Diagnosis and treatment of lichen sclerosus: an update

Low-level laser therapy: an efficient supplement to treatments of vulvar Lichen sclerosus to improve quality of life

BACKGROUND

Lichen sclerosus (LS) is a chronic, inflammatory disease of the genital and extra genital skin, causing pruritus, soreness, pain and dyspareunia. The aim of this study was to investigate whether Low Level Laser Therapy (LLLT) can improve the quality of life in women with Lichen sclerosus (LS) and insufficient topical treatment.

METHODS

In a descriptive prospective observational study conducted between 02.01.2016 and 08.01.2018, we included 100 women with LS with insufficient topical treatment because of poor response of symptoms. All participants received ten LLLT treatments (808 nm and 500 mW) over a period of 8 weeks. The first four treatments were planned as two treatments per week. The remaining six treatments were planned as once a week. A Danish health-related quality of life tool (HRQoL test) monitored the effect.

RESULTS

A total of 94 patients completed the study, median age of 62 [InterQuartile Range 53-69]. There was a statistically significant improvement in seven of the eight domains of the HRQoL test after ten LLLT. We found the results of DoloTest to be statistically significant in all of the groups except for smoking (p < 0.094).

CONCLUSIONS

LLLT treatment can improve the quality of life in women with LS.

EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness; it may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are usually a whitening of the genital skin, sometimes preceded by redness and oedema; fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS (part 1), highlight important aspects in the care of LS patients, generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

Lichen sclerosus of the eyelid involving the eyelash margin

Lichen sclerosus is a debilitating and chronic disease that typically affects the anogenital area, although it can also be found on extragenital locations such as the shoulders, neck, trunk, breasts, and arms. Facial involvement is rare, but there have been a few reported cases of extragenital lichen sclerosus affecting the infraorbital area. To our knowledge, there are 7 documented cases of extragenital lichen sclerosus affecting the eyelid in medical literature. This is a novel case and documented report of a patient with extragenital lichen sclerosus located on the eyelid with eyelash margin involvement.

Evaluation of the therapeutic effects of Photodynamic Therapy in vulvar lichen sclerosus and impact on patient quality of life and sexual funtion

BACKGROUND

Vulvar lichen sclerosus (VLS) is often associated with irritable symptoms of itching, burning pain and can lead to scarring, architectural changes and sexual dysfunction as well as a decline in quality of life.The etiology of the disease is unknown. This study sought to assess the therapeutic effects of Photodynamic Therapy (PDT) in VLS, and improvment of patient quality of life and sexual funtion.

METHODS

From January 2022 to April 2023, a total of 65 patients with vulvar sclerosi (VLS) were treated with PDT in our hospital. All 65 patients were divided into two groups: early-stage group and late-stage group. The Cattaneo scoring method, the Dermatology Life Quality Index (DLQI) and the Female Sexual Function Index (FSFI) scores were used to evaluate the clinical effectiveness of the treatment on patients' symptoms and clincal signs, quality of life as well as sexual function before and at 6-month after treatment.

RESULTS

The total effective rate of early-stage patients was significantly greater than that of late-stage patients at 6-month after PDT treatment (90.91% [40/44] vs 76.19% [16/21], p <0.05). At 6-month follow-up, the symptoms and clinical signs of patients in early-stage group were significantly improved compared with baseline, the average scores of itching, skin elasticity, whitening and lesion range were significantly lower than the scores before treatment (p <0.05). In late-stage group, The decrease in scores of itching, whitening and lesion range at the 6-months follow-up is significant(p <0.05), but skin elasticity (p=0.0625). On post-treatment follow-up examination, FSFI score was seen to have significantly improved in early-stage patients(from a median score of 17.45 to 21.1, p<0.05); DLQI also significantly improved after treatment (from a median score of 7 to 4, p<0.05). In late stage patients, The DLQI score improved significantly after treatment (from a median score of 18 to 15, p<0.05). However, the improvement in sexual function is not statistically significant (pre-treatment: median=10.55, post-treatment: median=10, p=0.1865).

CONCLUSION

Photodynamic therapy can effectively improve most symptoms and clinical signs, as well as quality of life of patients with VLS, especially for earlly stage patients. Moreover, improvement in sexual function is observed in early stage patients after PDT treatment. This study suggests that early and timely PDT treatment are recommended to achieve better results.

Clinical efficacy analysis of 5-aminolevulinic acid photodynamic therapy for vulvar lichen sclerosus

OBJECTIVE

The purpose of this study is to analyze the efficacy of photodynamic therapy in the treatment of vulvar lichen sclerosus who do not respond to topical glucocorticoid therapy, analyze whether there are factors that affect the efficacy, and identify adverse reactions to the treatment.

METHOD

This retrospective study included 42 patients with vulval lichen sclerosis treated with ALA-PDT. Basic data of all patients were collected, and the clinical symptoms and signs of the patients before treatment were evaluated. After one year of treatment, the clinical efficacy was evaluated and analyzed whether there were any factors that affected the treatment effect.

RESULT

One year after the ALA-PDT treatment, the clinical effective rate was 64.29 % (27/42), the general effective rate was 19.05 % (8/42), the ineffective rate was 4.76 % (2/42), and the recurrence rate was 11.90 % (5/42). There was no correlation between menopause, number of births given, body mass index, duration of disease, treatment times and treatment effect. For patients with severe itching and atrophy, PDT was less effective. Adverse effects were minimal and no structural complications were reported.

CONCLUSION

ALA-PDT can obviously alleviate itching in VLS patients, improve skin elasticity, skin color and reduce lesion area. ALA-PDT for VLS has a low recurrence rate and few side effects.

UrethroNAV: the aetiology and extent of idiopathic urethral stricture in an Australian population

Background

Lichen sclerosus (LS) is considered a causative factor in 10% of cases of idiopathic urethral stricture disease (IUSD), which is important for determining management strategies due to the underlying pathophysiology. Traditional excision urethroplasty may not be effective as inflammation often extends beyond the macroscopic stricture. This pilot study aims to answer two research questions: is LS an underlying cause of some idiopathic cause of strictures, and, if there is histological evidence suggesting predisposition of the surrounding tissue to strictures.

Methods

Biopsies were taken from the stricture site as well as 1 and 2 cm proximal and distal in patients with IUSD. Histological features, including macroscopic and microscopic findings, were reported, including the presence of LS, hyperkeratosis, epidermal changes, lichenoid infiltrates, ulceration, scarring, and inflammation. Methylene blue was used to aid in locating damaged urothelium. Patients were prospectively followed up after urethroplasty.

Results

From 109 urethroplasties performed between 2019 to 2022, 15 male patients were enrolled after meeting specific inclusion criteria. These criteria included a diagnosis of IUSD and the absence of any evidence of trauma, macroscopic inflammatory disease, or previous endoscopic instrumentation of the urethra. Patients had to be at least 16 years old and medically suitable for undergoing urethroplasty. The study was approved by the hospitals ethics committees. None had macroscopic evidence of LS. One patient had microscopic evidence of LS at the 2 cm proximal biopsy only. A total of 93% of patients had scarring proximal and distal to the stricture, while 20-40% had inflammatory change. The patient with microscopic LS and two inflammatory change patients had stricture recurrence after urethroplasty. Additionally, one patient with inflammatory changes was diagnosed with penile intraepithelial neoplasia (PeIN) and underwent partial penectomy.

Conclusions

Findings suggest that an underlying cause of IUSD could be LS. Additionally, the pathophysiology may involve scarring and inflammation beyond the limits of the stricture with extension distal from the stricture site. Careful evaluation for concomitant urethral pathology should be considered in cases of inflammatory changes. These findings should be considered in the surgical management of IUSD and warrant further research into the role of routine biopsy and drug targets in USD.

Lichen Sclerosus of the Labial Mucosa: A Case Report and Literature Review

Lichen sclerosus (LS) is an uncommon, chronic, inflammatory mucocutaneous disorder found predominantly in females with unknown etiology. It presents as a white sclerotic plaque commonly located on the anogenital area. Extragenital LS is less prevalent, and LS affecting the oral mucosa is extremely rare, with only 39 biopsy-confirmed cases reported in the literature. Due to its several mimicking conditions, histological examination is usually required for a definitive diagnosis, particularly in patients with oral LS. Current evidence-based treatment recommendations for oral LS are unavailable; however, most cases tend to improve after treatment with topical or intralesional corticosteroids. We report a case of a 58-year-old female referred from the otolaryngology department for evaluating an asymptomatic whitish sclerotic plaque on the lower lip mucosa that had existed for 1 year. Following a punch biopsy, the patient was diagnosed with LS of labial mucosa. The condition improved after 2 months of treatment with topical and intralesional corticosteroids. The present case report raises awareness in recognizing oral LS and contributes to knowledge of this rare disorder.

Topical 5-aminolevulinic acid (ALA)-photodynamic therapy (PDT) for lichen sclerosus of face: case report and literature review

Lichen sclerosus (LS) is a chronic inflammatory dermatosis typical of the genital region, with rare involvement of extragenital areas and particularly the face. LS therapeutic management is challenging, and common therapies including topical and systemic corticosteroids, topical calcineurin inhibitors, surgery are often ineffective. Herein, we present a case of LS occurred in a 36-year-old girl with facial involvement resistant to therapy with systemic corticosteroids and topical tacrolimus. Considering the involvement of a sensitive area, the young age of the patient, and the consistent clinical experience in using photodynamic therapy for the treatment of facial skin disease, we started a treatment with topical 5-aminolevulinic acid (ALA)-photodynamic therapy (PDT) with a dosage of 37 J/cm2 once a month. We compared our case with eight other facial LS patients from the literature and treated differently.

Vulvar Lichen Sclerosus: Navigating Sex Hormone Dynamics and Pioneering Personalized Treatment Paradigm

Vulvar lichen sclerosus (VLS) is a frequently overlooked inflammatory disorder affecting the skin and mucous membranes of the vulva. With a propensity for atrophy, severe scarring, functional impairment, and malignant evolution, VLS is a disease that recurs frequently; early diagnosis, rapid treatment, and ongoing patient follow-up are essential. Potent topical corticosteroids (TCSs) are now widely recognized as the most effective treatment for achieving remission in VLS, but considering the potential complications of long-term treatment with potent TCSs, understanding the evolution of VLS during puberty becomes particularly crucial in determining the necessity for aggressive or more conservative therapeutic interventions. Emerging treatments, including PRP (platelet-rich plasma), stem cell therapy, and energy-based lasers like fractional CO2 and Nd-YAG, are being investigated to identify more effective VLS treatments than ultrapotent topical corticosteroids. However, more research is needed to assess the efficacy and safety of these new medicines. Topical clobetasol 0.05% ointment daily for 4-12 weeks is the gold standard for treating VLS. This article is a narrative review of the English-language medical literature from 2017 to November 2023, following three main sections concerning VLS: studies of the evolution amid pubertal hormonal changes; studies of the outcomes of personalized conventional therapies; and studies addressing the spectrum of innovative modalities for VLS.

Systemic Therapy for Lichen Sclerosus: A Systematic Review

BACKGROUND

Lichen sclerosus (LS) is a chronic, inflammatory process affecting predominantly anogenital skin, with extragenital involvement in up to 20% of cases. The mainstay of therapy for anogenital LS is topical immunosuppression. However, in treatment-refractory cases, severe, or hypertrophic disease, systemic modalities may be used. Currently, there are no guidelines for systemic therapy in LS.

OBJECTIVE

This study aimed to provide a review of the current literature on use of systemic therapies for LS, including demographic and clinical features of LS, as well as reported outcomes.

METHODS

A primary literature search was conducted using the following databases: PubMed, Ovid, Scopus, and Web of Science, from the year the journal was published until June 2022.

RESULTS

Ultimately, 71 studies consisting of 392 patients were included. Of these, 65% (n = 254) had anogenital disease, 9% (n = 36) had extragenital disease, and 19% (n = 73) had both anogenital and extragenital disease, and in 7% (n = 29) of cases, location was not specified. The most frequent therapies, stratified by total cases, included oral retinoids (n = 227), methotrexate (n = 59), hydroxychloroquine (n = 36), and systemic steroids (prednisone, methylprednisolone, prednisolone, oral triamcinolone, and other systemic steroids) (n = 60). Overall, 76% (n = 194) of anogenital, 94% (n = 34) of extragenital, and 81% (n = 59) of patients with both anogenital and extragenital involvement were reported to have clinical or symptomatic improvement.

CONCLUSION

Overall, we found many therapies that have been used with reported success for extragenital and genital LS. However, future studies are needed to better define treatment outcomes and directly compare efficacy of different therapies for LS.

Implant-Retained Prosthetic Rehabilitation of a Patient with Severe Oral Lichen Sclerosus

Background

Lichen sclerosus is a rare condition that occurs in the genital area or on the extraoral skin but can also manifest orally (oral lichen sclerosus (OLS)). The condition is associated with atrophy, scarring, and functional limitations of the tissues. In the present case, an extremely pronounced variant is described, and the oral rehabilitation of the patient is presented. Case Report. The edentulous patient showed a progressive course with severely restricted mouth opening and persistent pain. Conventional dental treatment was therefore impossible. To address this issue, two implants were placed in each jaw at the position of the lateral incisors. After osseointegration and exposure of the implants, provisional bridges made of polymethyl-methacrylate were fitted to test the new jaw relation. After a successful provisional phase, an FDP in the sense of an extreme short dental arch (ESDA) has been inserted.

Conclusion

The experimental treatment of the patient with only a total of four implants and the ESDA concept represented a satisfactory therapy for the patient. The patient regained her chewing ability, which significantly increased her oral health-related quality of life (OHRQoL). Still, it should be noted that this is a high-risk and experimental prosthetic treatment.

Platelet-Rich Plasma (PRP) and Adipose-Derived Stem Cell (ADSC) Therapy in the Treatment of Genital Lichen Sclerosus: A Comprehensive Review

Lichen sclerosus (LS) is a chronic inflammatory dermatosis mostly localized in the genital area, characterized by vulvar alterations that can severely impact a patient's quality of life. Current treatment modalities often provide incomplete relief, and there is a need for innovative approaches to manage this condition effectively. Platelet-rich plasma (PRP) and adipose-derived stem cells (ADSCs) have emerged as potential regenerative therapies for LS, offering promising results in clinical practice. This comprehensive review explores the utilization of PRP and ADSC therapy in the treatment of genital LS, highlighting their mechanisms of action, safety profiles, and clinical outcomes. PRP is a blood product enriched in growth factors and cytokines, which promotes tissue regeneration, angiogenesis, and immune modulation. ADSC regenerative potential relies not only in their plasticity but also in the secretion of trophic factors, and modulation of the local immune response. Numerous studies have reported the safety of PRP and ADSC therapy for genital LS. Adverse events are minimal and typically involve mild, self-limiting symptoms, such as transient pain and swelling at the injection site. Long-term safety data are encouraging, with no significant concerns identified in the literature. PRP and ADSC therapy have demonstrated significant improvements in LS-related symptoms, including itching, burning, dyspareunia, and sexual function. Additionally, these therapies enable many patients to discontinue the routine use of topical corticosteroids. Several studies have explored the efficacy of combining PRP and ADSC therapy for LS. In combination, PRP and ADSCs seem to offer a synergistic approach to address the complex pathophysiology of LS, particularly in the early stages. The use of PRP and ADSC therapy for genital lichen sclerosus represents a promising and safe treatment modality. These regenerative approaches have shown significant improvements in LS-related symptoms, tissue trophism, and histological features. Combination therapy, which harnesses the synergistic effects of PRP and ADSCs, is emerging as a preferred option, especially in early-stage LS cases. Further research, including randomized controlled trials and long-term follow-up, is warranted to elucidate the full potential and mechanisms of PRP and ADSC therapy in the management of genital LS. These regenerative approaches hold great promise in enhancing the quality of life of individuals suffering from this challenging condition.

A Rare Presentation of Lichen Sclerosus Involving the Vaginal Canal After Radiation Therapy: A Case Report and Review of the Literature

Vaginal lichen sclerosus (LS) is an extremely rare entity. Classically, LS is referred to as a chronic, inflammatory skin disease with a distinct predilection for the anogenital skin that is observed in post-menopausal women and typically manifests clinically as white, atrophic plaques. Here, we report a case of a 61-year-old patient who presented for a follow-up visit three years after vaginal brachytherapy as an adjuvant treatment for endometrial adenocarcinoma. This lesion was biopsied and confirmed to be vaginal LS on histological analysis. While LS has been previously observed to impact mucosal areas outside of the anogenital region, such as the mouth, reported cases of vaginal LS are very rare in the literature. Our case highlights both the underrecognized location of this disease as well as radiation as a potential risk factor.

Urinary microbiome differences between lichen sclerosus induced and non-lichen sclerosus induced urethral stricture disease

OBJECTIVE

To describe differences in the urinary microbiome of patients with pathologically confirmed lichen sclerosus (LS) urethral stricture disease (USD) vs non-lichen sclerosus (non-LS) USD pre- and post-operatively.

METHODS

Patients were pre-operatively identified and prospectively followed, all underwent surgical repair and had tissue samples obtained to make a pathological diagnosis of LS. Pre- and post-operative urine samples were collected. Bacterial genomic DNA was extracted. Alpha and beta diversity measurements were calculated and compared. A zero-inflated negative binomial model was utilized to compare taxa abundances between disease status and surgery status.

RESULTS

Urine samples were obtained from both cohorts, 69 samples in total: 36 samples were obtained pre-operatively and 33 samples were obtained post-operatively. Ten patients provided both a pre-operative and post-operative urine sample. Twenty-six patients had pathological evidence of LS and 33 patients did not. There was a statistically significant difference in alpha diversity between the pre-operative urine samples of patients with non-LS USD and LS USD, (p = 0.01). There was no significant difference in alpha diversity within post-operative urine samples between patients with non-LS USD and LS USD, (p = 0.1). A significant difference was observed in Weighed UniFrac distances with respect to disease and operative status, (p = 0.001 and 0.002).

CONCLUSIONS

LS USD have significant alterations in diversity and differential abundance of urine microbiota compared to non-LS USD controls. These findings could be used to guide further investigations into the role of the urinary microbiome in LS USD pathogenesis, severity of presentation, and stricture recurrence.

Histopathological differences between vitiligo and lichen sclerosus et atrophicus using quantitative immunohistochemical analysis

Introduction

Lichen sclerosus et atrophicus (LS) is rare skin condition characterized by the presence of whitish patches primarily affecting the genital and perianal areas, though it can occur other parts of the body. LS may result in skin depigmentation without textural changes and should be differentiated from vitiligo. However, the histopathological features of hypopigmentation during vitiligo and LS have rarely been compared and have not been precisely described using quantitative immunohistochemical analysis. This study, therefore, aimed to investigate and compare the pigmentary characteristics of LS and vitiligo lesions using histochemical and immunohistochemical staining.

Methods

We included 31 and 46 patients diagnosed with LS and vitiligo, respectively, at Ajou University Hospital between March 2009 and March 2020 in this study. Their medical charts and skin biopsy specimens were retrospectively reviewed. Additionally, Fontana-Masson staining for melanin and immunohistochemical staining for Melan-A, NKI/beteb, tyrosinase, and microphthalmia-associated transcription factor was performed.

Results

The melanin content, as well as the number of melanocytes was, in general, significantly higher in the epidermis of patients in the LS group compared with that in the vitiligo group. However, 22.6% of LS tissues showed less melanin pigmentation, 25.8% of LS specimens exhibited a lower number of melanocytes, and 29.0% of LS specimens demonstrated less melanocyte activity when compared with the average of vitiligo specimens.

Conclusion

As lower melanin pigmentation and the near absence number of melanocytes were also observed in several LS specimens, both the clinical and histological findings must be comprehensively reviewed to differentiate vitiligo from LS.

Immunohistological Analysis of Lichen Sclerosus of the Foreskin in Pediatric Age: Could It Be Considered a Premalignant Lesion?

BACKGROUND

A major worry of juvenile penile LS is potential malignant degeneration to spinocellular carcinoma (SCC) in adulthood. LS is characterized by increased CD8+ and CD57+ cells, dermal sclerosis, epidermal atrophy, and hyperkeratosis. p53 and Ki67 are reliable premalignant markers. Our aim was to define the LS immunohistochemical profile of foreskin in children, focusing on tissue immune response and cell proliferation.

METHODS

Thirty specimens of foreskins removed from pediatric patients during circumcision were included: six from ritual operation (A), twelve from phimosis (B), and twelve from phimosis with LS (C). Formalin-fixed paraffin-embedded sections were stained for histomorphology and immunohistochemistry. A quantitative evaluation for CD8, CD57, p53, and Ki-67 and a statistical analysis were performed.

RESULTS

As compared to groups A and B, the samples from group C patients showed an acanthotic epidermis, a dermal band of lymphoid infiltrate with a significant enhancement of CD8+ CD57+ lymphocytes, and a keratinocytic hyperplasia with an overexpression of Ki67+ and p53+ cells.

CONCLUSIONS

Immunohistological findings confirmed an immune reaction and proliferative behavior in juvenile LS of foreskin. We believe that radical circumcision should be the first treatment of choice in pediatric patients with clinical suspicious of LS for the potential risk of transformation to SCC in adulthood.

Female Urethral Stricture Caused by Lichen Sclerosus: An Uncommon Presentation

Lichen sclerosus is an inflammatory disease of the mucocutaneous region. The etiology of lichen sclerosus is not well explained. Lichen sclerosus is more common in females and generally involves the genital area. Urethral involvement in lichen sclerosus is uncommon in females. Males have a higher propensity for urethral involvement in lichen sclerosus. Here we report a case of a 50-year-old female with lichen sclerosus and urethral stricture. Buccal mucosal graft urethroplasty was done. The success rate of urethroplasty is low in patients with lichen sclerosus. Meatal sparing urethroplasty is usually not recommended in females with urethral strictures associated with lichen sclerosus. Our patient was asymptomatic at six months of follow-up.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

[Skin manifestations of the external male genitals]

The urological examination includes the inspection of the external male genitals. Harmless normal variants, such as heterotopic sebaceous glands and pearly penile papules must be differentiated from malignant and infectious manifestations. Lichen sclerosus et atrophicus is a frequent connective tissue disease that can lead to functional impairments and an associated high level of suffering for those affected. Both conservative and invasive treatment options are available. Sexually transmitted diseases, such as syphilis, are gaining increasing importance in routine clinical and daily practice due to the increasing incidence in recent years. An early diagnosis and treatment of malignant neoplasms, such as Queyrat's erythroplasia can be carried out by routine inspection of the genital skin.

LASER treatment in gynaecology -A randomized controlled trial in women with symptomatic lichen sclerosus

OBJECTIVE

Aim of our study was to evaluate the therapeutic effect of laser treatment in vulvar lichen sclerosus, mainly the reduction of existing symptoms as itching, burning and pain. We asked about the different outcome by using different application doses.

STUDY DESIGN

We conducted a prospective randomized double-blind dose-controlled trial in our dysplasia unit specializing vulvar disorders. 67patients with active LS were included. LS was confirmed by biopsy or by the validated CSS (clinical scoring system of vulvar LS). Computer generated randomization resulted in two groups, each group received a different application dose.(LDG- low dose group, NDG- normal dose group) During the study period of 18 weeks all participants received three laser applications in three subsequent sessions of three weeks. Two follow-ups six and twelve weeks after the first application was performed. At every visit, the participants filled in the VAS (visual analogue scale) for recording the actual vulvar symptoms as itching burning or pain on a range from 0 to 10.

RESULTS

Before treatment the mean VAS-Score was 4.3 (STD ± 2.4) in the NDG and 5.1(±2.6) in the LDG. After 18 weeks, the mean reduction was -2.4 (±2.3) for NDG and -2.7 (±2.8) for LDG. Four patients (two of each group) reported more pain after than before treatment. Both groups show significant lower VAS-Scores 18 weeks after the treatment than before therapy (p < 0.0001). The reduction of symptoms after 18 weeks between NDG and LDG was not significant (p = 0.6244).

CONCLUSION

Laser treatment with the microablative CO2 laser leads to a significant improvement for symptoms of LS. A higher dosage of laser radiation shows no benefit concerning the symptoms. We have not observed any serious adverse events during this study.

Comparative effect of intraurethral clobetasol and tacrolimus in lichen sclerosus-associated urethral stricture disease

Background

Management of urethral stricture related to lichen sclerosus (LS) is now gradually changing from surgical to nonsurgical due to availability of anti-inflammatory agents such as corticosteroids and calcineurin inhibitors. We determined the clinical impact of these agents in such patients on outpatient department basis in terms of improvement in symptoms on International Prostate Symptom Score (IPSS), external skin appearance, and maximum urinary flow rate (Qmax).

Materials and Methods

Eighty patients of meatal stenosis and penile urethral stricture with histopathologically proven LS were divided into two groups, and clinical and predetermined parameters such as Qmax, IPSS, and changes in external appearance were compared between these groups after 3 months of topical and intraurethral application of clobetasol and tacrolimus with self-calibration.

Results

A significant intragroup difference was noted in IPSS (P < 0.001) as well as Qmax (P < 0.001); postintervention intergroup difference in IPSS was not significant (P = 0.94) and however postintervention intergroup difference in Qmax was significant in favor of clobetasol (P = 0.007). A significantly increased number of additional procedures were done in the group receiving intraurethral tacrolimus (P = 0.0473) with significantly less number of skin complication in the group with topically applied clobetasol (P = 0.003).

Conclusion

Though both clobetasol and tacrolimus, improved symptom score, Qmax and local external appearance yet topical and intra-urethral clobetasol application via urethral self calibration seems to be better option for lichen sclerosus related urethral stricture in terms cost and local complications.

Extragenital lichen sclerosus: a comprehensive review of clinical features and treatment

Lichen sclerosus (LS) is a chronic inflammatory skin disease commonly affecting the anogenital area with less frequent extragenital occurrence. Extragenital LS cutaneous manifestations vary and precipitating factors are not well described. Recent evidence for etiology and clinical associations of extragenital LS provide insight into disease recognition and pathogenesis. Novel diagnostic techniques as well as treatment standardization have the potential to improve management of this rare condition. This review details both past and new insights into the pathogenesis, clinical manifestations, and treatment options of extragenital LS.

Vulvar dermatoses-Can a pattern-based approach improve diagnostic yield?

BACKGROUND

Vulvar dermatoses (VD) pose a formidable challenge to clinicians and pathologists owing to various factors. The factors included are the histopathological heterogeneity of the vulva, moist and frictional environment, and the limited experience of gynecologists and general histopathologists in this field. To address this issue, the International Society for the Study of Vulvovaginal Disease (ISSVD) proposed a histopathological tissue reaction-based classification system for VD. Therefore, we attempted to study the utility of the 2006 ISSVD classification in reporting VD. We further evaluated if a dermatopathologist review could improve the diagnostic yield.

MATERIALS AND METHODS

The vulvar biopsy reports (N = 106) were retrieved from histopathology case files, out of which benign non-infectious conditions (n = 55) were included in the study. The diagnosis retrieved from the case files was considered the initial diagnosis. Three dermatopathologists reviewed each biopsy, and a tissue reaction pattern/diagnosis was assigned as per ISSVD 2006, and this was considered a review diagnosis. The initial and review diagnoses were compared and analyzed. We further studied and analyzed the effect of the dermatopathologist's review on the diagnostic yield.

RESULTS

The sclerotic pattern (34.6%) was the commonest tissue reaction pattern, followed by spongiotic (18%) and acanthotic patterns (14.5%) independently or in combination. The non-specific/descriptive report rate was significantly decreased following 2006 ISSVD and the dermatopathologist's review (83.6% vs.1.8%).

CONCLUSION

Rendering tissue reaction patterns to vulvar biopsies will enable a comprehensive understanding of lesions and aid in clinically relevant reporting. In addition, dermatopathologists' review of difficult vulvar biopsies increases the diagnostic yield.

Morphological features of various variants of the course of scleroatrophic lichen of the vulva

Relevance. Most of the scientific papers presented in the literature indicate morphological features of the stages of development of sclerotic lichen of the vulva, or in comparison with other vulvar skin lesions. At the same time, data on the features of morphological examination of vulvar biopsies, depending on the clinical variants of the course of sclerotic lichen of the vulva, is currently insufficient. The aim of the study - to determine the presence or absence of distinctive morphological features of the sclerotic lichen of the vulva, depending on the clinical variants of its course. Materials and Methods. The study included 292 patients with sclerotic lichen of the vulva (20-70 years old). Based on the scale of assessment of objective and subjective clinical signs of sclerotic lichen of the vulva developed by us, 3 clinical groups: 101 patients with an atrophic variant of the course, 154 with a sclerosing variant and 37 patients with a scleroatrophic variant of the course of sclerotic lichen of the vulva. In addition to clinical laboratory, instrumental and immunological studies, all patients underwent incisional biopsy of the vulva followed by morphological examination of biopsies. Results and Discussion. The features of the results of morphological examination of various clinical variants of the course of sclerotic lichen of the vulva are described and presented in the form of images. The characteristic morphological signs for each clinical group, as well as common signs characteristic of all variants of the course of this pathology, were revealed. Morphological examination of vulvar tissues is informative only to confirm the diagnosis of «Sclerotic lichen of the vulva», to determine the stage of the disease, as well as to exclude the malignant process, while for a clear differentiation of variants of the clinical course of sclerotic lichen of the vulva, conventional morphological examination is not enough, which requires further studies using immunohistochemical and molecular genetic methods. Conclusion. The revealed differences in morphological parameters of various variants of the course of sclerotic lichen of the vulva are insufficiently specific, which excludes the possibility of accurate morphological verification of the variants of the course of sclerotic lichen of the vulva and confirms the expediency of using clinical classification of variants of the course of sclerotic lichen of the vulva based on objective and subjective clinical signs.

A Potential Protective Effect of Alcohol Consumption in Male Genital Lichen Sclerosus: A Case-Control Study

Introduction and Objectives. Lichen sclerosus (LSc) is a chronic inflammatory process of the skin characterized by its unique histological features. It affects men and women of all ages, mainly in the anogenital area. The etiologies and exact pathophysiology are not well-known; however, LSc can be considered a precursor to male genital squamous cell carcinoma. We aim, through this case-control study, to potentially associate genital LSc with risk factors and certain patient characteristics in Lebanese adult males. Materials and Methods. A nested case-control study design was chosen. Subjects enrolled were adult male patients who had a circumcision between January 2010 and December 2020 at our university hospital, with a confirmed LSc diagnosis on pathology. Cases were matched with controls by age with a ratio of 1 : 1, all of whom were circumcised and had a negative pathology report. Data collection consisted of sociodemographic, behavioral, and past medical and familial history characteristics. Results. A total of 94 patients were enrolled. The mean age was 49.81 (±22.92) in the group of men with LSc. No significant differences in sociodemographic characteristics (age and BMI) were found between the two compared groups. Smoking cannot predict LSc as opposed to alcohol consumption, which we found to be a protective factor against the appearance of LSc ( $p=0.027$ ). Men with LSc had significantly higher rates of diabetes ( $p=0.021$ ) and hypertension ( $p=0.004$ ). No associations were found between LSc and the presenting chief complaints, family history of LSc, and past penile trauma. Conclusion. In this study, we were able to compare multiple variables between 47 circumcised patients diagnosed with LSc and a control group. We found that LSc patients showed higher rates of diabetes and hypertension. A potential protective effect of alcohol consumption is to be explored in future projects with bigger sample sizes and higher statistical powers.

Randomized clinical trial with fractional CO2 laser and Clobetasol in the treatment of Vulvar Lichen Sclerosus: a clinic study of feasibility

OBJECTIVES

The main objective of the study was to describe and compare the feasibility of using fractional CO₂ laser to the usual treatment with Clobetasol. Randomized clinical trials brought together 20 women from a Brazilian university hospital, 9 of them were submitted to Clobetasol treatment and 11 to laser therapy. Sociodemographic data were obtained and quality of life parameters, vulvar anatomy, self-perception and histopathological analysis of vulvar biopsies were evaluated. Evaluations were made before the beginning of the treatment, during its implementation, right after its completion (3 months), and 12 months after. The SPSS 14.0 software was used, obtaining descriptive measurements. The level of significance adopted was 5%.

RESULTS

The clinical/anatomical characteristics of the vulva did not differ between the treatment groups, as much before as after its performance. There was no statistically significant difference between the treatments performed regarding the impact on the life quality of the patients. A higher satisfaction degree with the treatment was obtained with the patients in the Laser group in the third month of evaluation. Laser therapy also revealed higher occurrence of telangiectasia after treatment completion. Fractional CO2 laser has proven to be well accepted and is a promising therapeutic option. Registration number and name of trial registry The institutional review board status was approved by the Research Ethics Committee of HU/ UFJF under advisory number 2881073 and registered in the Brazilian Clinical Trials, with consent under registration RBR-4p9s5y. Access link: https://ensaiosclinicos.gov.br/rg/RBR-4p9s5y.

Comparison of the efficacy of focused ultrasound at different focal depths in treating vulvar lichen sclerosus

OBJECTIVE

This study aimed to compare the efficacy and safety of focused ultrasound (FU) at different focal depths in treating vulvar lichen sclerosus (VLS).

METHODS

A retrospective study was conducted on 84 patients with VLS. Among them, 43 cases were treated with FU at a focal depth of 2.5 mm and 41 cases at a focal depth of 4.0 mm. Therapeutic time, treatment energy, postoperative efficacy, complications and recurrence rates were compared.

RESULTS

No statistically substantially differences in age, disease course, history of immune system diseases, lesion size and severity of symptoms were found between the two groups. All patients successfully received FU therapy. No significant difference in curative rate was observed between the two groups at 3, 6 and 12 months after FU therapy. At 12 months after FU therapy, the recurrence rate of the experimental group (FU treatment at 2.5 mm focal depth) was lower than the control group (FU treatment at 4.0 mm focal depth) (7.0% vs 24.4%, p = 0.027). The experimental group was treated for a shorter period of time [22.69 ± 0.64 (min) vs 24.93 ± 0.72(min), p = 0.022] and at a lower dose[5,026.05 ± 148.00(J) vs 5,484.26 ± 160.60(J) p = 0.039].

CONCLUSION

Compared with that at the routine focal depth (4.0 mm), FU therapy at a low treatment depth (2.5 mm) can achieve a similar therapeutic effect but lower recurrence rate, therapeutic time and treatment energy. This work provides insight into the optimization of clinical protocols.

Efficacy of non-invasive photodynamic therapy for female lower reproductive tract diseases associated with HPV infection: a comprehensive meta-analysis

Photodynamic therapy (PDT) is a proposed non-invasive, highly effective, and fertility-preserving method for the treatment of lower reproductive tract diseases in women. We aim to evaluate the effect of PDT on complete remission, recurrence, and HPV clearance in diseases of the female lower reproductive tract associated with the human papillomavirus (HPV) infection in this meta-analysis. PubMed, EMBASE, Scopus, Cochrane Library, and China National Knowledge Infrastructure databases were searched to compare PDT with other treatments for complete remission, recurrence, and HPV clearance in women with lower genital tract disease. Fixed or random effect models were performed to assess the pooled effect size. Sensitivity analysis was performed to detect heterogeneity in the included studies. The Begg and Egger test assessed publication bias. There were 12 studies qualified for inclusion; compared to other treatments, PDT had a significant advantage in complete remission (OR=2.97, 95%CI, 2.18-4.04, I2=0, P<0. 001) and recurrence (OR, 0.21; 95%CI, 0.11-0.39; I2=34.9%, P<0. 001). Furthermore, PDT clears HPV quickly and lastingly compared to other therapies (OR, 2.65; 95% CI, 1.41-4.95; I2=71.0%, P=0.002). In addition, the heterogeneity test of sensitivity analysis suggested that the results were robust. Begg test (P=0.73) and Egger test (P=0.71) showed no publication bias. PDT treats diseases of the female lower reproductive tract associated with HPV infection: high complete remission, low recurrence, and rapid and lasting HPV clearance. The PDT seems to be a non-invasive, effective, and promising treatment of female lower reproductive tract diseases associated with HPV infection.

The Efficacy and Safety of 5-Aminolevulinic Acid Photodynamic Therapy for Lichen Sclerosus: A Meta Analysis

Background

Lichen sclerosus (LS) is a chronic inflammatory dermatosis that occurs mainly in the anogenital area and causes itching, soreness, atrophy and scarring, which may result in burying of the clitoris in females and phimosis in males. Photodynamic therapy (PDT) has been suggested during the past years as an alternative non-invasive treatment for LS, but there is still no meta-analysis to evaluate its efficacy and safety.

Aims

To assess the efficacy and safety of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) for treatment of LS.

Methods

We undertook a meta-analysis using the methodology of the Cochrane Collaboration and the guideline of PRISMA. A systematic literature search was carried out in PubMed, EMBASE, The Cochrane Library, WanFang Data, CBM and CNKI up to 30 June 2020. Randomized controlled trials (RCTs) were compared with ALA-PDT, corticosteroids or tacrolimus ointments for treating LS. The risk of bias for each trial was rated according to the Cochrane Handbook. Risk ratios (RR) with 95% confidence intervals (CI) were utilized to express the comparative outcomes.

Results

We included 4 RCTs with a total of 184 participants. The meta-analysis showed ALA-PDT was better than topical ointments in treating LS (total effective rate: RR 1.38 [95% CI 1.19-1.60]).

Conclusions

The current limited evidence supports the efficacy and safety of ALA-PDT in treating LS. The adverse reactions included pain, swelling, redness and exfoliation which would decrease with the continuing sessions of treatment. Further high-qualified RCTs of large samples are necessarily needed.

Lichen sclerosus: The 2023 update

Lichen sclerosus (LS) is an underdiagnosed inflammatory mucocutaneous condition affecting the anogenital areas. Postmenopausal women are predominantly affected and, to a lesser extent, men, prepubertal children, and adolescents. The etiology of LS is still unknown. Hormonal status, frequent trauma and autoimmune diseases are well-known associations for LS, yet infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype. Furthermore, there is a distinct expression of tissue remodeling associated genes as well as microRNAs. Oxidative stress with lipid and DNA peroxidation provides an enabling microenvironment to autoimmunity and carcinogenesis. Circulating IgG autoantibodies against the extracellular matrix protein 1 and hemidesmosome may contribute to the progression of LS or simply represent an epiphenomenon. The typical clinical picture includes chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. In addition to genital scarring, and sexual and urinary dysfunction, LS may also lead to squamous cell carcinoma. Disseminated extragenital LS and oral LS are also reported. The diagnosis is usually clinical; however, a skin biopsy should be performed in case of an unclear clinical picture, treatment failure or suspicion of a neoplasm. The gold-standard therapy is the long-term application of ultrapotent or potent topical corticosteroids and, alternatively, topical calcineurin inhibitors such as pimecrolimus or tacrolimus. Collectively, LS is a common dermatological disease with a so far incompletely understood pathogenesis and only limited treatment options. To foster translational research in LS, we provide here an update on its clinical features, pathogenesis, diagnosis and (emerging) treatment options.

Female genital lichen sclerosus is connected with a higher depression rate, decreased sexual quality of life and diminished work productivity

Female genital lichen sclerosus is an underdiagnosed, distressing, chronic dermatosis affecting the well-being of women. The aim of this retrospective case-control study was to assess whether the disease is connected with work productivity and activity impairment, depression and decreased sexual quality of life. Fifty-one female patients with genital lichen sclerosus and forty-five healthy women were enrolled to the study and filled out an online survey including: Work Productivity and Activity Impairment: General Health (WPAI:GH), Patient Health Questionnaire-9 (PHQ-9) and The Sexual Quality of Life-Female (SQOL-F) questionnaires. The results showed that women with genital lichen sclerosus are at risk of having a diminished work productivity, are more often screened for depression and have a decreased sexual quality of life. The study highlights the importance of a multidisciplinary approach to treating female genital lichen sclerosus.

Therapeutic potential of adipose tissue-derivatives in modern dermatology

Stem cell-mediated therapies in combination with biomaterial and growth factor-based approaches in regenerative medicine are rapidly evolving with increasing application beyond the dermatologic field. Adipose-derived stem cells (ADSCs) are the more frequently used adult stem cells due to their abundance and easy access. In the case of volumetric defects, adipose tissue can take the shape of defects, restoring the volume and enhancing the regeneration of receiving tissue. When regenerative purposes prevail on volume restoration, the stromal vascular fraction (SVF) rich in staminal cells, purified mesenchymal stem cells (MSCs) or their cell-free derivatives grafting are favoured. The therapeutic efficacy of acellular approaches is explained by the fact that a significant part of the natural propensity of stem cells to repair damaged tissue is ascribable to their secretory activity that combines mitogenic factors, cytokines, chemokines and extracellular matrix components. Therefore, the secretome's ability to modulate multiple targets simultaneously demonstrated preclinical and clinical efficacy in reversing pathological mechanisms of complex conditions such atopic dermatitis (AD), vitiligo, psoriasis, acne and Lichen sclerosus (LS), non-resolving wounds and alopecia. This review analysing both in vivo and in vitro models gives an overview of the clinical relevance of adipose tissue-derivatives such as autologous fat graft, stromal vascular fraction, purified stem cells and secretome for skin disorders application. Finally, we highlighted the major disease-specific limitations and the future perspective in this field.

The Importance of Immunological Disorders in the Pathogenesis of Lichen Sclerosus in Pediatric Patients: A Systematic Review

Lichen sclerosus (LS) is defined as a chronic mucocutaneous inflammatory disease with a localization predominantly to the anus and genitals (vulvar sclerosus (VLS)). Pediatric lichen sclerosus (LS) is a chronic inflammatory skin condition with predilection for the anogenital area that if untreated can lead to scarring. Vulvar LS is characterized by two peaks in incidence: it occurs in prepubertal girls and in postmenopausal women. To date, several mechanisms and risk factors have been proposed in the pathogenesis of pediatric vulvar LS; however, the etiology of this condition is still not fully understood and constitutes a challenge for scientists and clinicians. The presented research aimed to systematically review the existing literature on the pathogenesis of pediatric LS and to identify possible underlying autoimmune mechanisms and molecular networks. The clinical presentation of pediatric lichen sclerosus and available treatment modalities are also presented to acquaint a broader audience with this underdiagnosed and undertreated condition. As a result of our review, we discuss several potential mechanisms, molecules, and pathways that have been recognized in this disease. The purpose of our review was also to summarize what we can induce in further studies, which will ultimately help to identify the mechanism responsible for the disease and aid in the development of new, more effective treatment strategies for diagnosis and treatment by clinicians and researchers.

Penile Lichen Sclerosis: A Surgical Perspective of its Aetiology and Treatment

Penile lichen sclerosis is a longstanding inflammatory disease of the skin with a controversial aetiology. Penile lichen sclerosis (PLS) is a growing, inflammatory dermatitis of the anogenital region, which involves the meatus, prepuce, penile shaft, and glans penis. Although the accurate aetiology of PLS is contentious, multiple factors including genetics, autoimmunity, infections of human papillomavirus, hepatitis C, Epstein-Barr virus, risk factors (hormonal and trauma), etc., can be considered to be a part of the etiopathogenesis of PLS. The initial clinical presentations of penile lichen sclerosis are white plaques, atrophied skin, erythema, erosions, and sclerosis in the anogenital region. When the disease advances, the following can occur, including meatal constraints, telangiectasia, petechiae, soreness, papular lesions, tightness of the foreskin, difficulties in passing urine, itching, tenderness on erections, pain, cracking, bleeding, redness, rashes, tightness at frenulum, and dysuria. This disease has a dangerous course of action and if untreated it may be linked with severe urologic and sexual morbidities. PLS is usually treated with medical and surgical interventions like topical or intralesional steroids and circumcision. The role of circumcision is very critical in the course of action and prognosis of PLS, and its treatment is dependent on the stage of the disease. This review brings up the knowledge regarding epidemiology, etiopathology, clinical presentation, and management of PLS with an emphasis on the role of circumcision.

Does treatment of lichen sclerosus improve overactive bladder symptoms?

INTRODUCTION AND HYPOTHESIS

Lichen sclerosus (LS) is a chronic disease which mainly affects the vulvar area in women. A few studies have shown a possible relationship between LS and overactive bladder (OAB) symptoms, but no studies have investigated whether OAB symptoms improve after initiating treatment of LS. The aim of this study was to investigate whether the treatment of LS also improves OAB symptoms in women newly diagnosed with LS.

METHODS

This was a prospective cohort pilot study based on questionnaires from women newly diagnosed with LS and with symptoms of OAB. Women above the age of 18 who were newly diagnosed with LS were included. The women completed two questionnaires on OAB at inclusion and after 3 months. The questionnaires consisted of the validated questionnaires OAB-q (33 questions, maximum score 198) and ICIQ-OAB (8 questions, maximum score 56). All women initiated treatment with local steroid by the time of the LS diagnosis.

RESULTS

A total of 40 women were included, and 13 women dropped out during the data collection time. Comparing month 0 to month 3 for the remaining 27 women, a mean difference at 28.8 points was observed for OAB-q and a mean difference of 5.7 points was observed for ICIQ-OAB. Both results showed a statistically significant difference after 3 months (p < 0.05). A total of 92.6% (25/27) of the women improved their symptoms.

CONCLUSION

Treatment with local steroid might improve OAB symptoms in women newly diagnosed with LS.

High-frequency ultrasound features in vulvar lichen sclerosus and correlation with histopathology

BACKGROUND

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disease initially involving anogenital areas. Noninvasive assessment is essential for precise management in VLS. We aim to analyze high-frequency ultrasound (HFUS) features and correlate HFUS with histopathological changes.

MATERIALS AND METHODS

Forty patients with histopathologically confirmed VLS lesions were retrospectively identified from August 2020 to September 2021. The clinical manifestations, dermoscopic images as well as both 20 and 50 MHz HFUS images were assessed. HFUS assessment included epidermal morphology, hypoechoic dermal band thickness, and hypoechoic dermal band internal echo. We compared HFUS images with histopathology, and Pearson's correlation coefficient was used to assess the relationship between hypoechoic dermal band thickness and histopathological depth.

RESULTS

Hypoechoic dermal band was present in 100% (40/40) VLS lesions. There was a significant linear positive correlation between the histopathological depth and corresponding hypoechoic dermal band thickness, with a Pearson correlation coefficient of 0.685 (p < 0.001). Besides, 95% (38/40) lesions revealed smooth epidermis, and the internal echo of hypoechoic dermal band was assessed as homogeneous in 60% (24/40) and inhomogeneous in 40% (16/40) lesions.

CONCLUSION

HFUS characteristics, as well as measurable hypoechoic dermal band thickness, may provide valuable information in the precise diagnosis and the treatment monitoring of VLS.

Extragenital lichen sclerosus: A comprehensive review

Lichen sclerosus (LS) is a chronic inflammatory mucocutaneous disease of unknown aetiology. About 85% of total cases of LS are genital cases, while extragenital form is seen in only 15-20% of cases. Extragenital LS (EGLS) can occur simultaneously with genital form; however, in 6% of the cases, only extragenital form has been described. Genetic, autoimmune, infectious, environmental and hormonal factors are implicated in its aetiology. Extragenital LS presents as asymptomatic white opalescent papules, which cluster in plaques and slowly progress over time resulting in parchment-like skin usually involving upper trunk, neck and shoulders. Lesions are frequently accompanied by purpura/haemorrhagic spots. The relationship with morphoea has been a topic of debate. Association with several autoimmune diseases has been observed. Diagnosis is usually based on clinical and dermoscopic examination and further supported by histopathological findings. LS needs to be differentiated from several other dermatological conditions such as discoid lupus erythematosus, vitiligo, mycosis fungoides (hypopigmented variant), lichen planus, graft-versus-host disease and morphoea depending upon the stage of the disease. Generally, extragenital LS is believed to lack carcinogenic potential. However, case reports with possible malignant transformation have been described. In this article, the authors have described a concise review of the extragenital form of LS.

Transcriptome Profiling and Network Analysis Provide Insights Into the Pathogenesis of Vulvar Lichen Sclerosus

Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis that affects female anogenital skin. Although VLS is considered a T cell-mediated autoimmune disease, the diagnosis criteria, molecular mechanism, and universally accepted therapies for this disease remain largely unresolved. To explore disease pathogenesis and potential biomarkers, we performed an RNA-Seq-based transcriptome analysis to profile the gene expression of VLS lesions. Differentially expressed gene (DEG) analysis revealed profound changes in expressions of coding genes, microRNAs, and long non-coding RNAs. Pathway and network analysis suggested that T cell activation-associated genes, including CD3G, CD3D, CD8B, LAT, LCK, ZAP70, CCR5, CXCR3, CXCL9, CXCL10, and CXCL11, were highly expressed in VLS, while NR4A family genes (NR4A1, NR4A2, NR4A3), whose coding products inhibit T cell activity, were significantly downregulated, suggesting heightened T cell response in VLS. Neutrophil chemoattractant genes CXCL1, CXCL2, CXCL3, CXCL8, and their cognate receptor CXCR2 were downregulated, suggesting dampened neutrophil activity. We also found the downregulation of genes involved in cell cycle progression, including cyclins (CCNB1, CCNB2, CCNL1, CCNE1, and CCNK) and centrosome factors (CENPA, CENPE, CENPF, and CENPN), while microRNA-203a and let-7, microRNAs known to inhibit cell growth, were found to be upregulated. These data collectively indicate that cell proliferation in VLS is compromised. In sum, these findings comprehensively deciphered key regulatory genes and networks in VLS, which could further our understanding of disease mechanisms and point toward therapeutic strategies.

Comparison of lichen sclerosus in boys and girls: A systematic literature review of epidemiology, symptoms, genetic background, risk factors, treatment, and prognosis

BACKGROUND

Studies concerning pediatric lichen sclerosus are limited, and, to date, there have been no studies comparing the course of lichen sclerosus in boys and girls. We sought to examine all publications on boys and girls with lichen sclerosus and assess and compare epidemiology, symptoms and signs, genetic background, risk factors, treatment, and prognosis.

METHODS

A systematic search was performed in the Embase, Medline, Cochrane, and Web of Science databases. Inclusion criteria were information on children ages 0-18 years and a clinical or histologic diagnosis of lichen sclerosus. Literature from 1985 to 2021 was reviewed.

RESULTS

A total of 1780 articles were retrieved from the search, of which 90 articles were eligible for inclusion. Boys and girls present similarly on many aspects; nonetheless, treatment and follow-up are approached differently.

CONCLUSIONS

Though the clinical approach is often different, lichen sclerosus in boys and girls demonstrates many similarities. More research is needed, especially on follow-up, to gain a better understanding of the course of lichen sclerosus and establish an advanced management plan for children.

Electroporation and Electrochemotherapy in Gynecological and Breast Cancer Treatment

Gynecological carcinomas affect an increasing number of women and are associated with poor prognosis. The gold standard treatment plan is mainly based on surgical resection and subsequent chemotherapy with cisplatin, 5-fluorouracil, anthracyclines, or taxanes. Unfortunately, this treatment is becoming less effective and is associated with many side effects that negatively affect patients’ physical and mental well-being. Electroporation based on tumor exposure to electric pulses enables reduction in cytotoxic drugs dose while increasing their effectiveness. EP-based treatment methods have received more and more interest in recent years and are the subject of a large number of scientific studies. Some of them show promising therapeutic potential without using any cytotoxic drugs or molecules already present in the human body (e.g., calcium electroporation). This literature review aims to present the fundamental mechanisms responsible for the course of EP-based therapies and the current state of knowledge in the field of their application in the treatment of gynecological neoplasms.

NASPAG Clinical Opinion: Diagnosis and Management of Lichen Sclerosis in Pediatric and Adolescent Patients

This Clinical Opinion replaces the NASPAG Clinical Recommendation: Pediatric Lichen Sclerosus published in 2014. The objective of this document is to provide guidance in the diagnosis and management of vulvar lichen sclerosus (LS) in the pediatric and adolescent patient in order to treat patient symptoms and reduce long-term sequelae. LS is a chronic inflammatory condition affecting the anogenital region that may present in the prepubertal or adolescent patient. Clinical presentations include significant pruritus, loss of pigmentation and vulvar adhesions with loss of normal vulvar architecture. Management includes topical agents for induction and maintenance therapy, as well as long-term follow-up for identification and treatment of recurrence and sequelae. This document is intended for use by both primary and specialty pediatric and adolescent gynecology (PAG) providers, including specialists in pediatrics, gynecology, adolescent medicine, and dermatology.

Extragenital Bullous Lichen Sclerosus Treated with Fractional CO2 Laser (FxCO2) and Wet Dressing of Halcinonide Solution: A Case Report

Lichen sclerosis (LS) is an insidious, chronic, relapsing skin disease characterized by atrophic, porcelain-appearing plaques. It usually arises in the anogenital area, but some cases can present in extragenital regions with a variety of presentations, including a bullous variant. Topical corticosteroids are a first-line therapy and are usually the most effective treatment to induce remission of LS. However, there is a subset of patients that does not respond well to topical steroids. Herein, we report an extragenital bullous LS case successfully treated with a fractional CO₂ laser (FxCO₂) and subsequent wet dressing of halcinonide solution.

Influence of Photodynamic Therapy on Lichen Sclerosus with Neoplastic Background

Background: Lichen sclerosus is the most common nonmalignant vulvar disease with morbidity in postmenopausal age. The first line of treatment is corticosteroid therapy. In case of insufficiency, tacrolimus or pimecrolimus can be provided. Photodynamic therapy (PDT) can be used as alternative way of treatment while symptoms recurrent despite other methods. Methods: the analyzed population of 182 women with diagnosis of lichen sclerosus treated using PDT was divided into three groups: patients with neoplastic disease or intraepithelial neoplasia; those with a positive family history of neoplastic disease; and a control group with no neoplastic disease and no familial history of neoplastic diseases. Results: Reduction of vulvar changes was assessed in the whole vulva in the groups as 21.9%, 21.2% and 21.8%, respectively. The most frequent symptom, itching, was reported to decrease in all groups, 39.3%, 35.5% and 42.5%, respectively. Improvement of quality of life was assessed in 91.3% of the whole group, stabilization of lichen sclerosus in 7.1% and progression in 1.6%. Conclusions: Photodynamic therapy gives positive results in most cases. Improvement after PDT is observed in objective vulvoscopic assessment and in subjective patients’ opinions. Neoplastic disease in the past can influence the effectiveness of PDT.