Vulvar lichen sclerosus in women of reproductive age

A Guide to Screening for Autoimmune Diseases in Patients With Vulvar Lichen Sclerosus

BACKGROUND

The aetiology of vulvar lichen sclerosus (VLS) remains unknown. However, there is evidence that in addition to a genetic predisposition, autoimmunity contributes to the pathogenesis.

OBJECTIVES

The objective of this study was to determine the prevalence of autoimmune disease and positive autoantibody serology in patients with VLS.

METHODS

A VLS database in Sydney, Australia, was retrospectively reviewed. A diagnosis of VLS was required for inclusion in the study. Data collected included demographics, comorbidities including any personal history of autoimmune disease, family history of autoimmune disease, and the results from autoantibody testing. A total of 2243 females with VLS were included in this study.

RESULTS

Autoimmune disease was found in 24.5% and 34.6% of children and adults with VLS, respectively. The most prevalent autoimmune conditions were psoriasis, Hashimoto's thyroiditis, lichen planus, and vitiligo. Antinuclear antibodies were common and found in 31.0% of patients. Thyroid peroxidase and thyroglobulin antibodies were present in 16.1% and 18.9% of cases, respectively. Thyroid function, determined by thyroid stimulating hormone, was abnormal in 8.2% of patients. 5.3% of patients had positive parietal cell antibodies, and 5.9% had low vitamin B12 levels.

CONCLUSIONS

This work provides support that VLS is of an autoimmune aetiology, and that there is an association between VLS and autoimmune diseases. The high proportion of patients with an abnormal thyroid test, positive thyroid antibodies, and intrinsic factor and gastric parietal cell antibodies with low vitamin B12 levels, warrants screening for thyroid disease and pernicious anaemia in patients with VLS. Initial autoimmune screening in VLS can be rationalised to TSH, vitamin B12 levels, intrinsic factor and parietal cell antibodies. Thyroid antibodiy testing shouls be performed in hypothyroid patients.

Vulvar Lichen Sclerosus: A Literature Review with Consideration of Integrative Therapies

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin condition characterized by vulvar pruritus, pain, dyspareunia, and architectural changes, including significant and permanent scarring and deformity of the vulva if left untreated. Untreated VLS significantly increases the risk of invasive squamous cell carcinoma, even in asymptomatic patients. However, there is an overall paucity of preclinical and clinical research on VLS. Although the disease is becoming more commonly recognized, it is often under- or misdiagnosed and its prevalence is likely underestimated. While the exact underlying etiology is still unknown, VLS is most likely an autoimmune disorder within the background of genetic predisposition and environmental triggers. The skin and gut microbiomes also appear to be involved. The first line treatment for VLS, ultrapotent topical corticosteroids, helps relieve symptoms and reduce the risk of architectural changes and vulvar cancer. The second-line medications and treatments with more limited evidence of efficacy include topical calcineurin inhibitors, topical hormones, platelet-rich plasma, and fractional CO2 laser therapy. Surgical intervention may also be required. Additionally, some VLS patients and practitioners report improvements with diet and lifestyle changes, nutritional supplements, low-dose naltrexone, botanical medicines, and other integrative treatments, although clinical research on these integrative therapies for VLS is generally lacking. This review aims to describe VLS in adult women, summarize the recently published literature, and provide a clinical overview that includes evidence-based integrative therapies.

The relationship between the vaginal and vulvar microbiomes and lichen sclerosus symptoms in post-menopausal women

Lichen sclerosus is a chronic inflammatory condition of unknown etiology that affects the genital and extragenital skin, which can lead to sexual dysfunction and has been associated with vulvar cancer. The vaginal microbiome has a critical role in gynecologic health, but little is known about the microbiome in lichen sclerosus. This study investigated the vaginal and vulvar microbiomes of 27 post-menopausal women with lichen sclerosus. The most abundant genera detected in the vaginal microbiome were Lactobacillus, Gardnerella, and Anaerococcus, while Lactobacillus, Anaerococcus, and Staphylococcus were the most abundant in the vulvar microbiome. The vaginal samples clustered into two main groups, Lactobacillus dominant (n = 6, > 50% microbiome Lactobacillus) and polymicrobial (n = 21) with no dominant genus. The vulvar samples were mainly polymicrobial (n = 25). Actinomyces, Anaerococcus, and Ezakiella in the vaginal microbiome and Actinomyces and Ezakiella in the vulvar microbiome were significantly associated with lichen sclerosus symptoms (adjusted p < 0.05). In this population of post-menopausal women with lichen sclerosus the majority have diverse, non-Lactobacillus dominant microbiomes, which is considered less optimal for gynecologic health based on studies of pre-menopausal women. Actinomyces, Ezakiella, and Anaerococcus were associated with lichen sclerosus symptoms. Understanding the role of these bacteria in lichen sclerosus pathogenesis will be an essential future investigation.

Pregnancy, parturition and postpartum considerations among patients with vulvar lichen sclerosus: A retrospective cross-sectional online survey

OBJECTIVE

Characterise VLS and obstetric considerations among women during pregnancy, parturition and postpartum.

DESIGN

Retrospective cross-sectional online survey, 2022.

SETTING

International, English-speakers.

POPULATION

Self-identified individuals aged 18-50 diagnosed with VLS with symptom onset prior to pregnancy.

METHODS

Participants recruited from social media support groups and accounts, completed a 47-question survey including yes/no, multiple answer, and free-text responses. Data were analysed with frequency, means and the Chi-square test.

MAIN OUTCOME MEASURES

VLS symptom severity, mode of delivery, perineal laceration, source and sufficiency of information provided about VLS and obstetrics, anxiety about delivery, and postpartum depression.

RESULTS

Of 204 responses, 134 met inclusion criteria, encompassing 206 pregnancies. Mean respondent age was 35 years (SD 6) and mean age of VLS symptom onset, diagnosis and birth, was 22 (SD 8), 29 (SD 7) and 31 (SD 4) years, respectively. Symptoms decreased in 44% (n = 91) of pregnancies and increased during the postpartum period in 60% (n = 123). In all, 67% (n = 137) of pregnancies resulted in vaginal birth and 33% (n = 69) in caesarean birth. Anxiety for delivery due to VLS symptoms was reported by 50% (n = 103); 31% (n = 63) experienced postpartum depression. Of respondents previously diagnosed with VLS, 60% (n = 69) used topical steroids prior to pregnancy, 40% (n = 45) were treated during pregnancy and 65% (n = 75) postpartum. In all, 94% (n = 116) reported receiving an insufficient amount of information on the topic.

CONCLUSION

In this online survey, we found reported symptom severity remained unchanged or decreased during pregnancy, but increased postpartum. Use of topical corticosteroids decreased during pregnancy compared with before and after pregnancy. Half of the respondents reported anxiety regarding VLS and delivery.

Vulvar lichen sclerosus in pregnancy: Unaddressed needs and systematic review

Women with vulvar lichen sclerosus (vLS) often express their concern over disease course, treatment, and complications relating to vLS in pregnancy and following childbirth. We used such patient concerns as study objectives in a systematic literature research. Although few, mostly low-quality studies have been published on that matter, and albeit the vast majority of women will have stable vLS during pregnancy, available data also suggest that in a small but significant proportion of patients, pregnancy and delivery may complicate the course of vLS and vice versa.

Does treatment of lichen sclerosus improve overactive bladder symptoms?

INTRODUCTION AND HYPOTHESIS

Lichen sclerosus (LS) is a chronic disease which mainly affects the vulvar area in women. A few studies have shown a possible relationship between LS and overactive bladder (OAB) symptoms, but no studies have investigated whether OAB symptoms improve after initiating treatment of LS. The aim of this study was to investigate whether the treatment of LS also improves OAB symptoms in women newly diagnosed with LS.

METHODS

This was a prospective cohort pilot study based on questionnaires from women newly diagnosed with LS and with symptoms of OAB. Women above the age of 18 who were newly diagnosed with LS were included. The women completed two questionnaires on OAB at inclusion and after 3 months. The questionnaires consisted of the validated questionnaires OAB-q (33 questions, maximum score 198) and ICIQ-OAB (8 questions, maximum score 56). All women initiated treatment with local steroid by the time of the LS diagnosis.

RESULTS

A total of 40 women were included, and 13 women dropped out during the data collection time. Comparing month 0 to month 3 for the remaining 27 women, a mean difference at 28.8 points was observed for OAB-q and a mean difference of 5.7 points was observed for ICIQ-OAB. Both results showed a statistically significant difference after 3 months (p < 0.05). A total of 92.6% (25/27) of the women improved their symptoms.

CONCLUSION

Treatment with local steroid might improve OAB symptoms in women newly diagnosed with LS.

Pruritus in Pregnancy

Pruritus in pregnancy is a common and burdensome symptom that may be a first sign of a pregnancy-specific pruritic disease (atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis, and intrahepatic cholestasis in pregnancy) or a dermatosis coinciding with pregnancy by chance. Despite its high prevalence, pruritus is often underrated by physicians, and data regarding the safety profiles of drugs for pruritus are very limited. In this review, we illustrate the epidemiology, possible pathophysiology, clinical characteristics, and diagnostic workup of various pregnancy-related diseases and discuss antipruritic treatments. The prevalence of pruritus in pregnancy demonstrates the importance of symptom recognition and the need for an holistic approach, taking into account both the potential benefits for the patient and the potential risks to the fetus.

Papulosquamous Disorders and Pregnancy

Pregnancy can influence the course of a number of dermatologic disorders. Interestingly, these disorders can also influence pregnancy outcomes negatively, due to a variety of underlying pathogenic mechanisms. These outcomes may range from low fetal birth weight, preterm birth, and miscarriages to perineal lacerations complicating deliveries. Our review highlights the impact that papulosquamous disorders may have on pregnancy and their course throughout pregnancy. We chose papulosquamous disorders due to their relatively high prevalence worldwide compared to other dermatologic disorders. This review also sheds light on any gaps in the literature relevant to this topic that should be addressed.