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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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Hagerman GF, Silva-Velazco J, Molina-Lopez JF. Miscellaneous Perianal Afflictions. Clin Colon Rectal Surg 2019; 32:394-402. [PMID: 31507350 DOI: 10.1055/s-0039-1687836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article provides an overview of hidradenitis suppurativa, lichen planus, lichen sclerosis, calcinosis cuti, pyogenic granuloma, intertrigo, and seborrheic keratosis. This article also focuses on recognition and management of these pleomorphic afflictions of the perianal region.
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Kondratyeva YS, Kokina OA, Vedler AA. 15 year experience of tacrolimus application in medical practice. VESTNIK DERMATOLOGII I VENEROLOGII 2016. [DOI: 10.25208/0042-4609-2016-92-5-63-71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The review presents modern literature data on the use of tacrolimus in medical practice. The results of national and international research on the effectiveness and safety of the drug at various dermatoses are presented.
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Funaro D, Lovett A, Leroux N, Powell J. A double-blind, randomized prospective study evaluating topical clobetasol propionate 0.05% versus topical tacrolimus 0.1% in patients with vulvar lichen sclerosus. J Am Acad Dermatol 2014; 71:84-91. [DOI: 10.1016/j.jaad.2014.02.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
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Abstract
Pruritus ani is a common condition with multiple causes. Primary causes are thought to be fecal soiling or food irritants. Secondary causes include malignancy, infections including sexually transmitted diseases, benign anorectal diseases, systemic diseases, and inflammatory conditions. A broad differential diagnosis must be considered. A reassessment of the diagnosis is required if symptoms or findings are not responsive to therapy. The pathophysiology of itching, an overview of primary and secondary causes, and various treatment options are reviewed.
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Affiliation(s)
- Yosef Y Nasseri
- The Surgery Group of Los Angeles, 8631 West 3rd Street, Suite 200E, Los Angeles, CA 90048, USA.
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Brodrick B, Belkin ZR, Goldstein AT. Influence of treatments on prognosis for vulvar lichen sclerosus: Facts and controversies. Clin Dermatol 2013; 31:780-6. [DOI: 10.1016/j.clindermatol.2013.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Li Y, Xiao Y, Wang H, Li H, Luo X. Low-concentration topical tacrolimus for the treatment of anogenital lichen sclerosus in childhood: maintenance treatment to reduce recurrence. J Pediatr Adolesc Gynecol 2013; 26:239-42. [PMID: 24049806 DOI: 10.1016/j.jpag.2012.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Lichen sclerosus (LS) is a chronic inflammatory skin disorder that is commonly found in the anogenital area, especially in females. Ultra-potent topical corticosteroids are first line for the treatment of LS, but their atrophic side effects and the recurrence of the disease restrict their use. An equally effective, safer, tolerant therapeutic option is required, especially in the treatment and preventing relapse of children. METHODS Fourteen prepubertal girls (range of age: 4 to 11 years) with anogenital lichen sclerosus were treated with 0.03% tacrolimus ointment twice daily for 16 weeks, then 9 of the 14 patients adhered to 2 times weekly for further 6 months (a total of 10 months). The therapeutic effects were evaluated according to 3 grades: complete response (O75% improvement, partial response (30%-75% improvement),or no response (!30% improvement). RESULTS Clinical improvement occurred in all patients (100%). Complete response of symptoms and signs was achieved in 5 (36%), 9 (64%) and 11 (79%) patients at week 8, week 16, and month 10 respectively. During the follow-up period of 1 year, 4 patients (4/5, 80%) who treated with tacrolimus ointment for 16 weeks had a recurrence of symptoms, while only 2 of 9 (22%) patients who insisted on maintenance therapy developed recurrence of disease. No severe side effects were observed. CONCLUSIONS Low-concentration topical tacrolimus appears to be an effective and safe treatment for children with anogenital lichen sclerosus. Maintenance therapy (2 times a week for 6 months) can reduce the relapse of the disease.
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Affiliation(s)
- Yongmei Li
- Department of Dermatology, Children’s Hospital of Chongqing Medical University, and Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.
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Focseneanu MA, Gupta M, Squires KC, Bayliss SJ, Berk D, Merritt DF. The course of lichen sclerosus diagnosed prior to puberty. J Pediatr Adolesc Gynecol 2013; 26:153-5. [PMID: 23507004 DOI: 10.1016/j.jpag.2012.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 12/13/2012] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE To help determine the long-term course of girls diagnosed with lichen sclerosus before puberty. DESIGN Retrospective chart review and follow-up interview. SETTING Washington University pediatric gynecology and dermatology clinics. PARTICIPANTS Premenarchal girls diagnosed with lichen sclerosus from 1989-2010. INTERVENTIONS Telephone interview. MAIN OUTCOME MEASURES Resolution of symptoms, specifically pain and/or pruritus. RESULTS Follow-up was available for 36 premenarchal girls. The mean age at lichen sclerosus (LS) diagnosis was 7 years (range: 3-14 years). The mean duration of follow-up was 5.3 years (range: 2 months-15 years). Treatment with topical steroids (primarily 0.05% clobetasol propionate ointment) resulted in improvement in symptoms within an average of 14 weeks (range: 2 weeks-2 years) in 33 girls. Eighty-three percent of patients (n = 30) experienced remission after initial treatment. Sixteen patients reported relapses requiring an average of 3.1 years of intermittent maintenance therapy. The mean length of remission to date was 3.6 years (range 1 months-10 years). 72% of patients reported remission at the time of the phone interview. Of note, 7 out of 9 patients in our study who continue to report symptoms are still premenarchal. One postmenarchal patient was asymptomatic but had signs of LS on physical exam. CONCLUSION The prognosis and long term course of LS diagnosed prior to puberty is unclear. Although remission may occur prior to menarche in some cases, once children reach menarche with active disease, complete remission may be less likely. Treatment duration of LS in our study had a wide range, but 3 months appears to be adequate for most patients to obtain remission.
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Affiliation(s)
- Mariel A Focseneanu
- Divisions of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO 63110-1010, USA
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Abstract
Lichen sclerosus (LS) is a chronic, inflammatory, mucocutaneous disorder of genital and extragenital skin. LS is a debilitating disease, causing itch, pain, dysuria and restriction of micturition, dyspareunia, and significant sexual dysfunction in women and men. Many findings obtained in recent years point more and more towards an autoimmune-induced disease in genetically predisposed patients and further away from an important impact of hormonal factors. Preceding infections may play a provocative part. The role for Borrelia is still controversial. Trauma and an occlusive moist environment may act as precipitating factors. Potent and ultrapotent topical corticosteroids still head the therapeutic armamentarium. Topical calcineurin inhibitors are discussed as alternatives in the treatment of LS in patients who have failed therapy with ultrapotent corticosteroids, or who have a contraindication for the use of corticosteroids. Topical and systemic retinoids may be useful in selected cases. Phototherapy for extragenital LS and photodynamic therapy for genital LS may be therapeutic options in rare cases refractory to the already mentioned treatment. Surgery is restricted to scarring processes leading to functional impairment. In men, circumcision is effective in the majority of cases, but recurrences are well described. Anogenital LS is associated with an increased risk for squamous cell carcinoma of the vulva or penis. This review updates the epidemiology, clinical presentation, histopathology, pathogenesis, and management of LS of the female and male genitals and extragenital LS in adults and children.
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Viana FDO, Cavaleiro LHDS, Unger DAA, Miranda MFRD, Brito ACD. Acral lichen sclerosus et atrophicus--case report. An Bras Dermatol 2012; 86:S82-4. [PMID: 22068779 DOI: 10.1590/s0365-05962011000700021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 02/14/2011] [Indexed: 01/26/2023] Open
Abstract
Lichen sclerosus et atrophicus is a chronic disorder of the skin and mucosal surfaces, most commonly affecting the female genitalia. Few cases of lichen sclerosus et atrophicus confined to the feet and/or hands have been reported. We report a case of lichen sclerosus et atrophicus involving first the extremities and then the perigenital area.
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Kim GW, Park HJ, Kim HS, Kim SH, Ko HC, Kim BS, Kim MB. Topical tacrolimus ointment for the treatment of lichen sclerosus, comparing genital and extragenital involvement. J Dermatol 2011; 39:145-50. [PMID: 22044240 DOI: 10.1111/j.1346-8138.2011.01384.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Lichen sclerosus is a chronic inflammatory dermatosis presenting with significant sclerosis, atrophy and pruritus. The treatment for this condition remains unsatisfactory, with potent corticosteroids being the most effective therapy. In this study, we investigated the efficacy and safety of tacrolimus ointment in patients with genital and extragenital lichen sclerosus. Sixteen patients with active lichen sclerosus (10 with anogenital and six with extragenital localization) were treated with topical tacrolimus ointment twice daily. The therapeutic effects were evaluated according to 3 grades: complete response (>75% improvement), partial response (25-75% improvement), or no response (<25% improvement). Applications were continued until complete disappearance or stabilization of the cutaneous lesions. In addition, we conducted telephone surveys to determine the long-term treatment outcome and relapse rate. Objective response to therapy occurred in nine of 10 patients (90%) with anogenital and one of six patients (16.7%) with extragenital lesions. Out of 10 patients with anogenital lichen sclerosus, five showed more than 75% improvement. Complete, partial and no response were achieved in five (50%), four (40%) and one (10%) patient, respectively. During the follow-up period of a mean of 29.3 months, six of nine patients had a relapse of symptoms. However, most patients with extragenital involvement did not respond to tacrolimus, except one patient showing partial response. No significant adverse effects were observed. Topical tacrolimus ointment was a safe and effective treatment for genital lichen sclerosus and should be used for long-term duration to prevent relapse. However, it was not useful for patients with extragenital lichen sclerosus.
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Affiliation(s)
- Gun-Wook Kim
- Department of Dermatology, Pusan National University School of Medicine, and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Kim CR, Jung KD, Kim H, Jung M, Byun JY, Lee DY, Lee JH, Yang JM, Lee ES. Linear Lichen Sclerosus along the Blaschko's Line of the Face. Ann Dermatol 2011; 23:222-4. [PMID: 21747625 DOI: 10.5021/ad.2011.23.2.222] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 05/31/2010] [Accepted: 05/31/2010] [Indexed: 11/08/2022] Open
Abstract
Lichen sclerosus et atrophicus (LSA) is an inflammatory disease that primarily causes anogenital lesion in middle aged women. We present here a case of facial LSA with an asymptomatic, well-demarcated, whitish to bluish, atrophic patch in a linear pattern on the forehead of a 48-year-old woman. This case showed an atypical clinical presentation and it mimicked en coup de sabre, but the histopathologic results confirmed the diagnosis of LSA.
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Affiliation(s)
- Cho Rok Kim
- Department of Dermatology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Topical tacrolimus and pimecrolimus are indicated for treatment of atopic dermatitis, but they have been studied in many off-label uses. Double-blind and open studies have shown favorable results with topical tacrolimus and pimecrolimus in oral lichen planus. In 1 study of oral lichen planus, blood tacrolimus was detected in 54% of patients, but there were no signs of systemic toxicity. Double-blind and open studies of vitiligo have shown favorable results with tacrolimus in combination with excimer laser, especially for lesions over bony prominences and on extremities. Similarly, double-blind studies of vitiligo have shown favorable results when pimecrolimus is combined with narrow-band UVB, especially for facial lesions. Double-blind and open studies of psoriasis have shown favorable results for tacrolimus and pimecrolimus, especially for inverse psoriasis. Topical calcineurin inhibitors have been effective in many other cutaneous disorders, and further studies would help clarify their roles.
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Affiliation(s)
- Andrew N Lin
- Division of Dermatology and Cutaneous Sciences, University of Alberta, 2-104 Clinical Sciences Building, Edmonton, Alberta, T6G 2G3, Canada.
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&NA;. Vulvar lichen sclerosus may be treated effectively with topical corticosteroids, but long-term surveillance is required. DRUGS & THERAPY PERSPECTIVES 2010. [DOI: 10.2165/11205180-000000000-00000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Lichen sclerosus is a chronic inflammatory disorder with a propensity to affect the mucocutaneous anogenital area. Topical corticosteroids remain the treatment of choice for this condition and constitute an effective therapeutic modality. However, in patients with corticosteroid-resistant disease, when long-term remission is not sustainable, or in those intolerant to these agents, topical calcineurin inhibitors may be considered. Studies have demonstrated their efficacy and tolerability; however, concerns remain with regard to their malignant potential with long-term use. As lichen sclerosus is a potentially precancerous dermatosis, topical calcineurin inhibitors should be used with caution in this disorder.
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Affiliation(s)
- Paul D Yesudian
- Department of Dermatology, Glan Clwyd Hospital, Rhyl, Denbigshire, United Kingdom.
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Goldstein AT, Thaçi D, Luger T. Topical calcineurin inhibitors for the treatment of vulvar dermatoses. Eur J Obstet Gynecol Reprod Biol 2009; 146:22-9. [DOI: 10.1016/j.ejogrb.2009.05.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Revised: 04/20/2009] [Accepted: 05/24/2009] [Indexed: 11/28/2022]
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Stanley BJ, Hauptman JG. Long-term prospective evaluation of topically applied 0.1% tacrolimus ointment for treatment of perianal sinuses in dogs. J Am Vet Med Assoc 2009; 235:397-404. [DOI: 10.2460/javma.235.4.397] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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STEFANAKI C, STEFANAKI K, KONTOCHRISTOPOULOS G, ANTONIOU C, STRATIGOS A, NICOLAIDOU E, GREGORIOU S, KATSAMBAS A. Topical tacrolimus 0.1% ointment in the treatment of localized scleroderma. An open label clinical and histological study. J Dermatol 2008; 35:712-8. [DOI: 10.1111/j.1346-8138.2008.00552.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sotiriou E, Apalla Z, Patsatsi A, Panagiotidou D. Recalcitrant vulvar lichen sclerosis treated with aminolevulinic acid-photodynamic therapy: a report of five cases. J Eur Acad Dermatol Venereol 2008; 22:1398-9. [DOI: 10.1111/j.1468-3083.2008.02661.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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van de Nieuwenhof H, van der Avoort I, de Hullu J. Review of squamous premalignant vulvar lesions. Crit Rev Oncol Hematol 2008; 68:131-56. [DOI: 10.1016/j.critrevonc.2008.02.012] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Revised: 02/15/2008] [Accepted: 02/26/2008] [Indexed: 01/31/2023] Open
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Sotiriou E, Panagiotidou D, Ioannidis D. An open trial of 5-aminolevulinic acid photodynamic therapy for vulvar lichen sclerosus. Eur J Obstet Gynecol Reprod Biol 2008; 141:187-8. [PMID: 18778886 DOI: 10.1016/j.ejogrb.2008.07.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 07/21/2008] [Indexed: 11/27/2022]
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Wakamatsu J, Yamamoto T, Uchida H, Tsuboi R. Lichen sclerosus et atrophicus of the lip: successful treatment with topical tacrolimus. J Eur Acad Dermatol Venereol 2008; 22:760-2. [DOI: 10.1111/j.1468-3083.2007.02469.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Simonart T, Lahaye M, Simonart JM. Vulvar lichen sclerosus: effect of maintenance treatment with a moisturizer on the course of the disease. Menopause 2008; 15:74-7. [PMID: 17603391 DOI: 10.1097/gme.0b013e3180616689] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Vulvar lichen sclerosus (LS) is an inflammatory disease of unknown etiology that may result in significant discomfort and psychological distress in postmenopausal women. One of the most troublesome features of LS is its chronically relapsing nature. The aim of this study was to investigate the effect of maintenance therapy with a moisturizer in preventing the risk of relapse and progression of vulvar LS in postmenopausal women. DESIGN Between January 1995 and January 2006, 34 postmenopausal women with vulvar LS were included in a prospective open trial. The participants were treated with a topical corticosteroid cream (0.1% betamethasone valerate) once daily for 1 month and then with maintenance therapy with a moisturizing cream alone once daily. Follow-up visits were scheduled after 1 month and then twice per year (median follow-up, 58 mo). RESULTS Overall the symptoms of all women improved after therapy with a topical steroid. Twenty-four women (71%) became symptom free, and 10 (29%) experienced partial response. Eighteen of the 24 women (75%) who became symptom free and 6 of the 10 women (60%) who exhibited a partial response reported no worsening of their symptoms while on therapy with a cold cream alone. Total resolution of the clinical signs occurred in 6 of the 19 women with mild vulvar architectural changes. Partial resolution of clinical signs was observed in 22 women (64%). No change was noticed in six (18%) women. None of the participants experienced worsening of vulvar scarring. None of the participants developed vulvar intraepithelial neoplasia or squamous cell carcinoma during the follow-up period. There were no side effects. CONCLUSION Long-term maintenance therapy of vulvar LS with a moisturizing cream can maintain the symptom relief induced by topical corticosteroids in women with vulvar LS while being safe and inexpensive. This treatment may also be associated with a reduction in topical corticosteroid use because more than half of the women could eliminate corticosteroids altogether.
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Affiliation(s)
- Thierry Simonart
- Department of Dermatology, Erasme University Hospital, Brussels, Belgium.
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Tacrolimus en enfermedades diferentes a la dermatitis atópica. ACTAS DERMO-SIFILIOGRAFICAS 2008; 99 Suppl 2:26-35. [DOI: 10.1016/s0001-7310(08)76208-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Virgili A, Mantovani L, Lauriola MM, Marzola A, Corazza M. Tacrolimus 0.1% Ointment: Is It Really Effective in Plasma Cell Vulvitis? Dermatology 2008; 216:243-6. [DOI: 10.1159/000112935] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 07/30/2007] [Indexed: 11/19/2022] Open
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Valdivielso-Ramos M, Bueno C, Hernanz JM. Significant improvement in extensive lichen sclerosus with tacrolimus ointment and PUVA. Am J Clin Dermatol 2008; 9:175-9. [PMID: 18429647 DOI: 10.2165/00128071-200809030-00006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Lichen sclerosus is an uncommon, chronic inflammatory skin disorder of unknown origin. It is clinically characterized by sclerotic, whitish, atrophic-type lesions. The most frequent site of the lesions is generally the genital region, with about 15-20% having additional extragenital involvement. We present the case of a 62-year-old woman with a very extensive extragenital lichen sclerosus who showed great clinical and subjective improvement with 0.1% tacrolimus ointment and psoralen plus UVA (PUVA), without any topical or systemic adverse effects. Combined treatment of 0.1% tacrolimus ointment and PUVA may be a good option in extensive cases of lichen sclerosus or when other treatment options have failed, and has a good tolerability and safety profile.
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Romero A, Hernández-Núñez A, Córdoba-Guijarro S, Arias-Palomo D, Borbujo-Martínez J. Treatment of recalcitrant erosive vulvar lichen sclerosus with photodynamic therapy. J Am Acad Dermatol 2007; 57:S46-7. [PMID: 17637374 DOI: 10.1016/j.jaad.2006.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 02/16/2006] [Accepted: 04/04/2006] [Indexed: 11/22/2022]
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Hunger RE, Brönnimann M, Kappeler A, Mueller C, Braathen LR, Yawalkar N. Detection of perforin and granzyme B mRNA expressing cells in lichen sclerosus. Exp Dermatol 2007; 16:416-20. [PMID: 17437484 DOI: 10.1111/j.1600-0625.2007.00543.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Granzyme B and perforin messenger RNA (mRNA) expression has been shown to be a specific in vivo activation marker for cytotoxic cells. The aim of this study was to assess the contribution of cell-mediated cytotoxicity in the pathogenesis of lichen sclerosus. In situ hybridization and immunohistochemistry were performed on serial tissue sections of lesional skin biopsies and normal skin as control. Immunohistochemical staining showed that the cellular infiltrate of diseased skin consisted predominantly of T cells (CD3+) and some B cells (CD20+). Among T cells CD4+ and CD8+ cells were found in about equal numbers. In normal skin samples perforin and granzyme B mRNA expressing cells were only rarely found. In contrast, in biopsies from diseased skin a high percentage of infiltrating cells expressed mRNA for perforin and granzyme B. The perforin and granzyme B expressing cells were found in the dermal infiltrate and intraepidermally in close proximity to keratinocytes suggesting in situ activation of these cells. These findings provide evidence that cell-mediated cytotoxicity plays a significant role in tissue destruction in lichen sclerosus.
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Affiliation(s)
- Robert E Hunger
- Department of Dermatology, University of Bern, Inselspital, 3010 Bern, Switzerland.
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Oskay T, Sezer HK, Genç C, Kutluay L. Pimecrolimus 1% cream in the treatment of vulvar lichen sclerosus in postmenopausal women. Int J Dermatol 2007; 46:527-32. [PMID: 17472689 DOI: 10.1111/j.1365-4632.2006.03185.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vulvar lichen sclerosus (LS), a poorly recognized chronic inflammatory skin disease, may represent a therapeutic challenge. Pimecrolimus cream 1% is a nonsteroidal, selective inflammatory cytokine inhibitor that has recently been indicated for some inflammatory cutaneous diseases. OBJECTIVE To investigate the efficacy, tolerability, and safety of 1% pimecrolimus cream therapy in postmenopausal women with LS. METHODS A total of 16 patients applied pimecrolimus cream 1% twice a day over the first 3 months and then as required. All the patients completed this study and were then followed up over the next 12 months. The symptoms and clinical appearance of the lesions in every subject were recorded before and after treatment using a severity scale. RESULTS Using pimecrolimus, most of the patients exhibited a significant improvement with respect to symptoms and the clinical appearance of the disease. After 3 months of treatment, complete remission was seen in 11 patients, partial remission in four, whereas one patient experienced no response at all. Over the subsequent 12 months of follow-up, 10 patients exhibited complete remission while five had partial remission. Four cases with complete remission experienced a few relapses during the follow-up period. Older patients and those with an advanced stage of the disease responded poorly. No significant side effects were observed. CONCLUSIONS Pimecrolimus cream 1% appears to be an effective and well-tolerated therapeutic alternative option in the treatment of early stage of vulvar LS. Pimecrolimus may reduce the incidence of flare ups, improve long-term disease control, and enhance the patients' quality of life, especially in postmenopausal women.
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Affiliation(s)
- Tugba Oskay
- Department of Dermatology, Bayindir Hospital, Ankara, Turkey.
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Hengge UR, Krause W, Hofmann H, Stadler R, Gross G, Meurer M, Brinkmeier T, Frosch P, Moll I, Fritsch P, Müller K, Meykadeh N, Marini A, Ruzicka T, Gollnick H. Multicentre, phase II trial on the safety and efficacy of topical tacrolimus ointment for the treatment of lichen sclerosus. Br J Dermatol 2007; 155:1021-8. [PMID: 17034535 DOI: 10.1111/j.1365-2133.2006.07446.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lichen sclerosus is a chronic inflammatory autoimmune disease causing significant sclerosis, atrophy and pruritus. Treatment remains unsatisfactory, with potent corticosteroids being the most effective therapy. OBJECTIVES To conduct a multicentre, phase II trial to assess the safety and efficacy of tacrolimus ointment 0.1% for the treatment of lichen sclerosus with a follow-up period of 18 months at 10 university and teaching hospitals in Germany and Austria. METHODS Eighty-four patients (49 women, 32 men and three girls) aged between 5 and 85 years with long-standing, active lichen sclerosus (79 with anogenital and five with extragenital localization) were treated with topical tacrolimus ointment 0.1% twice daily for 16 weeks. Computerized analysis of the lesional area was performed. The primary endpoint was clearance of active lichen sclerosus. Secondary endpoints were time to optimal response, reduction of sclerosis and duration of remission. RESULTS The primary endpoint (clearance of active lichen sclerosus) was reached by 43% of patients at 24 weeks of treatment. Partial resolution was reached in 34% of patients. Maximal effects occurred between week 10 and 24 of therapy. Treatment led to a significant reduction of the total lesional area (P < 0.01) and to a significant decline in the total symptom score (P < 0.005). Symptoms (e.g. itching) and findings (erythema, erosions and induration) showed significant improvement. No serious adverse events were observed. There were three (9%) recurrences during the follow-up period. CONCLUSIONS Topical tacrolimus ointment 0.1% was safe and effective for the treatment of long-standing active lichen sclerosus.
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Affiliation(s)
- U R Hengge
- Department of Andrology and Venereology, Philipps-University Marburg, Marburg, Germany.
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Kim YJ, Lee ES. Case of sequentially occurring lesions of facial lichen sclerosus following the lines of Blaschko. J Dermatol 2007; 34:201-4. [PMID: 17291303 DOI: 10.1111/j.1346-8138.2007.00250.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Extragenital lichen sclerosus (LS) is usually asymptomatic and appears as ivory- or porcelain-white macules, papules and plaques. It is most common on the neck, shoulders and upper portion of the trunk. To date, the linear form of extragenital LS corresponding to the lines of Blaschko on the trunk or limbs has been rarely reported. We describe a 25-year-old Korean woman with sequentially occurring lesions of extragenital LS confined to the face following the lines of Blaschko.
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Affiliation(s)
- Young Jin Kim
- Department of Dermatology, Ajou University School of Medicine, Suwon, Korea
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Matsumoto Y, Yamamoto T, Isobe T, Kusunoki T, Tsuboi R. Successful treatment of vulvar lichen sclerosus in a child with low-concentration topical tacrolimus ointment. J Dermatol 2007; 34:114-6. [PMID: 17239148 DOI: 10.1111/j.1346-8138.2006.00228.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Lichen sclerosus is a chronic inflammatory skin disorder that has a predilection for the anogenital area. Topical corticosteroid is occasionally effective; however, continuous treatment is often required and recurrence after its stoppage is frequent. Herein, we report a case of vulvar lichen sclerosus in a 5-year-old girl, which was refractory to topical corticosteroids. After 14 weeks of treatment with 0.03% tacrolimus ointment once daily, the lesions completely resolved without side-effects. Of interest, the number of milia within the plaque of lichen sclerosus was reduced in tandem with the improvement of lichen sclerosus. This is the first report of topical low-concentration tacrolimus treatment showing a dramatic effect in the treatment of childhood vulvar lichen sclerosus.
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Affiliation(s)
- Yuka Matsumoto
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
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36
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Benoit-Corven C, Foucher C, Maruani A, Machet L, Lorette G, Body G. [Vulvoperineoplasty for vulvar pain in the posterior fourchette (15 cases)]. Ann Dermatol Venereol 2006; 133:663-5. [PMID: 17053735 DOI: 10.1016/s0151-9638(06)70988-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vulvar pain is a common presenting complaint in dermatology consultations arising from numerous possible causes. Where such pain is mechanical, resulting from stretching of the vulva, particularly during sexual intercourse, the patient should be checked for anatomical features that could account for the pain, localised anatomical adhesions or sclerosis of the fourchette, and amenable to treatment by vulvoperineoplasty. PATIENTS AND METHODS A retrospective study of all patients undergoing vulvoperineoplasty for vulvar pain in the fourchette was carried out between 1.1.1993 and 1.1.2003. RESULTS Fifteen successive patients were included in the study. The mean rate of sexual intercourse doubled between the pre-operative period and the post-operative period, rising from 5 (0 to 30) to 9.8 (3 to 30). Mean pain intensity during intercourse on a scale of 1 to 10 fell from 7.6 (5 to 9) before surgery to 1.6 (0 to 5) after surgery. None of the patients experienced any sequelae. All patients except one (who was no longer sexually active), expressed willingness to undergo vulvoperineoplasty again if necessary. DISCUSSION Vulvoperineoplasty is a simple procedure and proved useful for female patients presenting vulvar pain and adhesions or sclerosis of the fourchette.
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Coelho WS, Diniz LM, Souza Filho JBD. Líquen escleroso e atrófico: relato de dois casos de apresentação atípica. An Bras Dermatol 2006. [DOI: 10.1590/s0365-05962006000900010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
O líquen escleroso e atrófico é doença crônica da pele que se apresenta clinicamente de forma variada. Pode acometer mulheres e, menos freqüentemente, homens e crianças, sendo a área mais afetada a região anogenital. Há forte associação com doenças auto-imunes, e estudos imunogenéticos têm revelado associação com o HLA DQ7. Raramente acomete áreas extragenitais; entretanto, os autores relatam dois casos da doença, com localizações atípicas (extragenitais) e fazem uma abordagem terapêutica distinta. O uso tópico de corticoterapia de alta potência é relatado, porém, com riscos; enquanto agentes imunomoduladores tópicos são descritos com boa resposta clínica e com menor risco de atrofia.
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Abstract
The effective management of vulval lichen sclerosus (LS) currently depends upon the use of topical steroids and emollients. There are concerns with regard to the long-term toxicity of potent steroids and therefore is a need to consider effective alternatives. Immunomodulatory macrolactams offer an alternative to steroids in the management of some other inflammatory skin disorders and it would seem reasonable therefore to assess their activity in LS. This pilot study of 16 histologically confirmed cases of LS suggests that macrolactams have a positive pharmacological effect.
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Affiliation(s)
- D M Luesley
- Department of Obstetrics and Gynaecology, City Hospital, Birmingham, UK
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Strittmatter HJ, Hengge UR, Blecken SR. Calcineurin antagonists in vulvar lichen sclerosus. Arch Gynecol Obstet 2006; 274:266-70. [PMID: 16830155 DOI: 10.1007/s00404-006-0151-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Accepted: 02/17/2006] [Indexed: 10/24/2022]
Abstract
Lichen sclerosus et atrophicus is a chronic inflammatory disorder that mainly affects girls of premenarchial age and women in their fifties. Besides the anogenital region, lichen sclerosus (LS) may also affect extragenital or mucosal areas. Symptoms include soreness and pruritus, but other less common symptoms are not rare. An increased activity of fibroblasts causes increased sclerosis of the affected skin. Latest studies have identified LS as a chronic inflammatory dermatosis. Auto-antibodies against the extracellular membrane protein-1 are present in up to 80% of the patients. Moreover, in the widely accepted therapy with potent corticosteroids promising results have been presented using calcineurin antagonists in the treatment of LS. An interdisciplinary management and a continued care of patients with LS will improve the clinical manifestations and quality of life.
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Affiliation(s)
- Hans J Strittmatter
- Department of Gynecology and Obstetrics, Alfried-Krupp-Hospital, Alfried-Krupp-Str 61, 45131 Essen, Germany.
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Ormerod AD. Topical tacrolimus and pimecrolimus and the risk of cancer: how much cause for concern? Br J Dermatol 2006; 153:701-5. [PMID: 16181449 DOI: 10.1111/j.1365-2133.2005.06899.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- Isabel Val
- Institute of Gynecology, Department of Gynecology and Obstetrics, Federal University of Rio de Janeiro, Brazil.
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Ginarte M, Toribio J. Vulvar lichen sclerosus successfully treated with topical tacrolimus. Eur J Obstet Gynecol Reprod Biol 2005; 123:123-4. [PMID: 16260345 DOI: 10.1016/j.ejogrb.2005.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2004] [Revised: 02/07/2005] [Accepted: 03/24/2005] [Indexed: 11/30/2022]
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Abstract
Within the last decade, healthcare providers have had a larger selection of effective novel topical immunomodulatory agents to treat many dermatologic conditions. Novel mechanisms of action of newer topical agents have facilitated differentiation from well-established topical agents such as corticosteroids and 5-fluorouracil. Further, because of a growing understanding of the immune mechanisms within the skin, the opportunity has arisen to use the body's immune system to effectively treat many dermatologic conditions, such as condyloma acuminata, actinic keratosis, basal cell carcinoma, and atopic dermatitis, while maintaining a favorable safety profile. Imiquimod 5% cream, an immune response modifier, is safe and effective in the treatment of condyloma acuminata, actinic keratosis, and primary superficial basal cell carcinoma (sBCC). Pimecrolimus cream 1% and tacrolimus ointment (0.1% and 0.03%) are safe and effective in the treatment of atopic dermatitis. This review highlights newer data on approved and investigational indications for these topical immunomodulatory agents.
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Affiliation(s)
- Robert Skinner
- Department of Medicine, Division of Dermatology, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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de Almeida HL, de Oliveira Filho UL. Topical pimecrolimus is an effective treatment for balanitis circinata erosiva. Int J Dermatol 2005; 44:888-9. [PMID: 16207202 DOI: 10.1111/j.1365-4632.2005.02366e.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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45
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Lee HH, Sterry W, Worm M. Wirksamkeit von Tacrolimus-0,1-%-Salbe bei Prurigoerkrankungen. Efficacy of tacrolimus 0.1 % ointment in prurigo. J Dtsch Dermatol Ges 2005; 3:690-4. [PMID: 16173976 DOI: 10.1111/j.1610-0387.2005.05740.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Potent topical corticosteroids are used the intense pruritus in prurigo diseases. Their long-term application leads to local side effects such as atrophy and telangiectasia. PATIENTS AND METHODS We treated 6 women (average age 64 years) with chronic prurigo with tacrolimus 0.1 % ointment (Protopic) to evaluate its efficacy in this clinical setting. Tacrolimus 0.1% ointment was applied twice a day for 4 weeks. RESULTS After one week, both clinical improvement and reduced pruritus were observed in all patients. CONCLUSION Tacrolimus 0.1% ointment represents a therapeutic option for the treatment of prurigo.
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Affiliation(s)
- Hae-Hyuk Lee
- Klinik für Dermatologie, Venerologie und Allergologie, Charité-Universitätsmedizin Berlin
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46
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Abstract
Lichen sclerosus et atrophicus is a chronic inflammatory disease that mainly affects women in the 5th decade. Although lichen sclerosus most often affects the anogenital region, it may occur in other cutaneous or mucosal sites. Increased fibroblast activity causes cutaneous sclerosis. Recent studies have identified lichen sclerosus as an autoantibody-mediated chronic inflammatory dermatosis. Autoantibodies against the extracellular matrix protein-1 are present in up to 80% of affected patients. In addition to the well-accepted therapy with potent corticosteroids, promising results have been obtained using calcineurin antagonists in the treatment of lichen sclerosus. Interdisciplinary management with regular monitoring can improve the clinical manifestations and quality of life.
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Affiliation(s)
- A Marini
- Hautklinik, Heinrich-Heine-Universität, Düsseldorf
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47
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Affiliation(s)
- Janet McLelland
- Dermatology Department, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK.
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48
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Abstract
Further understanding of the pathogenesis of dermatologic conditions at a molecular level has led to targeted therapies. The topical immune response modifiers have contributed significantly to the treatment of cutaneous diseases. New topical remedies, particularly the Toll-like receptor agonists and calcineurin inhibitors, have added to the clinical armamentarium and have further advanced clinicians' ability to treat a wide variety of benign, premalignant, and malignant conditions. Furthermore, these agents have contributed to the understanding of the disease process. The next decade will witness even greater advances in targeted immunotherapies for dermatologic disease.
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Affiliation(s)
- Daniel N Sauder
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21205-0900, USA.
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Marsland AM, Griffiths CEM. Therapeutic potential of macrolide immunosuppressants in dermatology. Expert Opin Investig Drugs 2005; 13:125-37. [PMID: 14996647 DOI: 10.1517/13543784.13.2.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dermatologists are frequently presented with inflammatory dermatoses that are responsive to treatment with immunomodulating drugs. Corticosteroids, particularly when applied topically, have been the mainstay of treatment in the past. Their undoubted efficacy, however, has been undermined by problems with repeated use including tachyphylaxis and side effects such as skin atrophy and hypertension. Macrolide immunosuppressive drugs, originally used for prophylaxis of organ transplant rejection, have been shown to be effective in the treatment of inflammatory dermatoses. The original drugs used in dermatology in this class have their own limitations including poor absorption when used topically and their distinct side-effect profiles. A search for other immunosuppressive macrolide antibiotics has led to the development of new agents, which have enhanced profiles for the treatment of skin disease. This review discusses the main dermatoses that may be targeted by this class of drugs and summarises the topical and systemic macrolides either currently in use, in clinical trials or preclinical development.
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Affiliation(s)
- Alexander M Marsland
- Konishi-MUSC Institute for Inflammation Research, Medical University of South Carolina, Charleston, SC 29425, USA
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Abstract
As our understanding of connective tissue disease expands, so too does our therapeutic armamentarium. We have learned that autoimmunity triggers inflammation through unchecked, proliferative cell-mediated inflammation. By targeting this arm of the cytokine cascade, it may be possible to arrest further progression. Several biologic agents, such as etanercept, alefacept, infliximab, efaluzimab, and, recently, adalimumab, have come to market for adult psoriasis and are now undergoing trials for juvenile SLE, psoriasis, and psoriatic arthritis. Of note, etanercept has been used successfully in juvenile rheumatoid arthritis for more than 10 years. These agents target cell-mediated inflammation through various mechanisms and hold great promise for the treatment of many of the disease states discussed above. Moreover, the biologics carry an improved side-effect profile not seen with traditional agents such as corticosteroids and will be central in the evolution of targeted therapeutics for these complex immunologic diseases.
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Affiliation(s)
- Robert L Buka
- Children's Hospital and Health Center San Diego, University of California San Diego, 8010 Frost Street, Suite 602, San Diego, CA 92123, USA.
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