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Wijaya M, Saunderson RB, Fischer G. Vulvovaginal lichen planus mimicking desquamative inflammatory vulvovaginitis: A case series. Australas J Dermatol 2024. [PMID: 38963185 DOI: 10.1111/ajd.14344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 06/12/2024] [Accepted: 06/16/2024] [Indexed: 07/05/2024]
Affiliation(s)
- Marlene Wijaya
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Rebecca Bronwyn Saunderson
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Gayle Fischer
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine, Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
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Wijaya M, Fischer G, Saunderson RB. The efficacy and safety of deucravacitinib compared to methotrexate, in patients with vulvar lichen planus who have failed topical therapy with potent corticosteroids: a study protocol for a single-centre double-blinded randomised controlled trial. Trials 2024; 25:181. [PMID: 38475894 PMCID: PMC10929110 DOI: 10.1186/s13063-024-08022-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Vulvar lichen planus (VLP) is a chronic vulvar dermatosis that is difficult to treat and can severely impair quality of life in the absence of adequate treatment. There is a lack of high-quality evidence to direct therapy for VLP. This randomised controlled trial will be the first double-blinded study comparing systemic treatments in VLP and aims to investigate the safety and efficacy of deucravacitinib compared to methotrexate, in patients with VLP who have failed treatment with potent topical corticosteroids. METHODS A total of 116 women aged ≥ 18 years with moderate to severe VLP (Genital Erosive Lichen Planus (GELP) score ≥ 5) will be recruited. All participants will initially be treated with Diprosone® OV daily, and their outcome will be assessed using the GELP score. At 8 weeks' follow-up, responders (GELP < 5) will be continued on Diprosone® OV. Non-responders (GELP ≥ 5) will be randomised 1:1 in a blinded fashion to receive (i) methotrexate 10 mg weekly + placebo tablet twice daily + folic acid 5 mg weekly or (ii) deucravacitinib 6 mg twice daily + placebo tablet weekly + folic acid 5 mg weekly. The primary endpoint is the difference in the mean change of GELP scores from baseline to week 32 between deucravacitinib and methotrexate groups. DISCUSSION High-quality evidence guiding the management of women with VLP is lacking. Once completed, this will be the first double-blinded RCT to compare systemic treatments in VLP. The results of this study will provide valuable, high-quality data to guide second-line therapy options for VLP that is recalcitrant to potent topical corticosteroids. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12623000682640. Registered on 26 June 2023.
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Affiliation(s)
- Marlene Wijaya
- Department of Dermatology, Royal North Shore Hospital, Reserve Rd, St Leonards, New South Wales, Australia.
- The University of Sydney, Northern Clinical School, St Leonards, New South Wales, Australia.
| | - Gayle Fischer
- Department of Dermatology, Royal North Shore Hospital, Reserve Rd, St Leonards, New South Wales, Australia
- The University of Sydney, Northern Clinical School, St Leonards, New South Wales, Australia
| | - Rebecca Bronwyn Saunderson
- Department of Dermatology, Royal North Shore Hospital, Reserve Rd, St Leonards, New South Wales, Australia
- The University of Sydney, Northern Clinical School, St Leonards, New South Wales, Australia
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3
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Caro-Chang LA, Fung MA. The role of eosinophils in the differential diagnosis of inflammatory skin diseases. Hum Pathol 2023; 140:101-128. [PMID: 37003367 DOI: 10.1016/j.humpath.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
Eosinophils are known to be present in inflammatory skin diseases, but their diagnostic utility is not well established. Upon review of the published status of lesional eosinophils, several categories were identified. 1) Lesional eosinophils highly characteristic such that, in their absence, the pathologist may question the diagnosis. These include arthropod bite reactions and scabies, urticarial dermatitis, and other eosinophilic dermatoses. 2) Lesional eosinophils rare or absent, such that, in their presence, the pathologist may question the diagnosis. These include pityriasis lichenoides, graft versus host disease, and connective tissue disorders. 3) Lesional eosinophils variable and, while in some cases expected, are not required for diagnosis. These include drug reactions, atopic dermatitis and allergic contact dermatitis. 4) Lesional eosinophils variable and not expected but may be seen to a limited extent. These include lichen planus and psoriasis.
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Xie F, Dasari S, Deschaine M, Gleue CA, Sartori-Valinotti JC, Torgerson RR, Davis MD, Charlesworth MC, Meves A, Lehman JS. Differential proteomic expression profiles in vulvar lichen planus as compared to normal vulvar tissue, vulvar lichen sclerosus, or oral lichen planus: An exploratory study. Exp Dermatol 2023; 32:1498-1508. [PMID: 37317627 PMCID: PMC10527766 DOI: 10.1111/exd.14854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 06/16/2023]
Abstract
Vulvar lichen planus (VLP) is a chronic inflammatory disease which adversely affects patients' quality of life. The pathogenesis of VLP is unknown although Th1 immune response has been implicated. We aimed to discover specific tissue-based protein biomarkers in VLP compared to normal vulvar tissue (NVT), vulvar lichen sclerosus (VLS) and oral lichen planus (OLP). We used laser capture microdissection-liquid chromatography- tandem mass spectrometry to assess protein expression in fixed lesional mucosal specimens from patients with VLP (n = 5). We then compared proteomic profiles against those of NVT (n = 4), VLS (n = 5), OLP (n = 6) and normal oral mucosa (n = 5), previously published by our group. IL16, PTPRC, PTPRCAP, TAP1 and ITGB2 and were significantly overexpressed in VLP compared to NVT. Ingenuity pathway analysis identified antigen presentation and integrin signalling pathways. Proteins overexpressed in both VLP versus NVT and OLP versus NOM included IL16, PTPRC, PTPRCAP, TAP1, HLA-DPB1, HLA-B and HLA-DRA. This proteomic analysis revealed several overexpressed proteins in VLP that relate to Th1 autoimmunity, including IL16. Overlapping pathways, including those involving IFNγ and Th1 signalling, were observed between VLP, VLS, and OLP.
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Affiliation(s)
- Fangyi Xie
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Maria Deschaine
- Department of Dermatology, Florida State University, Pensacola, FL
| | - Casey A. Gleue
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Rochelle R. Torgerson
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Mark D.P. Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | | | - Alexander Meves
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, Minnesota
| | - Julia S. Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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5
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Xie F, Morken CM, Zhang N, Pittelkow MR, Sartori Valinotti JC, Comfere NI, Meves A, Murphree DH, Mangold AR, Lehman JS. Development of the lichen planus quality of life questionnaire (LPQoL) informed by expert clinician input and patient feedback: a retrospective survey study. Arch Dermatol Res 2023; 315:1561-1569. [PMID: 36715723 DOI: 10.1007/s00403-023-02534-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/31/2023]
Abstract
Lichen planus (LP) can affect multiple body sites including skin, mucosae, scalp and nails, causing considerable impact on patients' quality of life. Currently, there are no LP patient-reported outcome measures (PROMs) that address all body sites potentially affected by LP. We developed a LP Quality of Life Questionnaire (LPQoL), informed by an expert consortium and patient survey study, to address this gap. The study was approved by our institution's Institutional Review Board. First, a 22-item LPQoL was designed with input from LP experts at our institution. The tool was then optimized by garnering input from patients recently diagnosed with LP, who were asked to complete the LPQoL, as well as the Dermatology Life Quality Index (DLQI) and a feedback form about the LPQoL. Fifty-eight of 150 patients (39% response rate) returned the questionnaire. Mean DLQI score was 4.9 ± 5.6 SD (range 0-25) and mean LPQoL score was 13.6 ± 10.4 SD (range 0-54). LPQoL score was positively correlated with DLQI score (r = 0.79; p < 0.001). Forty-nine out of 56 (88%) and 6/56 (11%) rated the LPQoL as 'very easy' or 'fairly easy' to complete, respectively. Based on participants' feedback, we increased the recall period from one week to one month and added questions on esophageal involvement. With iterative input from LP experts and patients, we developed a LPQoL to address the gap in a multi-site PROM specific to LP. This is a pilot study and there is ongoing validation studies; therefore, this measure should not be used in clinical practice or research until validated.
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Affiliation(s)
- Fangyi Xie
- Department of Dermatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Colleen M Morken
- Department of Dermatology, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Mark R Pittelkow
- Department of Dermatology, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | | | - Nneka I Comfere
- Department of Dermatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Alexander Meves
- Department of Dermatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Dennis H Murphree
- Department of Dermatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Artificial Intelligence and Informatics, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Aaron R Mangold
- Department of Dermatology, Mayo Clinic Arizona, 5777 E. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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The impact of genital lichen sclerosus and lichen planus on quality of life: A review. Int J Womens Dermatol 2022; 8:e042. [PMID: 36000015 PMCID: PMC9387966 DOI: 10.1097/jw9.0000000000000042] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 07/18/2022] [Indexed: 11/26/2022] Open
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Vieira-Baptista P, Pérez-López FR, López-Baena MT, Stockdale CK, Preti M, Bornstein J. Risk of Development of Vulvar Cancer in Women With Lichen Sclerosus or Lichen Planus: A Systematic Review. J Low Genit Tract Dis 2022; 26:250-257. [PMID: 35285455 DOI: 10.1097/lgt.0000000000000673] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Vulvar lichen sclerosus (VLS) and possibly vulvar lichen planus (VLP) are associated with an increased vulvar cancer (VC) risk. We analyzed the risk of VC and its precursors after a diagnosis of VLS or VLP. MATERIALS AND METHODS A search was performed to identify articles describing the development of vulvar neoplasia in women with VLS or VLP. This systematic review was registered with the PROSPERO database. RESULTS Fourteen studies on VLS included 14,030 women without a history of vulvar neoplasia. Vulvar cancer, differentiated vulvar intraepithelial neoplasia (dVIN), and vulvar high-grade squamous intraepithelial lesion occurred in 2.2% (314/14,030), 1.2% (50/4,175), and 0.4% (2/460), respectively. Considering women with previous or current VC, the rate was 4.0% (580/14,372). In one study, dVIN preceded VC in 52.0% of the cases. Progression of dVIN to VC was 18.1% (2/11).The risk was significantly higher in the first 1-3 years after a biopsy of VLS and with advancing age; it significantly decreased with ultrapotent topical steroid use.For the 14,268 women with VLP (8 studies), the rates of VC, dVIN, and vulvar high-grade squamous intraepithelial lesion were 0.3% (38/14,268), 2.5% (17/689), and 1.4% (10/711), respectively. CONCLUSIONS Vulvar lichen sclerosus is associated with an increased risk of VC, especially in the presence of dVIN and with advancing age. Ultrapotent topical steroids seem to reduce this risk. An increased risk of developing VC has been suggested for VLP. Hence, treatment and regular life-long follow-up should be offered to women with VLS or VLP.
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Affiliation(s)
| | | | | | - Colleen K Stockdale
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Mario Preti
- Department of Surgical Sciences University of Torino, Torino, Italy
| | - Jacob Bornstein
- Research Institute of the Azrieli Faculty of Medicine, Bar-Ilan University, Galilee Medical Center, Safed, Israel
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Kherlopian A, Fischer G. Identifying predictors of systemic immunosuppressive treatment of vulvovaginal lichen planus: A retrospective cohort study of 122 women. Australas J Dermatol 2022; 63:335-343. [PMID: 35500127 DOI: 10.1111/ajd.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/09/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Between 20% and 40% of women with vulvovaginal lichen planus (VLP) fail to respond to first-line ultra-potent topical corticosteroid treatment and require systemic immunosuppression to control disease. No data exist regarding risk factors for patients with severe VLP requiring systemic immunosuppression. We aimed to identify clinical features that predict women with VLP who are at risk of severe, recalcitrant disease requiring eventual escalation to systemic treatment. METHODS A chart review was performed on a cohort of 122 adult women with VLP followed prospectively for 15 years by the same clinician in a private dermatology practice in Australia between 1 January 2004 and 1 October 2021. Uni- and multivariable binary logistical regression analyses were performed to identify clinical features distinguishing women eventually requiring systemic treatment of VLP against those whose VLP was controlled with topical corticosteroids alone. RESULTS The mean age at diagnosis of VLP was 61 years, with 35 women (28.7%) requiring systemic treatment of VLP. A multivariable regression model utilising 'Age at Diagnosis' (adjusted OR = 0.97, 95% CI 0.94-0.99), 'Non-Caucasian Ethnicity' (adjusted OR = 10.3, 95% CI 2.27-73.9) and 'Vulvar Pruritus' (adjusted OR = 2.69, 95% CI 1.11-6.86) demonstrated moderate predictive capacity, with specificity and sensitivity for predicting whether a patient will require systemic treatment for VLP of 95.3% and 40.5%, respectively. CONCLUSIONS Our findings may indicate women with VLP who are younger, of non-Caucasian ethnicity, and presenting with vulval pruritus are the highest risk of severe disease requiring systemic immunosuppressive treatment and may benefit most from earlier initiation of systemic treatment.
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Affiliation(s)
- Ashod Kherlopian
- Department of Dermatology, Dermatology Research Office, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Gayle Fischer
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Kherlopian A, Fischer G. Successful treatment of vulvovaginal lichen planus with tildrakizumab: A case series of 24 patients. Australas J Dermatol 2022; 63:251-255. [PMID: 35099060 DOI: 10.1111/ajd.13793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 11/02/2022]
Abstract
Vulvovaginal lichen planus (VLP) is a chronic inflammatory dermatosis affecting the genital skin and mucosa that can have a profound negative impact on patient quality of life. Up to 43% of women with VLP require systemic immunosuppression to achieve disease remission, and some individuals prove to be highly treatment resistant. We present a case series of 24 women with severe VLP who successfully achieved remission using off-label treatment with the interleukin-23 (IL-23) monoclonal antibody blocker tildrakizumab, and highlight tildrakizumab as a treatment for women with recalcitrant VLP who have failed more conservative treatments.
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Affiliation(s)
- Ashod Kherlopian
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Gayle Fischer
- Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Boch K, Langan EA, Zillikens D, Ludwig RJ, Kridin K. Retrospective analysis of the clinical characteristics and patient-reported outcomes in vulval lichen planus: Results from a single-center study. J Dermatol 2021; 48:1913-1917. [PMID: 34668211 DOI: 10.1111/1346-8138.16191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 01/09/2023]
Abstract
Vulval lichen planus (VLP) is a rare, but often chronic, inflammatory disease whose symptoms include genital pain, discomfort, and dyspareunia. The clinical manifestations include erythema, erosions, and scarring. The aim of this study was to longitudinally investigate patient-reported outcomes and clinical findings in patients with VLP. Patients (>18 years) with histologically confirmed VLP were included in the retrospective analysis. Patient demographics, clinical features, symptomatology, quality of life, management, clinical outcomes, and comorbidities associated with VLP were analyzed. Twenty-four patients were identified with a mean (standard deviation [SD]) follow-up time of 19.3 (13.8) months. Classical VLP with glazed erythema was found in seven (29.2%) patients, erosive VLP was present in 15 (62.5%) patients, and hypertrophic VLP in two (8.3%). Seven patients had additional cutaneous involvement, while six patients had both vulval and oral mucosal involvement. The labia minora was the most frequently affected anatomical site (83.3%), followed by the clitoris (58.3%). Scarring lesions were found in 62.5% (n = 15) of patients. All study participants received treatment with potent and/or superpotent topical corticosteroids but 50% required systemic therapy (acitretin, corticosteroids, or hydroxychloroquine). Five (20.8%) patients underwent surgery due to adhesions and scarring resulting from VLP. One patient was diagnosed with a vulval squamous cell carcinoma during long-term follow-up. The mean (SD) Dermatology Life Quality Index score was 8.4 (5.5) at presentation and 8.9 (6.8) at the end of follow-up. In conclusion, VLP was associated with moderate quality of life impairments which persisted despite treatment, suggesting that current treatments for VLP are inadequate.
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Affiliation(s)
- Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Ewan A Langan
- Department of Dermatology, University of Lübeck, Lübeck, Germany.,Manchester Sciences, University of Manchester, Manchester, UK
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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11
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Diagnosis and Management of Vulvovaginal Lichen Planus. Obstet Gynecol Surv 2021; 75:624-635. [PMID: 33111963 DOI: 10.1097/ogx.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Genital lichen planus is a debilitating disorder that lacks definitive recommendations regarding diagnosis and treatment. Objective The aim of this study was to present best practices from available evidence for the diagnosis and treatment of genital lichen planus. Evidence Acquisition We conducted a narrative review of the literature on genital lichen planus by searching PubMed using the following search terms: "vulvar lichen planus" OR (vulvar diseases[mesh] OR vulva[mesh]) AND lichen planus[mesh] OR vulvar[ti] AND "lichen planus"[ti]. We included all languages and years in the search. Results The search resulted in 273 citations that we reviewed for relevancy and selected 60 as the foundation for this review that focuses on genital sites. Diagnosis can be made without biopsy, and when a biopsy is taken, the pathologic findings may be nonspecific. Topical ultrapotent corticosteroids are most commonly used as first-line treatment of genital lichen planus. Conclusions and Relevance When patients present with genital lichen planus, a complete review of systems and a thorough physical examination should be performed because of the prevalence of extragenital sites. Treatment of genital disease should start with a topical, ultrapotent steroid, and follow-up visits should occur to ensure improvement and to monitor for adverse drug reactions and malignancy.
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Abstract
OBJECTIVE The aim of the study was to describe the clinical and histopathologic features required for a clinicopathologic diagnosis of vulvar lichen planus (LP), which is divided into 3 types: erosive, classic, and hypertrophic. MATERIALS AND METHODS The International Society of the Study of Vulvovaginal Diseases tasked the Difficult Pathologic Diagnoses committee with development of a consensus document for the clinicopathologic diagnosis of vulvar LP, lichen sclerosus, and differentiated vulvar intraepithelial neoplasia. The LP subgroup reviewed the literature and formulated diagnostic criteria, then approved by the International Society of the Study of Vulvovaginal Diseases membership. RESULTS The clinicopathologic diagnosis of erosive LP incorporates 5 criteria: (a) a well-demarcated, glazed red macule or patch at labia minora, vestibule, and/or vagina, (b) disease affects hairless skin, mucocutaneous junction, and/or nonkeratinized squamous epithelium, (c) evidence of basal layer damage, categorized as degenerative or regenerative, (d) a closely applied band-like lymphocytic infiltrate, and (e) absent subepithelial sclerosis. The clinicopathologic diagnoses of classic and hypertrophic LP each require a characteristic clinical appearance accompanied by hyperkeratosis, hypergranulosis, acanthosis, basal layer degeneration, a closely applied lymphocytic infiltrate, and absent dermal sclerosis, with hypertrophic LP showing marked epithelial abnormality compared with classic LP. CONCLUSIONS Clinicopathological correlation yields the most reliable diagnosis of vulvar LP. Disease appearance overlaps with other physiologic, dermatologic, infectious, and neoplastic entities; a low threshold for biopsy at all morphologically distinct areas is recommended. Use of the histopathologic criteria described in this document may reduce the nondiagnostic biopsy rate for clinically diagnosed LP.
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13
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Hunt KM, Klager S, Kwak YJ, Sami N. Successful systemic treatment outcomes of lichen planus: A single-center retrospective review. Dermatol Ther 2021; 34:e14903. [PMID: 33605044 DOI: 10.1111/dth.14903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/05/2021] [Accepted: 02/13/2021] [Indexed: 12/15/2022]
Abstract
Lichen planus (LP) affects up to 4% of adults and can cause significant distress and morbidity, especially to those with persistent disease. As many as 20% of patients with LP may exhibit widespread or recalcitrant disease necessitating systemic treatment options. We sought to evaluate the effectiveness of systemic treatments for severe and recalcitrant LP not responsive to topical corticosteroids or calcineurin inhibitors. Over a 10-year period, 374 patients with cutaneous and mucosal LP were evaluated at a major regional tertiary medical center; 94 qualified for inclusion in the study. In all, 26 (28%) patients achieved remission, 52 (55%) experienced stable disease control, and 16 (17%) failed all attempted treatments. Among medications most trialed, intramuscular triamcinolone (IM TAC), hydroxychloroquine, and methotrexate were most successful with 79%, 61%, and 42% respective response rates. In contrast, oral corticosteroids and dapsone were less frequently successful at rates of 24% and 20%. IM TAC represented the highest level of treatment success and was statistically significant compared to other systemic treatments (P < .01). Among adjuvant therapies, intralesional triamcinolone (IL TAC) demonstrated higher success (71%) than oral corticosteroids (29%). Based on this multi-year evaluation, we recommend that clinicians consider IM TAC as a first-line systemic option for severe or refractory LP, with hydroxychloroquine as the steroid-sparing treatment of choice. For patients requiring adjuvant therapy, IL TAC should be considered to hasten response and symptom relief. Patients with severe or widespread disease may benefit from earlier initiation of systemic therapy to prevent significant morbidity and impact on daily function.
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Affiliation(s)
- Katherine M Hunt
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Skylar Klager
- University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Young J Kwak
- Laser Skin Care Center, Long Beach, California, USA
| | - Naveed Sami
- Department of Medicine, University of Central Florida, Orlando, Florida, USA
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Lyra J, Melo C, Figueiredo R, Polonia-Valente R, Falcão V, Beires J, Vieira-Baptista P. Erosive Vulvar Lichen Planus and Risk of Vulvar Neoplasia. J Low Genit Tract Dis 2021; 25:71-75. [PMID: 33214502 DOI: 10.1097/lgt.0000000000000581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to assess the risk of vulvar cancer and precursors in a cohort of women with vulvar lichen planus (LP) and the clinical and therapeutic features of these patients. MATERIALS AND METHODS A retrospective cohort study, including all the women with the diagnosis of vulvar LP, followed in one institution during a period of 11 years, was performed. Demographic and clinical data, as well as treatment, follow-up, and histology results, were evaluated. RESULTS A total of 127 women were diagnosed with vulvar LP. The mean follow-up time was 3.9 ± 0.5 years (range = 1-11 years). Ultrapotent topical corticosteroids were first-line treatment in 91.8% (n = 112), with 32 cases (25.2%) needing an alternative treatment. Overall, 30 biopsies were performed in 19 women (15%). Vulvar high-grade squamous intraepithelial lesion was diagnosed in 3 women (2.4%), 2 (1.6%) of whom were later diagnosed with vulvar squamous cell carcinoma. No cases of differentiated vulvar intraepithelial neoplasia were observed. CONCLUSIONS Premalignant/malignant transformation in women with vulvar LP under surveillance and compliant with treatment is low. A close follow-up seems to be crucial to prevent future malignancy. Biopsies should be performed whenever a suspicious lesion seems during follow-up.
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Affiliation(s)
- Joana Lyra
- Serviço de Ginecologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Catarina Melo
- Serviço de Ginecologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Figueiredo
- Serviço de Ginecologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Rita Polonia-Valente
- Serviço de Ginecologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Vera Falcão
- Serviço de Ginecologia, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Jorge Beires
- Serviço de Ginecologia, Centro Hospitalar Universitário São João, Porto, Portugal
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15
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Sonthalia S, Agrawal M, Sharma A, Pandey A. Genital lichen planus: Adding to the review of an “underrecognized entity”. Indian J Sex Transm Dis AIDS 2021; 43:104-105. [PMID: 35846528 PMCID: PMC9282707 DOI: 10.4103/ijstd.ijstd_11_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 09/04/2020] [Accepted: 01/27/2021] [Indexed: 11/15/2022] Open
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16
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Cline A, Cuellar-Barboza A, Jorizzo JL, Pichardo RO. Methotrexate for the Treatment of Recalcitrant Erosive Lichen Planus of the Vulva. JAMA Dermatol 2020; 156:215-217. [PMID: 31895434 DOI: 10.1001/jamadermatol.2019.4062] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Abigail Cline
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adrian Cuellar-Barboza
- Department of Dermatology, Hospital Universitario Dr José E. Gonzalez, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Joseph L Jorizzo
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Rita O Pichardo
- Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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17
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Lacarrubba F, Borghi A, Verzì AE, Corazza M, Stinco G, Micali G. Dermoscopy of genital diseases: a review. J Eur Acad Dermatol Venereol 2020; 34:2198-2207. [PMID: 32531092 DOI: 10.1111/jdv.16723] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/20/2020] [Indexed: 12/15/2022]
Abstract
The male and female external genital regions are anatomical areas in which various types of skin disorders may occur. Although most of these conditions can be diagnosed by means of clinical examination and an accurate medical history, in most cases further investigations with time-consuming and/or invasive procedures are needed in order to reach the correct diagnosis. Dermoscopy, as a modern non-invasive tool, is able to better diagnose pigmented and non-pigmented skin tumours along with various inflammatory and infectious skin and appendage disorders. The aim of this paper was to provide a review of the use of dermoscopy in genital disorders based on published data and to include personal experience gained from real life, focusing on any possible gender difference and whether disease mucosal/semimucosal dermoscopy features may differ from those observed on the skin. In conclusion, genital dermoscopy should always be considered during clinical inspection in order to enhance the diagnosis or to rule out those conditions that may look similar but that show a different dermoscopy pattern, thus narrowing down the differential diagnoses and avoiding unnecessary invasive investigations.
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Affiliation(s)
- F Lacarrubba
- Dermatology Clinic, University of Catania, Catania, Italy
| | - A Borghi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - A E Verzì
- Dermatology Clinic, University of Catania, Catania, Italy
| | - M Corazza
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - G Stinco
- Department of Experimental and Clinical Medicine, Institute of Dermatology, University of Udine, Udine, Italy
| | - G Micali
- Dermatology Clinic, University of Catania, Catania, Italy
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18
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Kherlopian A, Fischer G. Vulvar malignancy in biopsy-proven vulval lichen planus: A retrospective review of 105 cases. Australas J Dermatol 2020; 61:386-388. [PMID: 32578871 DOI: 10.1111/ajd.13368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 01/23/2023]
Affiliation(s)
- Ashod Kherlopian
- Department of Dermatology, Royal North Shore Hospital, St Leonards, Australia
| | - Gayle Fischer
- Department of Dermatology, Royal North Shore Hospital, St Leonards, Australia
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19
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Khurana A, Tandon S, Marfatia YS, Madnani N. Genital lichen planus: An underrecognized entity. Indian J Sex Transm Dis AIDS 2020; 40:105-112. [PMID: 31922099 PMCID: PMC6896385 DOI: 10.4103/ijstd.ijstd_45_19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Genital lichen planus (LP) is an underrecogonized dermatosis. The appearance is often unlike classical LP elsewhere, and hence, the condition goes undiagnosed in many. Vulvo-vaginal LP in particular, can be a distressing condition often leading to scarring and a poor quality of life. Treatment for most of the genital LP variants is similar to managing LP elsewhere; however, the erosive variant requires special attention as treatment outcomes are often disappointing and the disease runs a protracted course. Potential for development of malignancy also exists, as in oral LP, and hence close follow up is essential.
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Affiliation(s)
- Ananta Khurana
- Department of Dermatology, Venereology and Leprosy, Postgraduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Sidharth Tandon
- Department of Dermatology, Santosh Medical College, Gaziabad, Uttar Pradesh, India
| | - Yogesh S Marfatia
- Department of Dermatology, Government Medical College, Vadodara, Gujarat, India
| | - Nina Madnani
- Department of Dermatology, P. D. Hinduja National Hospital and Sir H. N. Reliance Foundation Hospital, Mumbai, Maharashtra, India
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20
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Mahajan R, Jain V, Ninama K, Marfatia YS. Hypertrophic lichen planus of the vulva - A missed diagnosis. Indian J Sex Transm Dis AIDS 2020; 41:116-118. [PMID: 33062998 PMCID: PMC7529173 DOI: 10.4103/ijstd.ijstd_51_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/24/2019] [Accepted: 12/05/2019] [Indexed: 11/30/2022] Open
Abstract
Lichen planus (LP) is an inflammatory dermatosis which can affect the skin, nails, and all mucous membranes, including the genitalia. Lichen planus on vulvar keratinized skin can manifest with diverse clinical features, probably due to higher temperature, PH, humidity, and bacterial flora which may modify typical cutaneous features. While lichen planus (LP) may affect the vulva in isolation, it may also be part of generalized outbreak in up to 20% cases. Herein, a case of a 53 year-old female who presented with a severely pruritic plaque over labia majora Since 6 -7 months, with no response to potent topical corticosteroids is reported. Provisional diagnosis of lichen simplex chronicus was considered however, histopathology was suggestive of hypertrophic lichen planus.
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Affiliation(s)
- Rashmi Mahajan
- Department of Dermatology, SBKS MI and RC, Dhiraj Hospital, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Varun Jain
- Department of Dermatology, SBKS MI and RC, Dhiraj Hospital, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Kishan Ninama
- Department of Dermatology, SBKS MI and RC, Dhiraj Hospital, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
| | - Yogesh S Marfatia
- Department of Dermatology, SBKS MI and RC, Dhiraj Hospital, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
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21
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Mi L, Zhang H, Zhang D, Zhang M. Lichen planus with multiple system involvement including the mouth, vagina, urethra, and scalp: a case report. ACTA ACUST UNITED AC 2019; 52:e8823. [PMID: 31618369 PMCID: PMC6787949 DOI: 10.1590/1414-431x20198823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/02/2019] [Indexed: 01/03/2023]
Abstract
This is a case report of lichen planus (LP) with multiple system involvement. A 35-year-old female patient was admitted in November 2014 with a 5-year history of painful/difficult sexual intercourse and loss of oral mucosa, and an 8-year history of focal hair loss. Earlier, the patient had been unable to adhere to corticosteroid therapy because of severe adverse side effects. In September 2014, labia minora mucosa defects and stricture of the urethral orifice (with dysuria), vaginal orifice, and vagina were identified. Biopsy was performed and a diagnosis of erosive LP was made. The patient was treated with an oral immunosuppressant (cyclosporine A) and urethral/vaginal dilatation. Urine flow rate and sex life were improved after 6 months and she discontinued medication. Four years later, the patient reported a good overall treatment efficacy. LP can involve multiple systems and should be considered in patients with dyspareunia. Immunosuppressive agents can achieve a satisfactory effect in patients with contraindication to corticosteroid.
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Affiliation(s)
- Lan Mi
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Hong Zhang
- Department of Pathology, Peking University First Hospital, Beijing, China
| | - Dai Zhang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Miao Zhang
- Department of Obstetrics and Gynecology, Beijing Aiyuhua Hospital for Women and Children, Beijing, China
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22
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Reply to "Is Vulvovaginal Lichen Planus Associated With Squamous Cell Carcinoma?". J Low Genit Tract Dis 2019; 23:184. [PMID: 30817688 DOI: 10.1097/lgt.0000000000000464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Borghi A, Virgili A, Corazza M. Dermoscopy of Inflammatory Genital Diseases: Practical Insights. Dermatol Clin 2019; 36:451-461. [PMID: 30201154 DOI: 10.1016/j.det.2018.05.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Diagnosis of genital inflammatory disorders may be difficult for several reasons, such as their similar appearance, possible misdiagnosis with infectious and malignant conditions, and peculiar anatomic conditions that may lead to modification of clinical features. Dermoscopy could be included as a part of the clinical inspection of genital diseases to support diagnosis, as well as to ideally avoid unnecessary invasive investigation. Practical guidance for the use of dermoscopy in the assessment of the main inflammatory genital diseases is provided, namely for lichen sclerosus, lichen planus, psoriasis, lichen simplex chronicus, and plasma cell mucositis.
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Affiliation(s)
- Alessandro Borghi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Via L. Ariosto 35, Ferrara 44121, Italy.
| | - Annarosa Virgili
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Via L. Ariosto 35, Ferrara 44121, Italy
| | - Monica Corazza
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Via L. Ariosto 35, Ferrara 44121, Italy
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24
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Dubey R, Fischer G. Vulvo-vaginal lichen planus: A focussed review for the clinician. Australas J Dermatol 2018; 60:7-11. [PMID: 29961956 DOI: 10.1111/ajd.12875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/22/2018] [Indexed: 01/04/2023]
Abstract
Vulvo-vaginal lichen planus is a condition which imposes a significant burden of symptoms and sequale. There is a paucity of knowledge and evidenced-based management with significant diagnostic delay prior to appropriate treatment being common. There remains great variability in clinician practice in the context of limited knowledge. This clinical review presents current evidence on the clinicopathological features, practical assessment and management options. Learning points include characterization of this chronic, burdensome clinical entity that has no standardized diagnostic or management protocols. We provide practical clinical conclusions based on current knowledge and identify areas for future research to improve patient outcomes.
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Affiliation(s)
- Ritika Dubey
- Northern Sydney Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Gayle Fischer
- Northern Sydney Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Royal North Shore Hospital, Sydney, New South Wales, Australia
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