Herein, we report a case of vulvar lichen sclerosus in a 5-year-old girl, which was refractory to topical corticosteroids. After 14 weeks of treatment with 0.03% tacrolimus ointment once daily, the lesions completely resolved without side-effects. Of interest, the number of milia within the plaque of lichen sclerosus was reduced in tandem with the improvement of lichen sclerosus. This is the first report of topical low-concentration tacrolimus treatment showing a dramatic effect in the treatment of childhood vulvar lichen sclerosus.

Lichen sclerosus of the lip

Lichen sclerosus is a chronic inflammatory mucocutaneous disorder predominately affecting prepubertal girls and postmenopausal women. Isolated lichen sclerosus affecting the oral mucosa is exceedingly rare. Only 13 patients with biopsy-proved isolated oral disease have been reported in the literature. We report a 10-year-old Caucasian girl with a well-demarcated 1.5 cm x 1.2 cm atrophic white plaque with a violaceous border and focal telangiectases on the right inferior vermillion lip, extending on to the labial mucosa. No other cutaneous surfaces, including genitalia, were involved. Incisional biopsy of the plaque on the lip revealed a patchy lichenoid infiltrate of lymphocytes associated with sclerosis of the papillary dermis and a thinned epidermis consistent with a diagnosis of lichen sclerosus. Treatment with a short course of high potency topical corticosteroids likely prevented the progression of this lesion.

Ultrapotent topical corticosteroid treatment of hemangiomas of infancy

BACKGROUND

Superficial cutaneous hemangiomas of infancy represent a therapeutic challenge. Two small case series using ultrapotent topical corticosteroids for periocular hemangiomas were reported in the ophthalmologic literature. The use of this therapy for hemangiomas of infancy at other sites on the body has not been reported.

OBJECTIVE

We sought to assess the clinical effects of short-term application of ultrapotent topical corticosteroids for the treatment of hemangiomas of infancy.

METHODS

The records of 34 infants with proliferating hemangiomas of infancy that were treated with ultrapotent topical steroids were reviewed retrospectively. Treatment response was based on: (1) cessation of growth; (2) shrinkage or flattening of the lesion; and (3) lightening of the surface color. Lesions demonstrating responses of two of the three criteria were judged to have good response; one criterion, partial response; and no improvement, no response.

RESULTS

Of the patients, 35% demonstrated good response, 38% partial response, and 27% no response.

CONCLUSIONS

Hemangiomas in 74% of the infants demonstrated either good or partial response to treatment with ultrapotent topical corticosteroids. Of the responders, the majority reported cessation of growth before what would have been expected for their age. Improvement varied, with thinner superficial hemangiomas demonstrating better cosmetic improvement than thicker lesions.

Connective tissue disease in children

As our understanding of connective tissue disease expands, so too does our therapeutic armamentarium. We have learned that autoimmunity triggers inflammation through unchecked, proliferative cell-mediated inflammation. By targeting this arm of the cytokine cascade, it may be possible to arrest further progression. Several biologic agents, such as etanercept, alefacept, infliximab, efaluzimab, and, recently, adalimumab, have come to market for adult psoriasis and are now undergoing trials for juvenile SLE, psoriasis, and psoriatic arthritis. Of note, etanercept has been used successfully in juvenile rheumatoid arthritis for more than 10 years. These agents target cell-mediated inflammation through various mechanisms and hold great promise for the treatment of many of the disease states discussed above. Moreover, the biologics carry an improved side-effect profile not seen with traditional agents such as corticosteroids and will be central in the evolution of targeted therapeutics for these complex immunologic diseases.

Lichenoid eruptions in children

Lichenoid eruptions are quite common in children and can result from many different origins. In most instances the precise mechanism of disease is not known, although it is usually believed to be immunologic in nature. Certain disorders are common in children, whereas others more often affect the adult population. Lichen striatus, lichen nitidus, Gianotti-Crosti syndrome, and lichen spinulosus are examples of lichenoid lesions that are more common in children than adults. Distinguishing these diseases is necessary for prediction of the course of the eruption and for optimal management. In most cases, certain clinical characteristics enable the clinician to reach a diagnosis, whereas in other cases biopsy is required for a definitive answer. Many of these lesions are self-limited and only require symptomatic treatment, although corticosteroids can hasten resolution in certain disorders. Discontinuation of the medication is often sufficient for resolution of lichenoid drug eruptions.

Therapy of pediatric genital diseases

Infants and children have special issues with regard to genital disease. Infants are incontinent, and have an increase in local irritation and infection risk. In addition, the adult sex hormones which enhance the health of genital skin are deficient. Also, the choice of therapy must be modified to take into account the more fragile nature of prepubertal skin, the tolerance of children to painful treatments, and the lack of experience of some medications in children.

Pimecrolimus for the treatment of vulvar lichen sclerosus in a premenarchal girl

BACKGROUND

Lichen sclerosus is a chronic cutaneous disorder with a predilection for the vulva. Lichen sclerosus affects more than one in 900 girls. Superpotent corticosteroids like clobetasol propionate are the most effective treatment for vulvar lichen sclerosus. However, recurrence after stopping steroids is very high. As repeated courses of corticosteroids are frequently needed, there are concerns about potential side effects. Therefore, a treatment regimen that does not rely on corticosteroids may be beneficial. As lichen sclerosus is a T-lymphocyte mediated disorder, it has been suggested that pimecrolimus, a topical T-lymphocyte inhibitor, may be safe and effective for the treatment of lichen sclerosus in children.

CASE REPORT

A 10-year-old girl with lichen sclerosus was initially treated with clobetasol. Remission was achieved, but 3 months later she had a recurrence. Subsequent treatment with clobetasol led to a breakdown of her peri-anal skin with a superimposed infection. She was then treated with pimecrolimus and remission was achieved. She has had no recurrence of active lichen sclerosus and has less burning with pimecrolimus than with clobetasol.

CONCLUSION

Pimecrolimus may be an effective treatment of vulvar lichen sclerosus. Pimecrolimus has been shown to be very safe in the pediatric population for the treatment of mild to moderate eczema, without causing dermal atrophy, tachyphylaxis, striae, rebound flares, or hypothalamic-pituitary axis suppression. As the recurrence rate of active lichen sclerosus in prepubertal girls treated with topical corticosteroids is high, and the majority of prepubertal girls with lichen sclerosus continue to have disease after menarche, a treatment regimen that does not rely on corticosteroids may be beneficial.

Vulvar lichen sclerosus : pathophysiology and treatment

Lichen sclerosus is a chronic disorder of the skin and mucosal surfaces, and is most commonly seen on the female genital skin. It also occurs on other areas of the body. Any age group may be affected, although it is seen more often in elderly women. The exact cause of lichen sclerosus is unknown. There have been reports of family members with lichen sclerosus; thus it may have a genetic link. There is also the possibility of an autoimmune connection. Currently, ultra-potent topical corticosteroids are the medical treatment of choice. Other treatments that have been utilized for this condition include testosterone, progesterone, tacrolimus, surgery, and phototherapy. Surgery should be reserved for symptomatic patients who fail to respond to multiple medical treatments, as there is a high recurrence rate following surgery. The risk of developing squamous cell carcinoma of the vulva approaches 5% in women with vulvar lichen sclerosus, and therefore close surveillance by the healthcare provider and patient is needed. This review discusses the history, clinical features, pathophysiology, and treatment of lichen sclerosus of the vulva, as well as pregnancy issues and sexual function in patients with this condition. In addition, problems specific to children with lichen sclerosus are reviewed.

Lichen sclerosus: a review and practical approach

Lichen sclerosus (LS) is a chronic dermatitis predominantly found in the anogenital area. It can be found in patients of any age group, sex, or race, but is most commonly present in Caucasian peri- or postmenopausal women. Although the etiology of LS remains uncertain, an autoimmune process is believed to underlie this condition. With many cases going unreported, its incidence is still unknown. There is no cure for LS, but treatment offers control of the condition. They are three reasons for treating LS: relief of symptoms and discomfort; prevention of any or further anatomical changes; and a theoretical prevention of malignant transformation. Although many treatments have been suggested to treat LS over the years, only potent or ultra-potent corticosteroids remain as the treatment of choice. After initial therapy, some patients might only use corticosteroids as needed, while others may require a twice-weekly maintenance therapy. There is no place for surgery in uncomplicated LS. Surgery should be limited exclusively to patients with malignancy and to correct scarring secondary to the disease. Lichen sclerosus is associated with a 4-6% risk of squamous cell carcinoma, making long-term follow-up essential in these patients.

Guidelines for the management of lichen sclerosus

These guidelines for the management of lichen sclerosus have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Vulval disease in pre-pubertal girls

Children present with vulval complaints less frequently than do adults; although there are many similarities between paediatric and adult groups of patients with vulval disease, there are also important differences. In both groups, dermatitis, psoriasis and lichen sclerosus are the most frequently seen dermatoses. Birthmarks and congenital abnormalities presenting for the first time are more of an issue in children than in adults. Fusion of the labia and streptococcal vulvovaginitis are conditions seen only in the paediatric group. Sexually transmitted diseases such as genital warts and genital herpes are not common in this group and should always raise the possibility of child sexual abuse. Chronic vulvovaginal candidiasis, although a very common problem in adult patients, is not seen in the prepubertal group.

Management of anogenital lichen sclerosus

Lichen sclerosus (LS) is a skin condition that affects genital and extra genital epithelia in both males and females of all ages and it may occur in association with other autoimmune disease. Currently, the first line effective treatment is an ultra-potent topical corticosteroid. The long-term sequelae of LS include scarring, malignancy, which is rare, and psychosexual disfunction, which is common.