Lichen Sclerosus

Review of Terminology of Precursors of Vulvar Squamous Cell Carcinoma

The popular term for vulvar squamous cell carcinoma in situ/dysplasia is vulvar intraepithelial neoplasia (VIN). VIN is a histological diagnosis based on loss of squamous epithelial maturation associated with enlarged, hyperchromatic, pleomorphic nuclei and increased, usually atypical mitoses. There are two types of VIN: the usual (not otherwise specified) type, also known as warty-basaloid, and the differentiated type. There are 3 grading systems for warty-basaloid VIN: the traditional 3-grade system of VIN 1-3, a low-grade/high grade Bethesda-like system and the International Society for the Study of Vulvovaginal Disease's proposal for only 1 grade. The ISSVD system eliminates VIN 1 and combines VIN 2 and 3 on the grounds that VIN 1 has not been shown to be a reproducible diagnosis and VIN 2 and 3 are not reliably separated. The evidence supports the ISSVD proposal. Warty basaloid VIN may be sub-typed into warty and basaloid VIN. Sub-typing has clinical relevance but its reproducibility is not proven. Warty-basaloid VIN may regress. Differentiated VIN has been typically diagnosed co-incident with squamous cell carcinoma. With increased frequency of performance of biopsy of hyperplastic lesions, differentiated VIN should be diagnosed more commonly before squamous carcinoma occurs.

Vulvar lichen sclerosus : pathophysiology and treatment

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

Oral lichen sclerosus et atrophicus: a case report

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory mucocutaneous disease usually affecting the female genitalia. Involvement of the oral mucosa is extremely rare but is sometimes the only manifestation of the disease. A review of the literature has disclosed only 10 histopathologically verified cases of oral LSA. We present another case with a solitary oral LSA lesion and summarize the current knowledge about this rare oral mucosal lesion.

Lichen sclerosus et atrophicus manifesting with localized loss of periodontal attachment

Lichen sclerosus et atrophicus (LSA) is a chronic mucocutaneous inflammatory disorder of uncertain aetiology that is clinically characterized by the appearance of well delimited white plaques or papules, preferentially affecting the skin and genitals, and more rarely the oral cavity. We present the case of a woman with LSA limited to the oral cavity in the form of a well delimited, flat whitish lesion affecting the vestibular gingiva of the right upper incisors and left central incisor, and extending towards the vestibular fundus and frenulum of the upper lip. Widening of the periodontal space was observed, with gingival recession and attachment loss limited to these teeth. Local corticosteroid injections caused the mucosal lesion but not the periodontal alterations to resolve. Emphasis is placed on the importance of knowledge of this condition in relation to establishing a diagnosis, and on its periodontal repercussions.

Benign vulvar disorders. Identifying features, practical management of nonneoplastic conditions and tumors

Benign vulvar disorders are infrequent, but symptoms such as pruritus, pain, burning, and irritation or the finding of a mass or growth can cause significant patient concern. In this article, Drs Larrabee and Kylander differentiate common nonneoplastic disorders and benign tumors and offer practical management options.

Decrease in epidermal CD44 expression as a potential mechanism for abnormal hyaluronate accumulation in superficial dermis in lichen sclerosus et atrophicus

CD44 is a polymorphic integral membrane glycoprotein that serves as the principal cell surface receptor for hyaluronate, the major component of the extracellular matrix. CD44 is abundantly found in the skin and functions as a cell adhesion molecule. In a recent study we have observed a massive dermal accumulation of hyaluronate as a result of the in vivo selective suppression of CD44 in keratinocytes in mice expressing a keratin 5 promoter-driven CD44 anti-sense transgene. As the histologic features of the dorsal skin of these transgenic mice display some similarities to those of the skin lesions of lichen sclerosus et atrophicus, we explored the nature of the material accumulated in the dermis of genital and extragenital lesions of 14 patients with lichen sclerosus et atrophicus by Alcian Blue and human CD44 receptor globulin stainings, as well as the epidermal expression of CD44 protein and mRNA by immunohistochemistry and in situ hybridization. In this study we provide evidence that hyaluronate is accumulated in the superficial dermis of lichen sclerosus et atrophicus lesions, in particular by the use of human CD44 receptor globulin staining, which binds specifically to hyaluronate. In addition we show that the protein and mRNA expression of CD44 in the epidermis of the involved lichen sclerosus et atrophicus skin from genital and extragenital areas is significantly decreased, and in some cases completely lost. In contrast, keratinocyte CD44 expression was un-altered in the skin lesions of lupus erythematosus, scleroderma and reticular erythematous mucinosis, despite the presence of a mucinous material in the dermis. These results suggest that a decrease in CD44 in the keratinocytes may be correlated with an abnormal dermal accumulation of hyaluronate in the lesions of lichen sclerosus et atrophicus, and may play a pathogenetic role in this disease. J Invest Dermatol 115:1054-1058 2000

Surgicel in the management of labial and clitoral hood adhesions in adolescents with lichen sclerosus

STUDY OBJECTIVE

Lichen sclerosus (LS) is an inflammatory dermatosis of the vulva with potentially destructive consequences to the young woman's perineum. Long-term sequelae include atrophy of the labia minora, scarring of the clitoral hood, and labial and/or clitoral hood adhesions. This study aims to find techniques for preventing these devastating effects.

PARTICIPANTS

Three young women, ages 14 and 15 years, with a long history of lichen sclerosus and labial adhesions, presented with recurrent labial and periclitoral adhesions. Increasing pain prior to presentation, exquisite enough to inhibit even walking, necessitated urgent operative intervention. Scarring of the clitoral hood with an area of firmness beneath the scarring was present. Sharp dissection of the clitoral hood was performed with the entrapped keratinaceous debris and hair expressed. The adherent labia were separated. Surgicel, oxidized regenerated cellulose gauze (Johnson & Johnson, Arlington, TX), was sutured to the exposed clitoral hood and labial surfaces with vicryl suture. Complete dissolution of the Surgicel occurred between postoperative day 4-6 without recurrence of adhesions. One-year follow-up did not reveal any evidence of recurrence in any of the three patients.

CONCLUSION

The recurrence of labial and clitoral hood adhesions in young women with a history of LS was prevented for at least 1 year by surgical lysis and application of Surgicel to the affected area. This technique has prevented the recurrence during the interval when these surfaces are at highest risk of re-agglutination.

Incidence of preputial lichen sclerosus in adults: histologic study of circumcision specimens

BACKGROUND

Narrowing of the prepuce in men is poorly documented, and the causes are often unknown, except in the case of clinical infections or skin diseases such as lichen sclerosus (LS).

OBJECTIVE

We conducted a histologic study of circumcision specimens with phimosis or paraphimosis.

METHODS

This prospective study included 43 men with contraction referred for circumcision.

RESULTS

LS was present in 32% of cases, but only 12% of these cases of LS had not been diagnosed before circumcision. In 31% of cases the histologic findings were normal. Subacute nonspecific inflammatory changes were diagnosed in 37% of all cases, and secondary narrowing of the prepuce in 62% of cases. It is probable that this histologic modification of the preputial mucosa is involved in narrowing of the prepuce.

CONCLUSION

Phimosis in young adults is usually not associated with LS (only 14%). In contrast, most older patients had secondary phimosis caused by progressive LS (40%) or subacute nonspecific inflammatory changes (40%). Although all cases of phimosis in men should be treated by complete circumcision to prevent penile cancer, paraphimosis associated with preputial dyspareunia, with the exception of cases associated with LS, can be treated by corrective surgery.

Oral lichen sclerosus et atrophicus. A case report

Lichen sclerosus et atrophicus affecting only the oral mucosa is extremely rare. We report here a case of oral lichen sclerosus et atrophicus presenting as a white, flat lesion involving the right buccal and labial mucosa and vermillion border. The diagnosis was based on histopathologic features. Treatment with intralesional corticosteroid was successful in reducing the size of the lesion and the symptoms of the patient. A free gingival graft was also performed to restore the lost attached gingiva. No recurrence of the lesion was found after a 1-year follow-up period, and no skin or genital lesions developed during the 3 years of treatment.

Vulvar lichen sclerosus and squamous cell carcinoma: a cohort, case control, and investigational study with historical perspective; implications for chronic inflammation and sclerosis in the development of neoplasia

The histological changes of lichen sclerosus (LS) are frequently found in association with vulvar squamous cell carcinoma (SCC). The importance of chronic inflammation and scarring in oncogenesis is well recognized. Thirty-two patients with symptomatic vulvar LS and 60 with vulvar SCC were studied. Paraffin sections of vulvar LS, and three controls groups (acute scars, normal vulva, and vulvar lichen simplex chronicus [LSC]) were investigated with a panel of seven tissue markers and for DNA content in areas without vulvar intraepithelial neoplasia (VIN). All published cases to date of vulvar LS associated with SCC were reviewed. Of the cohort of symptomatic vulvar LS patients (mean/median age, 60 years), 9% developed VIN lesions and 21% invasive SCC; symptomatic LS preceded the carcinoma by a mean of 4 years (range, 1 to 23 years). Second and third primary tumors developed in three of these patients. Of the series of 60 patients presenting with vulvar SCCa, the clinical setting and histological features of SCCs associated with LS were significantly distinctive compared with SCCas without LS: SCCs associated with LS occurred in an older age-group (74 v 65 years; P = .01), were located on the clitoris (41% v 5%; P = .003), were of conventional SCCa type (85% v 57%; P = .02), were associated with a prominent fibromyxoid stromal response (46% v 10%; P = .004), were not associated with VIN 3 (SCC in situ) (5% v 67%; P = .02) and diffusely expressed tumor suppressor gene product p53 (43% v 19%; P = .01) and cytokine TGF-beta (33% v 9%; P = .05). The epidermis of vulvar LS was similar to that of acute scars and differed significantly compared with normal vulva with respect to keratinocytic expression of markers to keratin AE 1, involucrin and filaggrin, epidermal thickness (0.13 mm [LS] v 0.05 mm [normal]; P < .03), and proliferative index by PCNA and Mib-1 labeling (53/60 [LS] v 15/19 [normal] per 200 basal cells [bc]; P < .003). Vulvar LS showed significantly higher expression of p53 than all three control groups (80 [LS] v 3 [normal]/44 [acute scar]/28 [LSC] per 200 bc; P < .008), and aneuploidy (33% v diploid controls) in the absence of VIN. Comparing LS with and without associated SCCa found significant increases in age of patients (74 v 66 years; P = .001), and DNA aneuploidy (52% v 11%; P = .0001) and no differences in epidermal thickness, sclerotic thickness, proliferative index, or p53 expression. However, those cases of LS with an aneuploid DNA content showed significantly elevated p53 expression (88 v 60/200 bc; P = .01) and epidermal thickness (0.16 v 0.11 mm; P = .005) compared with LS with a diploid DNA content. Review of published cases supports an association between LS and vulvar SCC. The phenomenon of chronic inflammation and scarring giving rise to carcinoma has been well documented. Vulvar lichen sclerosus (LS) is an inflammatory dermatosis characterized by clinicopathologic persistence and hypocellular fibrosis (sclerosis). A subset of vulvar SCCs is significantly associated with the presence of LS and diffusely express the p53 gene product. Keratinocytes affected by LS show a proliferative phenotype and can exhibit markers of neoplastic progression such as increased p53 expression and DNA aneuploidy. As a chronic scarring inflammatory dermatosis, vulvar LS could act as both "initiator and promoter" of carcinogenesis, explaining the frequent coexistence of these diseases. Because keratinocytes of LS significantly express tumor suppressor gene p53 protein, the p53 gene may be involved early in this proposed pathway of carcinogenesis.

Lichen sclerosus et atrophicus. Findings after complete circumcision

We prospectively evaluated 75 patients, 30-77 years old, with severe phimosis. All patients were treated surgically by complete circumcision and all surgical specimens were sent for histological evaluation. All patients with histologically proven lichen sclerosus et atrophicus (LSA) (eight patients, 10.6%) were re-evaluated 6 months postoperatively, and all but one were examined 5 years after the operation. All patients with histologically proven balanoposthitis (BP) (47 patients, 62.6%) were also re-evaluated 6 months postoperatively, and 41 patients 5 years after surgery. This group (BP) was the control group of our study. Six months after the operation, the eight patients with histologically proven LSA all had an excellent convalescence, and the lesions observed during the operation resolved in four patients and regressed in two patients. In one patient the glans presented with a pale grey-white-coloured plaque. Biopsy was performed and a well-differentiated squamous cell carcinoma infiltrating the glans was revealed. The control group of patients with histologically proven BP were also re-evaluated 6 months and 5 years after surgery. An excellent convalescence was observed in all patients who completed the follow-up examination. Care must be taken not to underestimate the potential relationship between LSA and squamous cell carcinoma, because the latter is usually invasive, very aggressive and requires immediate treatment.

Lichen sclerosus et atrophicus causing phimosis in boys: a prospective study with 5-year followup after complete circumcision

We prospectively investigated 100 pediatric patients suffering from phimosis and found a 10% incidence of lichen sclerosus et atrophicus. This condition usually can be diagnosed preoperatively because of its classic manifestation of severe phimosis due to a sclerotic, whitish ring at the tip of the prepuce, which in our cases was accompanied by sclerogenous glanular lesions. To our knowledge our study represents the first evidence that the development of secondary phimosis with no apparent reason in school-age boys is highly suggestive for lichen sclerosus et atrophicus. Complete circumcision is the therapy of choice because it completely removes all affected tissue and it allows spontaneous regression or resolution of glanular lesions. There has been no recurrence after 5 years of followup.