Lichen sclerosus

EuroGuiderm guideline on lichen sclerosus-introduction into 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 redness and oedema, typically followed by whitening of the genital skin; sometimes 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, highlight important aspects in the care of LS patients (part 1), 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.

[Lichen sclerosus in clinically relevant phimosis: incidence, risk factors, and association with squamous cell carcinoma of the penis]

BACKGROUND

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory skin disease. It is frequently diagnosed following circumcision. Diabetes mellitus (DM) is a known risk factor in men. Malignant pathology is more common in patients with LSA. Data on LSA in men are very limited.

OBJECTIVE

This study investigated the incidence of LSA in men who had undergone circumcision. Risk factors and likelihood of malignancy were captured.

MATERIALS AND METHODS

Data of 215 patients were retrospectively analyzed. As potential risk factors, age, body mass index (BMI), DM, coronary heart disease (CHD) and arterial hypertension were identified. Data were analyzed and displayed graphically as spike histograms. Logistic regression was applied. Age and BMI were transformed using cubic spline function.

RESULTS

Mean age of patients was 37 years (± 22 years). Mean BMI was 26.4. In all, 24% of the patients had a BMI > 30. Of the patients, 11% had DM, 5.1% had CHD, and 19% had arterial hypertension. Pathology revealed LSA in 47% of patients. Malignant disease was apparent in 3.3% of patients (2.7% without concomitant LSA, 4% with concomitant LSA). Age (55 vs 20 years, odds ratio [OR]: 3.210 [1.421, 7.251]) was a significant risk factor for LSA. BMI (30 vs 22 kg/m2, OR 1.059 [0.614, 1.828]) and DM (OR: 0.42 [0.148, 1.192]) elevated the risk for LSA.

CONCLUSION

We saw high rates of LSA in patients had undergone circumcision. Higher age represents a significant risk factor. In 3.3%, final pathology revealed squamous cell carcinoma of the penis. Therefore, pathologic work-up of circumcision specimen is mandatory.

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.

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.

Post-Inflammatory Hypopigmentation: Review of the Etiology, Clinical Manifestations, and Treatment Options

Post-inflammatory hypopigmentation is a common acquired pigmentary disorder that is more prominent in skin of color, leading to great cosmetic and psychosocial implications. Often, a diagnosis with a pigmentary disorder can negatively impact an individual's health-related quality of life and may result in stigma. Although most cases of post-inflammatory hypopigmentation resolve spontaneously over time, a systematic diagnostic approach can help with identifying the underlying etiology and informing treatment strategies. It can be due to cutaneous inflammation, sequelae of inflammatory or infectious dermatoses, or dermatologic procedures. Therefore, a thorough understanding of the epidemiology, patient history, physical exam findings, and clinical features of post-inflammatory hypopigmentation phenomenon can explain the primary cause to providers and allow for patient education. It is also important to understand the various therapeutic approaches available and the efficacy of these options, which will inform providers to choose the appropriate therapy for patients. Although algorithms exist for classifying acquired disorders of hypopigmentation, there are no established algorithms for the diagnosis and treatment of post-inflammatory hypopigmentation, which warrants further exploration and discourse.

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.

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.

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.

An evaluation of the pharmacotherapeutic options for the treatment of adult phimosis. A systematic review of the evidence

INTRODUCTION

Topical pharmacotherapy is often practiced in the treatment of adults with phimosis or Lichen Sclerosus (LS). However, it is unclear if it is effective.

AREAS COVERED

The authors review pharmacological treatments in adults with phimosis or LS using the Preferred Reporting of Items for Systematic Reviews and Meta- analysis (PRISMA) methodology. They searched seven databases using key words phimosis, drug treatment, medical, treatment, lichen sclerosis, pharmacological treatment, medications, comparison study for all English language articles from 1962-2021. Inclusion criteria were patients >18 yr., and the use of topical medical treatment with outcome data. The article includes the authors' expert opinion and their perspectives for the future.

EXPERT OPINION

There is limited research, with significant heterogeneity, which suggests the probable safety of topical steroids with some potential to reduce the signs and symptoms of LS. However, good quality research, with patient reported outcome data, is required to establish its true role and effectiveness.

Clinical and histopathological spectrum of genital lichen sclerosus in 133 cases: Focus on the diagnosis of pre-sclerotic disease

BACKGROUND

Early inflammatory lesions of lichen sclerosus are histopathologically difficult to diagnose until the hallmark of the disease i.e., papillary sclerosis becomes visible in histological sections. Pre-sclerotic and late or resolved phases of the disease have not been extensively studied.

METHODS

We retrospectively reviewed all cases diagnosed as genital lichen sclerosus over a ten-year period from 2006 to 2016, correlating the clinical findings with the histological features.

RESULTS

A total of 133 cases of genital lichen sclerosus (90 males and 43 females) were identified. Both genders demonstrated a similar histological spectrum. Fifty eight (44%) cases were identified as having pre-sclerotic lichen sclerosus, 64 (48%) as having progressive disease and 11 (8%) cases were classified as fully resolved with atrophy. Asymptomatic vitiligoid lesions were identified in 19 (14%) cases of which 12 were male. Low-grade squamous cell carcinoma was seen within the areas affected by long-standing lichen sclerosus, in four patients (3%, 2 male).

LIMITATIONS

We studied only haematoxylin and eosin stained sections. The presence of basement membrane thickening could have been better illustrated with the periodic acid-Schiff stain.

CONCLUSION

The pathogenesis of lichen sclerosus probably involves an immune reaction to the basement membrane at the epidermal interface and around the adnexa. The initial band of inflammation shifts gradually downwards from the epidermal interface into the dermis destroying the vascular channels and appendages, resulting in excessive deposition of altered extracellular matrix. Basilar infiltration of lymphocytes along with a grossly vacuolated or thickened basement membrane is proposed as the characteristic diagnostic feature of the pre-sclerotic stage. Greater awareness of the clinicopathological spectrum of lichen sclerosus should enable early diagnosis and treatment, thereby preventing structural damage and possible malignant transformation in chronic cases.

A study on clinical spectrum of lichen sclerosus in a tertiary care Centre in North India

Introduction:

Lichen sclerosus (LS) is a chronic dermatosis frequently located over labial, perineal, and perianal areas. The etiology is multifactorial and includes genetic, autoimmune, hormonal, and infectious aspects.

Materials and Methods:

A series of twenty genital LS patients was carried out to evaluate the signs, symptoms, complications, and affliction of quality of life.

Results:

Eighteen out of twenty patients were female between 30 and 73 years and showed smooth, glistening, and whitish plaques. The mean duration was 8.4 years. Itching and burning was the most common symptom (75%) corresponding to excoriation and fissuring of genitalia (75%). Malignancy was seen in two cases (10%). The mean Vulvar Quality of Life Index was 9.2, higher in younger patients.

Discussion:

LS is a disorder of older age group with female preponderance. It is a source of significant morbidity, and long-standing cases predispose to vulvar malignancy.

Conclusion:

To conclude, early diagnosis with proper counselling of the patient and his/her partner regarding various aspects of disease are essential for a wholesome approach.

Vulvar leukoplakia: therapeutic options

Vulvar leukoplakia is not a histological diagnosis and involves several diseases. Most commonly, these are vulvar lichen sclerosus and squamous cell hyperplasia of the vulva. These two conditions have similar aetiology, clinical presentation and treatment but different histopathological changes. They both lead to significant impairment of quality of life, risk of malignancy, as well as recurrence after treatment.

Treatment of these conditions includes topical corticosteroids as a first-line therapy, but they have their side effects and not all patients are receptive to this therapy. This requires the use of alternative therapeutic options such as topical calcineurin inhibitors, topical and systemic retinoids, other steroid creams, various destructive techniques and, as a last resort, surgical removal of affected tissues. Surgical treatment should be avoided, despite the malignant potential, because of recurrence risk in both diseases

New therapeutic approaches are coming into effect in gynaecological practice due to potential risks of the above-mentioned methods. Platelet-rich plasma therapy, ablative and non-ablative laser treatment, and new topical medicines, are some of the new options applied to improve the efficacy of treatment avoiding the side effects of conventional medications. A number of them are still in their initial phase of application and time will tell their effectiveness.

Acrosyringeal variant of extragenital lichen sclerosus et atrophicus

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory dermatosis of the anogenital area, and approximately 15% to 20% of patients with LSA have extragenital lesions. Here, we report the case of an 18-year-old Korean man presenting with multiple asymptomatic punctated hypopigmented atrophic macules on the dorsa of both feet. Dermoscopic examination revealed hypopigmented atrophic macules with several central keratotic plugs. The histopathologic findings indicated LSA but were confined to the acrosyringium. Based on the clinical and histopathological findings, the patient was diagnosed with an acrosyringeal variant of extragenital LSA. The patient in this case showed a unique histopathological finding in which the typical features of LSA were confined to the acrosyringium, as well as an unusual clinical presentation of non-coalescing atrophic punctate macules on the dorsum of the feet.

[Lichen sclerosus in children]

Lichen sclerosus (LS) is a chronic inflammatory disease of the skin. It mainly affects the anogenital area. More knowledge of the disease is needed to avoid delay in diagnosis as early treatment may cure the disease in some and reduce or prevent scarring. Initial treatment for girls and boys comprises the daily application of a potent cortisone ointment for 3 months. After remission the treatment should be continued long-term intermittently. If there is no complete remission in boys complete circumcision is recommended. LS usually cannot be healed but only well suppressed, and also after circumcision recurrences may occur years later. Therefore, patients have to be well informed and should be followed up long-term.

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.

Lichen planus and lichenoid dermatoses: Clinical overview and molecular basis

Deriving from the Greek word λειχήν for "tree moss" and the Latin word planus for "planar," lichen planus is a relatively uncommon and heterogeneous cutaneous disorder that typically develops in middle-aged adults. Despite the significant clinical burden associated with the disorder, little well-conducted molecular research has been undertaken, possibly because of heterogeneity impeding consistent and confident phenotyping. The multiple variants of lichenoid disease bear overlapping clinical and pathologic features despite manifesting as distinct clinical disorders. The first article in this 2-part continuing medical education series provides a comprehensive overview of the clinical and pathologic characteristics of cutaneous lichenoid dermatoses and links these manifestations to recent advances in our understanding of the underlying pathobiology of such diseases.

Raman spectroscopy and multivariate analysis for the non invasive diagnosis of clinically inconclusive vulval lichen sclerosus

Vulval lichen sclerosus (LS) is a common inflammatory condition associated with an increased risk of developing vulval carcinoma. Diagnosis is usually clinical although biopsy is necessary if the diagnosis is uncertain or if there is a failure to respond to adequate initial treatment. Raman spectroscopy has the potential to be applied in vivo for near real time objective non-invasive optical diagnosis, avoiding the need for invasive tissue biopsies. The aim of this study was to evaluate the diagnostic performance of Raman spectroscopy for differentiating LS from other vulval conditions in fresh vulval biopsies. Biopsies were analysed from 27 women with suspected LS in whom the attending gynaecologist could not establish the diagnosis on clinical presentation alone. Spectral variance was explored using principal component analysis and in conjunction with the histological diagnoses was used to develop and test a multivariate linear discriminant classification model. This model was validated with leave one sample out cross validation and the diagnostic performance of the technique assessed in comparison with the pathology gold standard. After cross validation the technique was able to correctly differentiate LS from other inflammatory vulval conditions with a sensitivity of 91% and specificity of 80%. This study demonstrates Raman spectroscopy has potential as a technique for in vivo non-invasive diagnosis of vulval skin conditions. Applied in the clinical setting this technique may reduce the need for invasive tissue biopsy. Further in vivo study is needed to assess the ability of Raman spectroscopy to diagnose other vulval conditions before clinical application.

Balanitis xerotica obliterans: a review of diagnosis and management

Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin. It is associated with significant morbidity and may result in impaired urinary and sexual function. It was initially described by Stuhmer in 1928, named after its pathological features, and is considered the male equivalent of vulvar lichen sclerosis (LS).^3,40 The etiology of BXO is uncertain; however, autoimmune disease, local trauma, and genetic and infective causes have been proposed. BXO occurs most commonly on the prepuce and glans penis. It is considered to have premalignant potential to transform into squamous neoplasia. This postulation rests on retrospective studies and parallels drawn with vulvar LS and squamous cell carcinoma (SCC) development. Histologically, BXO and vulvar LS are considered the same disease.⁴¹ There is a paucity of evidence-based guidelines to assist with appropriate follow-up for patients with BXO.

Lichen sclerosus of the oral mucosa: clinical and histopathological findings. Review of the literature and a case report

OBJECTIVES

Lichen sclerosus (LS) is a rare, chronic mucocutaneous disease that most frequently affects the female genital area. Oral manifestations are seldom detected; only 36 well-documented and histopathologically verified oral LS cases have been published.

MATERIALS AND METHODS

Here we describe one patient affected by oral (LS) and review of the literature 1957-2017.

RESULTS

Findings in our review suggest a female to male ratio of 1.64:1. It is most commonly diagnosed at the age of 10-29 years (46%). Oral LS can appear as symptomless, irregular-shaped, porcelain-white and flat lesions situated asymmetrically. Lesion is commonly sole, well-demarcated area and its size varies from 2 mm (small macula) to 7 cm (large plaque). The most common sites in the oral cavity include the labial mucosa, lips and gingiva. The histopathological criteria include atrophy and sometimes hyperkeratosis of the epithelium, hydropic degeneration of basal cells, hyalinization of the lamina propria, lymphocyte infiltration beneath the zone of hyalinization and scantiness of elastin. Surgical excision is an effective treatment for small lesions; intralesional triamcinolone or corticosteroid injections are used for larger lesions.

CONCLUSIONS

Oral LS may be under-recognized due to its asymptomatic nature and rarity.

Anogenital Lichen Sclerosus in Women

A study of 350 women with lichen sclerosus, originally made to elucidate the relationship between lichen sclerosus and autoimmunity, led to the amassing of a considerable amount of clinical material. Our review is confined to those with anogenital lesions (342), supplemented by some new cases (15), giving a total of 357 women with biopsy proven lichen sclerosus. It demonstrates the wide age range of the condition, the association with morphoea and lichen planus and the occurrence of squamous cell carcinoma in some cases. It also shows that inappropriate surgery has continued to be carried out for benign disease.

Genital diseases in the mature woman

Vulvovaginal conditions are common in mature women. This reflects age-related changes in immunity and skin barrier function of vulvovaginal tissues. Vaginal atrophy is commonly complicated by dryness and inflammation, which makes postmenopausal atrophic vaginitis a virtually ubiquitous condition. The differential of vaginitis includes inflammatory, infectious, and malignant diseases, plus drug hypersensitivity. Atrophic vaginitis is treated with estrogen replacement therapy. Vulvovaginal malignant melanoma occurs predominantly in postmenopausal women and carries a poor prognosis. Similarly, the incidence of vulvovaginal malignancies, such as squamous cell carcinoma and extramammary Paget disease, rises exponentially after 65 years of age. Early diagnosis of these malignancies is of utmost importance. Lichen sclerosus et atrophicus and vulvovaginal candidosis are among the most common postmenopausal vulvovaginal conditions. Lichen sclerosus et atrophicus is associated with significant morbidity, and its management can be challenging. The incidence of vulvovaginal candidosis increases in patients on estrogen replacement therapy.

Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision

Penile inflammatory skin conditions such as balanitis and posthitis are common, especially in uncircumcised males, and feature prominently in medical consultations. We conducted a systematic review of the medical literature on PubMed, EMBASE, and Cohrane databases using keywords "balanitis," "posthitis," "balanoposthitis," "lichen sclerosus," "penile inflammation," and "inflammation penis," along with "circumcision," "circumcised," and "uncircumcised." Balanitis is the most common inflammatory disease of the penis. The accumulation of yeasts and other microorganisms under the foreskin contributes to inflammation of the surrounding penile tissue. The clinical presentation of inflammatory penile conditions includes itching, tenderness, and pain. Penile inflammation is responsible for significant morbidity, including acquired phimosis, balanoposthitis, and lichen sclerosus. Medical treatment can be challenging and a cost burden to the health system. Reducing prevalence is therefore important. While topical antifungal creams can be used, usually accompanied by advice on hygiene, the definitive treatment is circumcision. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in risk of penile cancer. Because of the high prevalence and morbidity of penile inflammation, especially in immunocompromised and diabetic patients, circumcision should be more widely adopted globally and is best performed early in infancy.

Lichen sclerosus and risk of cancer

Malignant potential of lichen sclerosus (LS) has been suspected, but evidence is sparse. We used the population-based Finnish Cancer Registry data to further study this connection. We identified all women with the diagnosis of LS (n = 7,616) listed in the Finnish Hospital Discharge Registry from 1970 to 2012. The cohort was followed through the Finnish Cancer Registry for subsequent cancer diagnoses until 2014. Standardized incidence ratios (SIRs) were calculated for different cancers by dividing the observed numbers of cancers by expected ones. The expected numbers were based on national cancer incidence rates. During the follow-up period, we found 812 cancers among patients with LS (SIR: 1.13, 95% CI 1.05-1.21). LS was associated with an increased risk of vulvar (182 cases, SIR: 33.6, 95% CI 28.9-38.6) and vaginal cancer (4 cases, SIR: 3.69, 95% CI 1.01-9.44). The risk of cancers of the uterine cervix and lung was significantly decreased. LS is associated with an increased risk for vulvar and vaginal cancer. These data are important when designing the care of women diagnosed with LS.

Oral Lichen Sclerosus: A Rare Case Report and Review of the Literature

Lichen sclerosus (LS) is a chronic inflammatory mucocutaneous disease that often affects the anogenital area and causes significant discomfort and morbidity. Oral mucosal lesions in LS are extremely rare and might be associated with genital and/or skin manifestations. As a unique manifestation of LS, oral lesions are even more rare, with only 20 cases reported in English-language literature. In reviewing that literature in this paper, we present the case of a 44-year-old white man who sought dental assistance with a complaint of a white spot on his upper lip. Extraoral clinical examination revealed a slight white macule on the left upper lip vermilion next to the labial commissure. Intraoral examination revealed that the macule was approximately 3.5 × 2.0 cm, extended to the upper left labial mucosa, and presented an ivory-white color. Following an incisional biopsy and microscopy, the lesion was shown to be covered by a stratified squamous epithelium showing hyperkeratosis and atrophy. The superficial lamina propria revealed a well-marked band of subepithelial hyalinization and, below it, a band-like mononuclear inflammatory infiltrate. Sections stained by Verhoeff's technique revealed a scantiness of elastic fibers in the superficial lamina propria. The diagnosis of LS was then established. The patient was referred for dermatologic evaluation, which identified no skin or genital lesions, and no treatment was employed. After 6 years, no significant changes in clinical features were observed. Altogether, this rare case makes an important contribution to knowledge on this uncommon condition.

Lichen Sclerosus: Incidence and Risk of Vulvar Squamous Cell Carcinoma

BACKGROUND

The association between lichen sclerosus and vulvar squamous cell carcinoma (VSCC) has long been recognized, but large epidemiologic studies are lacking.

METHODS

Data of women diagnosed with vulvar pathology in the Netherlands were retrieved from the Dutch Pathology Registry. All vulvar pathology reports of this historical cohort were reviewed to construct a research database, including 3,038 women with lichen sclerosus diagnosed between 1991 and 2011. The incidence rate of lichen sclerosus and the cumulative incidence of VSCC among women with lichen sclerosus were estimated.

RESULTS

Between 1991 and 2011, the incidence rate of lichen sclerosus increased from 7.4 to 14.6 per 100,000 woman-years. The median age at time of lichen sclerosus diagnosis was 59.8 years and the cumulative VSCC incidence was 6.7%. The 10-year VSCC incidence in women with lichen sclerosus was associated with concurrent vulvar intraepithelial neoplasia (VIN; 18.8% in women with VIN and 2.8% in women without VIN) and age at time of lichen sclerosus diagnosis (5.9% in women of ≥70 years, 3% in women between 50 and 70 years, and 1.8% in women <50 years). The effects of presence of VIN and age remained significant in adjusted Cox regression analysis.

CONCLUSION

This historical cohort showed a nearly 100% increase in incidence of lichen sclerosus between 1991 and 2011. Concurrent VIN and age ≥70 years at time of lichen sclerosus diagnosis are important risk factors for vulvar cancer development.

IMPACT

The incidence of lichen sclerosus is rising and special attention is needed in particular in women with concurrent VIN because of their high risk of cancer. Cancer Epidemiol Biomarkers Prev; 25(8); 1224-30. ©2016 AACR.

A Unique Ocular Presentation of Extragenital Lichen Sclerosus

Lichen sclerosus is a chronic, debilitating, and recurring disease that is most commonly seen affecting the anogenital region. Extragenital locations of lichen sclerosus has been well documented, frequently seen in the shoulders, neck, trunk, breasts, and arms, however, infrequently of the face. Specifically, extragenital lichen sclerosus has been reported in several cases to be involving the infraorbital region, but to our knowledge it has never been found affecting the adnexa of the eye. To our understanding, this is the first documented report of a patient with extragenital lichen sclerosus of an eyelid.

Complications after surgery for the relief of dyspareunia in women with lichen sclerosus: a case series

INTRODUCTION

The objective of this study was to analyse complications after surgical intervention on the vulva, especially with grafting of the vaginal epithelium, for the relief of dyspareunia in women with lichen sclerosus.

MATERIAL AND METHODS

A case series of 23 women with histologically confirmed lichen sclerosus who underwent vulvar surgery because of disabling sexual dysfunction. Surgical care was provided in a university hospital (tertiary referral center) between 2008 and 2012. The interventions were posterior vestibuloplasty (perineoplasty), dehooding of the glans clitoridis and anterior vestibuloplasty with grafts of vaginal epithelium.

RESULTS

A posterior vestibuloplasty was performed in all 23 women. Short-term complications included postoperative infection with subtotal dehiscence of the advanced vaginal epithelium (n = 1), and reactivation of lichen sclerosus with the formation of bullae due to the postoperative discontinuation of dermatosteroid use (n = 1). The long-term complications included localized pain (n = 3); although the relation with the surgical intervention was unclear. Four women underwent dehooding of the glans clitoridis, all without complications. Anterior vestibuloplasty with a free full-thickness graft of vaginal mucosa was performed in five women. One woman underwent a second operation because of contraction and keratinization of the graft. The importance of estrogens for the condition of the graft was unclear.

CONCLUSIONS

After reconstructive vulvar surgery in women with lichen sclerosus, issues such as infection, reactivation of the disease and pain require attention. The use of vaginal grafts in the repair of the anterior vestibule is a novel approach and deserves further exploration.

Extragenital Lichen Sclerosus et Atrophicus

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory dermatosis with anogenital and extragenital presentations. Extragenital lichen sclerosus is most common on the neck, shoulders and upper trunk. Linear lesions are uncommon in LSA. We report a case of linear extragenital LSA involving forehead and scalp, along with grouped white papules of LSA in the right side of the back in a postmenopausal woman. The patient showed atypical clinical presentation of LSA in face which clinically mimicked ‘en coup de sabre’ as seen in morphea, but other clinical features suggested the diagnosis of LSA and the histopathological findings confirmed it.

Penile lichen sclerosus: An urologist's nightmare! - A single center experience

PURPOSE

Penile lichen sclerosus (LS) is a nagging condition and its progression result in devastating urinary and sexual problems and reduction in the quality-of-life. This study has been carried out to present our experience about this disease with simultaneous review of the available literature.

MATERIALS AND METHODS

This retrospective study has been done at a tertiary care center of eastern India. The data of 306 patients affected with LS were analyzed for clinical presentation, physical examination, investigations, and treatment offered.

RESULTS

Presenting symptoms were non-specific. The prepuce was most commonly involved location followed by glans and meatus. Urethral involvement was not isolated as the primary site. Circumcision was done in 237 patients, while 63 patients underwent meatotomy. Thirty-six of 39 cases of LS induced stricture were treated with buccal mucosal graft (BMG) either in one stage or in two stages.

CONCLUSION

LS varies from being a highly aggressive disease of the penis and anterior urethra to a burnt out condition affecting just the meatus and surrounding glans. Early diagnosis and treatment are required to prevent its complication and associated morbidity. Management depends on the anatomical location of lesion, extent of involvement, rapidity of progression and its severity. Use of BMG in LS induced urethral stricture has shown encouraging results.

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.

The impact of vulvar lichen sclerosus on sexual dysfunction

BACKGROUND

Lichen sclerosus (LS) is a chronic inflammatory condition that is known to arise on the vulva. Many women with LS report vulvar pain, often affecting a patient's quality of life. In this study, the sexual function of LS patients, with and without pain, was compared to control populations.

MATERIALS AND METHODS

A case-control study to examine the relationship between LS and sexual dysfunction was conducted. A total of 335 women presenting to the gynecology clinic were included in the study: 197 women with biopsy confirmed LS were compared to two control groups (95 asymptomatic women were "healthy" controls and 43 women had vulvovaginal candidiasis) on self-reported current health complaints, medical and surgical history and current symptoms such as pain and itching, type and frequency of sexual activity, and satisfaction with sexual activity.

RESULTS

Women with LS reported less frequent sexual activity than healthy controls (p=0.007) and Candida controls (p=0.04). Currently sexually active women with LS were significantly less likely to report vaginal intercourse (71.6%) than healthy controls (89.0%, p=0.003) or Candida controls (100%, p=0.0003), even though similar proportions of all three groups reported that vaginal intercourse was important. Satisfaction towards the quality of current sexual activity was significantly lower among women with LS compared with both the healthy and Candida control groups. 23.7% of women with LS reported that sexual activity was rarely or never satisfactory as compared with 0% of healthy controls (p<0.0001) and 6.5% of Candida controls (p=0.03).

CONCLUSION

Women with LS have less frequent sexual activity and less satisfying sexual activity when compared with controls.

Squamous Cell Carcinoma in Untreated Lichen Sclerosus of the Penis: A Rare Complication

Lichen sclerosus et atrophicus (LSA) is an uncommon disease of the skin and mucosae of either sex. Apart from a number of complications, SCC developing from a lesion of LSA in males is rare, although it is well known in females. We report two cases recently seen by us to alert clinicians of this potentially fatal complication in males.

Epidemiology of urethral strictures

Urethral stricture disease is relatively common and is associated with a significant financial cost and potentially debilitating outcomes. Understanding urethral stricture epidemiology is important to identify risk factors associated with the etiology or progression of the disease. This understanding may lead to better treatments and preventative measures that could ameliorate disease severity, produce better health outcomes, and reduce expenditures. We performed a comprehensive review of urethral stricture disease based on available published case series, identified gaps in knowledge of this disease, and recommend future directions for research.

Co-existence of Lichen Sclerosus et Atrophicus and Morphoea Along Lines of Blaschko

Lichen sclerosus (LS) is an inflammatory dermatitis of unknown etiology that mostly affects the genital region in both the sexes. In active cases the histopathologic changes differentiate between LS and morphoea though in chronic cases it is very difficult to diagnose with certainty. Coexistence of both the conditions in a single patient indicates that these lesions represent a spectrum of similar pathologic process. Coexistence of both the conditions along Blaschko's lines is so far not described in literature. We report an Indian patient with both LS and morphoea occurring along Blaschko's lines.