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Di Giuseppe J, Delli Carpini G, Giannella L, Terenzi T, Fichera M, Ragno F, Campanati A, Boero V, Caia C, Pesce E, Vercellini P, Gardella B, Dominoni M, Spinillo A, Sopracordevole F, Clemente N, Del Fabro A, Rossi R, Corazza M, Borghi A, Martinello R, Greco P, Rizzo G, Criscuolo AA, Mappa I, Matteini E, Botti E, Campione E, Bianchi L, Ciavattini A. A Longitudinal Multiinstitutional Study of Vulvar Lichen Sclerosus: From Childhood to Perimenopause. J Low Genit Tract Dis 2024; 28:276-281. [PMID: 38661348 DOI: 10.1097/lgt.0000000000000816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE The main outcome of this study was the evaluation of clinical characteristics, comorbidities, and therapeutic approaches in patients with vulvar lichen sclerosus (VLS) aged from childhood to perimenopause. Secondly, it was intended to compare these characteristics according to the menarchal status. METHODS Patients less than 45 years of age with a diagnosis of VLS from January 2002 to June 2022 in 10 referral centers were included in this retrospective longitudinal study. The univariate analysis compared the dependent variables according to menarchal status. RESULTS One hundred eighty-six patients met the inclusion criteria. At diagnosis, between 25% and 40% of premenarchal patients reported signs related to subepithelial hemorrhage. A significantly greater presence of bleeding ( p < .005), easy bruising ( p = .028), fissures ( p = .008), petechiae/splinter hemorrhages ( p < .001), and bleeding/blistering or open sores ( p = .011) was observed in premenarchal patients with respect to the postmenarchal group. The perineum ( p = .013) and the perianal region ( p < .001) were significantly more involved in the premenarchal group. Topical calcineurin inhibitors were more used in the premenarchal population ( p = .004), whereas vitamin E oil and moisturizers were more used in the postmenarchal population ( p = .047). CONCLUSIONS Vulvar lichen sclerosus is a chronic condition that can cause vulvar changes that result in severe morbidity and affects sexual function and quality of life, even before menopause. Vulvar lichen sclerosus continues to be misdiagnosed in this population. This may lead to an average delay from symptom onset to diagnosis. Evaluating clinical manifestations of VLS in premenarchal and postmenarchal age allowed us to find different clinical characteristics between the 2 periods suggestive of the diagnosis.
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Affiliation(s)
- Jacopo Di Giuseppe
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Giovanni Delli Carpini
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Luca Giannella
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Tomas Terenzi
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Mariasole Fichera
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Federica Ragno
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Anna Campanati
- Dermatological Clinic, Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Veronica Boero
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlotta Caia
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Pesce
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Vercellini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Arsenio Spinillo
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Francesco Sopracordevole
- Gynecological Oncology Unit, IRCCS CRO - Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Nicolò Clemente
- Gynecological Oncology Unit, IRCCS CRO - Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Anna Del Fabro
- Gynecological Oncology Unit, IRCCS CRO - Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy
| | - Riccardo Rossi
- Preventive Gynecological Oncology Section, European Medical Center, Florence, Italy
| | - Monica Corazza
- Section of Dermatology and Infectious Diseases, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alessandro Borghi
- Section of Dermatology and Infectious Diseases, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Ruby Martinello
- Obstetrics and Gynaecology Clinic, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Pantaleo Greco
- Obstetrics and Gynaecology Clinic, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome Italy
| | - Anna Angela Criscuolo
- Department of Obstetrics and Gynecology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome Italy
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome Italy
| | - Enrico Matteini
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Elisabetta Botti
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Elena Campione
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Luca Bianchi
- U.O.C. Dermatology, Policlinico Tor Vergata, Università Roma Tor Vergata, Rome, Italy
| | - Andrea Ciavattini
- Obstetrics and Gynecologic Section, Department of Odontostomatologic and Specialized Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy
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Kirtschig G, Kinberger M, Kreuter A, Simpson R, Günthert A, van Hees C, Becker K, Ramakers MJ, Corazza M, Müller S, von Seitzberg S, Boffa MJ, Stein R, Barbagli G, Chi CC, Dauendorffer JN, Fischer B, Gaskins M, Hiltunen-Back E, Höfinger A, Köllmann NH, Kühn H, Larsen HK, Lazzeri M, Mendling W, Nikkels AF, Promm M, Rall KK, Regauer S, Sárdy M, Sepp N, Thune T, Tsiogka A, Vassileva S, Voswinkel L, Wölber L, Werner RN. EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus. J Eur Acad Dermatol Venereol 2024. [PMID: 38822598 DOI: 10.1111/jdv.20083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/22/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness; it may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are usually a whitening of the genital skin, sometimes preceded by redness and oedema; fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early. OBJECTIVES The guideline intends to provide guidance on the diagnostic of LS (part 1), highlight important aspects in the care of LS patients, generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects. MATERIALS AND METHODS The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives. RESULTS Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases. CONCLUSIONS LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.
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Affiliation(s)
- G Kirtschig
- Medbase Health Centre, Frauenfeld, Switzerland
| | - M Kinberger
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - A Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
| | - R Simpson
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - A Günthert
- Gynäkologisches Tumorzentrum St. Anna, Lucerne, Switzerland
| | - C van Hees
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - K Becker
- Office for Paediatric Surgery, Bonn, Germany
| | - M J Ramakers
- CenSeRe (Centre for Psychological, Relational, Sexual Health), Voorschoten, The Netherlands
| | - M Corazza
- Section of Dermatology and Infectious Diseases, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - S Müller
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | | | - M J Boffa
- Department of Dermatology, Mater Dei Hospital, Msida, Malta
| | - R Stein
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - G Barbagli
- Centro Chirurgico Toscano, Arezzo, Italy
| | - C C Chi
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - J N Dauendorffer
- Department of Dermatology, Centre for Genital and Sexually Transmitted Diseases, University Hospital Saint Louis, Paris, France
| | - B Fischer
- The Swiss Lichen Sclerosus Association, Switzerland/Verein Lichen Sclerosus e.V., Dottikon, Switzerland
| | - M Gaskins
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - E Hiltunen-Back
- Department of Dermatovenereology, Helsinki University Hospital, Helsinki, Finland
| | - A Höfinger
- The Swiss Lichen Sclerosus Association, Switzerland/Verein Lichen Sclerosus e.V., Dottikon, Switzerland
| | - N H Köllmann
- The Swiss Lichen Sclerosus Association, Switzerland/Verein Lichen Sclerosus e.V., Dottikon, Switzerland
| | - H Kühn
- The German Lichen Sclerosus Association, Hamburg, Germany
| | - H K Larsen
- Department of Dermatology and Venereology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - M Lazzeri
- Department of Urology, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - W Mendling
- German Center for Infections in Gynecology and Obstetrics, Helios University Hospital Wuppertal-University Witten/Herdecke, Wuppertal, Germany
| | - A F Nikkels
- Department of Dermatology, University Medical Center of Liège, Liège, Belgium
| | - M Promm
- Department of Paediatric Urology and Clinic St. Hedwig, University Medical Centre of Regensburg, Regensburg, Germany
| | - K K Rall
- Department of Women's Health, Women's University Hospital Tuebingen, Tuebingen, Germany
| | - S Regauer
- Diagnostic and Research Institute of Pathology, Medical University Graz, Graz, Austria
| | - M Sárdy
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - N Sepp
- Department of Dermatology and Venereology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - T Thune
- Department of Dermatology, Haukeland University Hospital, Bergen, Norway
| | - A Tsiogka
- 1st Department of Dermatology-Venereology, Faculty of Medicine, Andreas Sygros Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - S Vassileva
- Department of Dermatology and Venereology, University Hospital "Alexandrovska", Medical University - Sofia, Sofia, Bulgaria
| | - L Voswinkel
- The German Lichen Sclerosus Association, Hamburg, Germany
| | - L Wölber
- Department of Gynaecology, University Medical Centre Hamburg-Eppendorf and Centre for Colposcopy and Vulvovaginal Disease Jersualem Hospital Hamburg, Hamburg, Germany
| | - R N Werner
- Division of Evidence-Based Medicine (dEBM), Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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3
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Kumar KS, Morrel B, van Hees CLM, van der Toorn F, van Dorp W, Mendels EJ. Comparison of lichen sclerosus in boys and girls: A systematic literature review of epidemiology, symptoms, genetic background, risk factors, treatment, and prognosis. Pediatr Dermatol 2022; 39:400-408. [PMID: 35229894 PMCID: PMC9545843 DOI: 10.1111/pde.14967] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies concerning pediatric lichen sclerosus are limited, and, to date, there have been no studies comparing the course of lichen sclerosus in boys and girls. We sought to examine all publications on boys and girls with lichen sclerosus and assess and compare epidemiology, symptoms and signs, genetic background, risk factors, treatment, and prognosis. METHODS A systematic search was performed in the Embase, Medline, Cochrane, and Web of Science databases. Inclusion criteria were information on children ages 0-18 years and a clinical or histologic diagnosis of lichen sclerosus. Literature from 1985 to 2021 was reviewed. RESULTS A total of 1780 articles were retrieved from the search, of which 90 articles were eligible for inclusion. Boys and girls present similarly on many aspects; nonetheless, treatment and follow-up are approached differently. CONCLUSIONS Though the clinical approach is often different, lichen sclerosus in boys and girls demonstrates many similarities. More research is needed, especially on follow-up, to gain a better understanding of the course of lichen sclerosus and establish an advanced management plan for children.
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Affiliation(s)
- Kajal S Kumar
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Beth Morrel
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Colette L M van Hees
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Fred van der Toorn
- Department of Urology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Wendy van Dorp
- Department of Obstetrics and Gynecology, IJsselland Hospital, Rotterdam, The Netherlands
| | - Elodie J Mendels
- Department of Dermatology, Center of Paediatric Dermatology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
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4
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van der Meijden WI, Boffa MJ, Ter Harmsel B, Kirtschig G, Lewis F, Moyal-Barracco M, Tiplica GS, Sherrard J. 2021 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol 2022; 36:952-972. [PMID: 35411963 DOI: 10.1111/jdv.18102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/14/2022] [Indexed: 12/27/2022]
Affiliation(s)
- W I van der Meijden
- Department of Dermatology, Betsi Cadwaladr University Health Board, Bangor, UK
| | - M J Boffa
- Department of Dermatology, Mater Dei Hospital, Msida, Malta
| | - B Ter Harmsel
- Department of Gynaecology, Roosevelt kliniek, Leiden, The Netherlands
| | - G Kirtschig
- Gesundheitszentrum Frauenfeld, Frauenfeld, Switzerland
| | - F Lewis
- St John's Institute of Dermatology, Guy's and St Thomas' Hospital, London, UK
| | - M Moyal-Barracco
- Department of Dermatology, Tarnier-Cochin Hospital, Paris, France
| | - G-S Tiplica
- Dermatology 2, Colentina Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - J Sherrard
- Department of Sexual Health, Wycombe General Hospital, Bucks, UK
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Simms-Cendan J, Hoover K, Marathe K, Tyler K. NASPAG Clinical Opinion: Diagnosis and Management of Lichen Sclerosis in Pediatric and Adolescent Patients. J Pediatr Adolesc Gynecol 2022; 35:112-120. [PMID: 34610442 DOI: 10.1016/j.jpag.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/25/2021] [Indexed: 12/18/2022]
Abstract
This Clinical Opinion replaces the NASPAG Clinical Recommendation: Pediatric Lichen Sclerosus published in 2014. The objective of this document is to provide guidance in the diagnosis and management of vulvar lichen sclerosus (LS) in the pediatric and adolescent patient in order to treat patient symptoms and reduce long-term sequelae. LS is a chronic inflammatory condition affecting the anogenital region that may present in the prepubertal or adolescent patient. Clinical presentations include significant pruritus, loss of pigmentation and vulvar adhesions with loss of normal vulvar architecture. Management includes topical agents for induction and maintenance therapy, as well as long-term follow-up for identification and treatment of recurrence and sequelae. This document is intended for use by both primary and specialty pediatric and adolescent gynecology (PAG) providers, including specialists in pediatrics, gynecology, adolescent medicine, and dermatology.
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Affiliation(s)
- Judith Simms-Cendan
- Division of Pediatric Adolescent Gynecology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Kimberly Hoover
- Division of Pediatric Adolescent Gynecology, Department of Women's Reproductive Health, University of Alabama, Birmingham, Alabama
| | - Kalyani Marathe
- Division of Dermatology, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Kelly Tyler
- Departments of Dermatology and Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Vulvar Lichen Sclerosus from Pathophysiology to Therapeutic Approaches: Evidence and Prospects. Biomedicines 2021; 9:biomedicines9080950. [PMID: 34440154 PMCID: PMC8394941 DOI: 10.3390/biomedicines9080950] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Vulvar lichen sclerosus (VLS) is a chronic, distressing, inflammatory disease with an enormous impact on quality of life. Treatment goals are relieving symptoms, reversing signs and preventing anatomical changes. Despite the availability of numerous therapeutic options, treatment outcome may not be entirely satisfactory and a definitive cure does not exist. This may be due to the fact that the exact VLS etiopathogenesis remains unknown. The objectives of this paper were to review the most up-to-date knowledge on VLS etiopathogenesis and to consider the available therapies through the lens of a plausible pathogenetic model. An electronic search on both VLS etiopathogenesis and its treatment was performed using the National Library of Medicine PubMed database. Based on current knowledge, it is conceivable that various, heterogeneous environmental factors acting on a genetic background trigger an autoimmune, Th-1 response, which leads to a chronic inflammatory state. This, in turn, can determine both tissue and micro-vascular injury and activation of signaling pathways involved in fibroblast and collagen metabolism. This pathogenetic sequence may explain the effectiveness of anti-inflammatory treatments, mostly topical corticosteroids, in improving VLS clinical-pathological changes. Further deepening of the disease pathways will presumably allow key mediators to become new therapeutic targets and optimize the available treatments.
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Pediatric Vulvar Lichen Sclerosus-A Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137153. [PMID: 34281089 PMCID: PMC8297112 DOI: 10.3390/ijerph18137153] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 01/06/2023]
Abstract
Vulvar lichen sclerosus (VLS) is a chronic inflammatory condition affecting the anogenital region, which may present in a prepubertal or adolescent patient. The most popular theories are its autoimmune and genetic conditioning, although theories concerning hormonal and infectious etiology have also been raised. The most common presenting symptoms of VLS is vulva pruritus, discomfort, dysuria and constipation. In physical examination, a classic “Figure 8” pattern is described, involving the labia minora, clitoral hood, and perianal region. The lesions initially are white, flat-topped papules, thin plaques, or commonly atrophic patches. Purpura is a hallmark feature of VLS. The treatment includes topical anti-inflammatory agents and long-term follow-up, as there is a high risk of recurrence and an increased risk of vulvar cancer in adult women with a history of lichen sclerosus. This article reviews vulvar lichen sclerosus in children and provides evidence-based medicine principles for treatment in the pediatric population. A systematic search of the literature shows recurrence of VLS in children. Maintenance regimens deserve further consideration.
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Abstract
Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. The aim of this review is to focus on first-line, second-line, and maintenance therapies as well as follow-up of women with VLS. With numerous controversies, we decided to conduct a scoping review on this subject. A review protocol was developed, and the Knowledge Resource Services website was used to run a search of articles pertaining to VLS with keywords “Vulvar,” “Vulval,” and “Lichen Sclerosus.” The search was limited to published data from the last 10 years, i.e., July 2009 onward, and researches published in English language. A total of 338 articles pertaining to VLS were obtained. Out of this, 62 were original articles related to management of VLS. Effective treatments such as high-potency topical steroids are now the standard of care and first-line treatment. Follow-up may be done every three to six months for the first two years and then at least yearly to ensure adequacy of treatment and encourage compliance. Long-term follow-up in specialist clinics is recommended for women who have persistent complaints, thickened skin, or history of neoplastic lesion. Monitoring young patients yearly is recommended as there are chances of recurrence.
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Affiliation(s)
| | - Neha Mishra
- Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, Greater Noida, IND.,Obstetrics and Gynecology, Government Institute of Medical Sciences, Greater Noida, IND
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10
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Gautam MM, Singh V, Nadkarni NJ, Patil SP. Anogenital lichen sclerosus. Indian J Sex Transm Dis AIDS 2020; 41:1-9. [PMID: 33062974 PMCID: PMC7529185 DOI: 10.4103/ijstd.ijstd_49_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/06/2017] [Accepted: 12/22/2019] [Indexed: 11/25/2022] Open
Abstract
Lichen sclerosus (LS) was first described by Hallopeau in 1887. It is a chronic inflammatory condition most commonly involving the anogenital region with a relapsing course and a potential for destruction, functional impairment, atrophy, and malignant changes. LS affects both sexes with a female preponderance of 5:1. The exact prevalence of the disease is difficult to predict as the lesions are asymptomatic in the initial phase and later when the complications arise patients might visit the surgeon, pediatrician, gynecologist, or urologist. The etiology of LS has a complex interplay of genetic factors, autoimmunity, infections, and trauma. Physical examination to assess the extent of the disease and decide the line of management is the most crucial step in the management. Corticosteroids, calcineurin inhibitor, retinoids, phototherapy, and surgery can be helpful. Self-examination and long-term follow-up are necessary.
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Affiliation(s)
- Manjyot Manish Gautam
- Department of Dermatology, Dr. DY Patil Hospital and Research Centre, Navi Mumbai, Maharashtra, India
| | - Vasundhara Singh
- Department of Dermatology, Dr. DY Patil Hospital and Research Centre, Navi Mumbai, Maharashtra, India
| | - Nitin J. Nadkarni
- Department of Dermatology, Dr. DY Patil Hospital and Research Centre, Navi Mumbai, Maharashtra, India
| | - Sharmila P. Patil
- Department of Dermatology, Dr. DY Patil Hospital and Research Centre, Navi Mumbai, Maharashtra, India
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Morrel B, van Eersel R, Burger CW, Bramer WM, Ten Kate-Booij MJ, van der Avoort IAM, Pasmans SGMA. The long-term clinical consequences of juvenile vulvar lichen sclerosus: A systematic review. J Am Acad Dermatol 2019; 82:469-477. [PMID: 31437545 DOI: 10.1016/j.jaad.2019.08.030] [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] [Received: 02/22/2019] [Revised: 08/01/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Beth Morrel
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Dermatology, Center of Pediatric Dermatology, Sophia Children's Hospital, Erasmus MC University Medical Center Rotterdam-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rachel van Eersel
- Department of Obstetrics and Gynecology, University Medical Center, Gent, Belgium
| | - Curt W Burger
- Research and Development Office, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marianne J Ten Kate-Booij
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Suzanne G M A Pasmans
- Department of Dermatology, Center of Pediatric Dermatology, Sophia Children's Hospital, Erasmus MC University Medical Center Rotterdam-Sophia Children's Hospital, Rotterdam, The Netherlands.
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12
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Alyami F, Ferandez N, Koyle MA, Salle JP. Keloid formation after pediatric male genital surgeries: an uncommon and difficult problem to manage. J Pediatr Urol 2019; 15:48.e1-48.e8. [PMID: 30206024 DOI: 10.1016/j.jpurol.2018.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/01/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Penile and genital keloids are uncommon despite frequent surgeries in the genital area. Keloid scar pathogenesis is not well understood, and a uniform effective therapeutic regimen for keloids has not yet been established. In the present study, the clinical features and subsequent management in cases of severe keloid formation after pediatric genital surgery are described. METHODS A retrospective review of keloid cases that had developed after genital procedures between 2000 and 2017 was conducted. Pre-operative characteristics, operative procedures, postoperative management, and follow-up were reviewed for each case. All cases were managed by a multidisciplinary team that included plastic surgeons and dermatologists. RESULT Six cases developed genital keloids. The mean age at surgery was 5.6 years (± standard deviation 4.6 years). Procedures included phalloplasties, penile curvature correction, penoscrotal transposition, redo hypospadias repair, and circumcision. Treatment options included excision of the keloid ± topical steroid injections and postoperative use of silicone gel. Two cases of severe keloid lesions developed after using posterior auricular grafts. Ultimately, a successful outcome was achieved in all cases. CONCLUSION Genital keloids are rare and difficult to treat. Many therapeutic options are available with varying degrees of proven clinical success. As a result, pediatric urologists must be aware of advances in other fields such as plastic surgery and dermatology to treat and ideally prevent the occurrence of this serious complication.
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Affiliation(s)
- F Alyami
- Division of Urology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Urology Division, Department of Surgery, King Saud University, King Saud University Medical City and College of Medicine, Riyadh, Saudi Arabia.
| | - N Ferandez
- Division of Urology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - M A Koyle
- Division of Urology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - J P Salle
- Division of Urology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Division of Urology, Sidra Medical and Research Center, Doha, Qatar
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13
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Mazzilli S, Diluvio L, Di Prete M, Rossi P, Orlandi A, Bianchi L, Campione E. Tacrolimus 0.03% ointment for treatment of paediatric lichen sclerosus: a case series and literature review. J Int Med Res 2018; 46:3724-3728. [PMID: 30058419 PMCID: PMC6136000 DOI: 10.1177/0300060518778219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Objectives This study aimed to investigate the usefulness and tolerability of topical
tacrolimus in paediatric vulvar lichen sclerosus (LS). We examined whether
there was improvement of the most problematic symptoms, such as itching,
pain, and vulvar constipation. Methods Ten girls, aged from 4 to 9 years old who were affected by vulvar LS, were
enrolled in an open clinical study to confirm the efficacy of tacrolimus
0.03% ointment to treat LS. Tacrolimus was applied twice a day for 6 weeks
and then stopped during the follow-up period. The study duration included 6
weeks of treatment and 6 weeks of follow-up. A literature search of the
PubMed (MEDLINE) database was conducted of reports published since 1
January, 2004. Results Our study and previous studies indicated the potential effectiveness of
tacrolimus in LS. Treatment with topical tacrolimus was well tolerated with
significant improvement of itching, pain, and constipation. Conclusion Tacrolimus may be a safe and effective alternative treatment, without the
risk of corticosteroid-related vulvar atrophy, for paediatric vulvar LS. LS
could become a further indication of topical tacrolimus therapy if these
promising results are confirmed in the future.
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Affiliation(s)
- Sara Mazzilli
- 1 Department of Dermatology, University of Rome Tor Vergata, Viale Oxford, Rome, Italy
| | - Laura Diluvio
- 1 Department of Dermatology, University of Rome Tor Vergata, Viale Oxford, Rome, Italy
| | - Monia Di Prete
- 2 Department of Pathological Anatomy, University of Rome Tor Vergata, Viale Oxford, Rome, Italy
| | - Piero Rossi
- 3 Department of General Surgery, University of Rome Tor Vergata, Viale Oxford, Rome, Italy
| | - Augusto Orlandi
- 2 Department of Pathological Anatomy, University of Rome Tor Vergata, Viale Oxford, Rome, Italy
| | - Luca Bianchi
- 1 Department of Dermatology, University of Rome Tor Vergata, Viale Oxford, Rome, Italy
| | - Elena Campione
- 1 Department of Dermatology, University of Rome Tor Vergata, Viale Oxford, Rome, Italy
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14
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Mashayekhi S, Flohr C, Lewis FM. The treatment of vulval lichen sclerosus in prepubertal girls: a critically appraised topic. Br J Dermatol 2017; 176:307-316. [PMID: 28244087 DOI: 10.1111/bjd.15202] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 11/29/2022]
Abstract
Lichen sclerosus is one of the dermatoses that specifically affects the anogenital skin. It has peaks of incidence in prepubertal girls and postmenopausal women. The objective of this critical appraisal was to review systematically the evidence for efficacy and safety of different treatments. There are no randomized controlled studies of treatment in prepubertal girls and most studies are small case series or case reports. There is little focus on quality of life.
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Affiliation(s)
- S Mashayekhi
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, U.K
| | - C Flohr
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, U.K
| | - F M Lewis
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, U.K
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15
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Nerantzoulis I, Grigoriadis T, Michala L. Genital lichen sclerosus in childhood and adolescence-a retrospective case series of 15 patients: early diagnosis is crucial to avoid long-term sequelae. Eur J Pediatr 2017; 176:1429-1432. [PMID: 28856426 DOI: 10.1007/s00431-017-3004-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/02/2017] [Accepted: 08/21/2017] [Indexed: 11/29/2022]
Abstract
UNLABELLED Lichen sclerosus is a chronic skin disease, mainly localised at the introitus and perineum. When the condition remains untreated, gradual atrophy of skin structures leads to permanent scarring, making early diagnosis and treatment crucial. We reviewed all patients diagnosed with lichen sclerosus presenting to a tertiary referral centre for paediatric and adolescent gynaecology between January 2011 and December 2015 to assess disease presentation and response to treatment. We identified 15 cases, with a mean age at diagnosis of 8.8 years. Their main presenting symptoms were vulvar pruritus and vulvar soreness. Seven girls had already atrophic changes, and in four girls, this amounted to clitoral phimosis, labial resorption or labial adhesion formation. The median delay in diagnosis was 7 months. Thirteen patients received local treatment with potent corticosteroids, responding well to treatment. However, 4 girls relapsed within 2 to 36 months. Two adolescents required surgical treatment, one because of urinary retention and the second because of dyspareunia caused by clitoral entrapment. CONCLUSIONS There was a delay in diagnosis in most patients and this resulted in irreversible genital skin changes, which would have been preventable, had treatment been instituted promptly. The response to treatment with local corticosteroids was usually effective, leading to both symptom alleviation and prevention of disease progression. Atrophic changes and skin complications however were not reversed. What is Known: • Lichen sclerosus affects women of all ages, including girls, particularly prior to adolescence. • Lichen sclerosus responds well to local corticosteroid treatment. What is New: • In the majority of patients with lichen sclerosus there was a long delay between onset of symptoms and diagnosis. • Nearly half of the children diagnosed with lichen sclerosus had irreversible atrophic genital skin changes at the time of first presentation. These changes may have been prevented by a timely diagnosis and intervention.
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Affiliation(s)
- Ioannis Nerantzoulis
- First Department of Obstetrics and Gynaecology, University of Athens, 80 Vas Sofias Avenue, Athens, Greece
| | - Themistoklis Grigoriadis
- First Department of Obstetrics and Gynaecology, University of Athens, 80 Vas Sofias Avenue, Athens, Greece
| | - Lina Michala
- First Department of Obstetrics and Gynaecology, University of Athens, 80 Vas Sofias Avenue, Athens, Greece.
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16
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„Klassiker“ aus der Praxis. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0377-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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van der Meijden WI, Boffa MJ, Ter Harmsel WA, Kirtschig G, Lewis FM, Moyal-Barracco M, Tiplica GS, Sherrard J. 2016 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol 2017; 31:925-941. [PMID: 28164373 DOI: 10.1111/jdv.14096] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 12/14/2016] [Indexed: 12/21/2022]
Abstract
Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).
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Affiliation(s)
| | - M J Boffa
- Department of Dermatology, Sir Paul Boffa Hospital, Floriana, Malta
| | - W A Ter Harmsel
- Department of Gynaecology, Roosevelt kliniek, Leiden, The Netherlands
| | - G Kirtschig
- University Hospital of Tübingen, Tübingen, Germany
| | - F M Lewis
- St John's Institute of Dermatology, Guy's and St Thomas' Hospital, London and Frimley Health NHS Trust, London, UK
| | - M Moyal-Barracco
- Department of Dermatology, Tarnier-Cochin Hospital, Paris, France
| | - G S Tiplica
- Dermatology 2, Colentina Clinical Hospital, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - J Sherrard
- Department of Sexual Health, Churchill Hospital, Oxford, UK
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18
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Kirtschig G, Becker K, Günthert A, Jasaitiene D, Cooper S, Chi CC, Kreuter A, Rall KK, Aberer W, Riechardt S, Casabona F, Powell J, Brackenbury F, Erdmann R, Lazzeri M, Barbagli G, Wojnarowska F. Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus. J Eur Acad Dermatol Venereol 2015. [PMID: 26202852 DOI: 10.1111/jdv.13136] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.,Institute of General Practice and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - K Becker
- (representing the Deutsche Gesellschaft für Kinderchirurgie), Office for Paediatric surgery, Bonn, Germany
| | - A Günthert
- (representing the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG), Deptartment of Obstetrics and Gynecology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - D Jasaitiene
- (representing the Lithuanian Association of Dermatovenereologists), Department of Skin and Venereal Diseases of Republican Hospital of Panevezys, Panevezys, Lithuania
| | - S Cooper
- Department of Dermatology, Oxford University Hospitals NHS Trust and University of Oxford, Oxford, UK
| | - C-C Chi
- Department of Dermatology, Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - A Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, Oberhausen, Germany
| | - K K Rall
- Research Centre and Department for Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - W Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - S Riechardt
- (representing the Deutsche Gesellschaft für Urologie), Department of Urology and paediatric Urology, University of Hamburg, Hamburg, Germany
| | - F Casabona
- Dirigente Medico, S. C. Chirurgia Plastica, Chirurgia Plastica Rigenerativa, Ospedale Andrea Gallino, Genova-Pontedecimo, Italy
| | - J Powell
- Department of Dermatology, Hampshire Hospitals foundation Trust, Hampshire, UK
| | - F Brackenbury
- (patient representative) www.lichensclerosus.org, Association for Lichen Sclerosus and Vulval Health, Oxford, UK
| | - R Erdmann
- (development of the search strategy and performance of the literature search), Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence Based Medicine, Charite - Universitätsmedizin Berlin, Berlin, Germany
| | - M Lazzeri
- Centro Chirurgico Toscano, Arezzo, Italy
| | - G Barbagli
- Centro Chirurgico Toscano, Arezzo, Italy
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
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19
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Anderson K, Ascanio NM, Kinney MA, Krowchuk DP, Jorizzo JL. A retrospective analysis of pediatric patients with lichen sclerosus treated with a standard protocol of class I topical corticosteroid and topical calcineurin inhibitor. J DERMATOL TREAT 2015; 27:64-6. [DOI: 10.3109/09546634.2015.1054777] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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