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Brandon A, Joshi T, Ahmed Z, Tahir M, Phung T, Pierce JY, Knowles K. A Rare Presentation of Lichen Sclerosus Involving the Vaginal Canal After Radiation Therapy: A Case Report and Review of the Literature. Cureus 2023; 15:e47077. [PMID: 38021954 PMCID: PMC10644119 DOI: 10.7759/cureus.47077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 12/01/2023] Open
Abstract
Vaginal lichen sclerosus (LS) is an extremely rare entity. Classically, LS is referred to as a chronic, inflammatory skin disease with a distinct predilection for the anogenital skin that is observed in post-menopausal women and typically manifests clinically as white, atrophic plaques. Here, we report a case of a 61-year-old patient who presented for a follow-up visit three years after vaginal brachytherapy as an adjuvant treatment for endometrial adenocarcinoma. This lesion was biopsied and confirmed to be vaginal LS on histological analysis. While LS has been previously observed to impact mucosal areas outside of the anogenital region, such as the mouth, reported cases of vaginal LS are very rare in the literature. Our case highlights both the underrecognized location of this disease as well as radiation as a potential risk factor.
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Affiliation(s)
- Arcole Brandon
- Medicine, University of South Alabama College of Medicine, Mobile, USA
| | - Tanvi Joshi
- Obstetrics and Gynaecology, University of South Alabama College of Medicine, Mobile, USA
| | - Zan Ahmed
- Pathology and Laboratory Medicine, University of South Alabama Health University Hospital, Mobile, USA
| | - Muhammad Tahir
- Pathology and Laboratory Medicine, University of South Alabama Health University Hospital, Mobile, USA
| | - Thuy Phung
- Pathology and Laboratory Medicine, University of South Alabama Health University Hospital, Mobile, USA
| | - Jennifer Y Pierce
- Obstetrics and Gynaecology, University of South Alabama College of Medicine, Mobile, USA
| | - Kurt Knowles
- Pathology and Laboratory Medicine, University of South Alabama Health University Hospital, Mobile, USA
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Guidozzi F. Lichen sclerosus of the vulva. Climacteric 2021; 24:513-520. [PMID: 34313164 DOI: 10.1080/13697137.2021.1948004] [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: 10/20/2022]
Abstract
Lichen sclerosus of the vulva (LSV) is seen frequently enough to warrant knowing how to diagnose it and institute appropriate treatment strategies. LSV is a chronic skin disorder, very likely of autoimmune origin, which may affect various areas of the perineum, although some women may be affected in extragenital areas. The disease has significant adverse impact on quality of life and sexual activity and may undergo malignant transformation. History of symptomatology and clinical examination is sufficient to make the diagnosis. Skin biopsy is only necessary in specific scenarios. Topical corticosteroids are still the mainstay of therapy, initially to institute remission and then for maintenance. Long-term therapy and surveillance are invariably necessary. Surgery does have a role, but only in specific associated conditions. A number of alternative treatment options have been mooted, especially if the disease is resistant to topical corticosteroids, but these options are still being assessed and studied.
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Affiliation(s)
- F Guidozzi
- Department of Obstetrics and Gynaecology, Parklane Clinic, Johannesburg, South Africa.,Department of Obstetrics and Gynaecology, University of Witwatersrand, Johannesburg, South Africa
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Krapf JM, Mitchell L, Holton MA, Goldstein AT. Vulvar Lichen Sclerosus: Current Perspectives. Int J Womens Health 2020; 12:11-20. [PMID: 32021489 PMCID: PMC6970240 DOI: 10.2147/ijwh.s191200] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022] Open
Abstract
Vulvar lichen sclerosus (LS) is a chronic, inflammatory dermatosis that may lead to scarring of the vulva and sexual dysfunction. LS affects women of all ages and often goes unrecognized and underreported. Uncertainty continues to exist around its pathogenesis, histologic diagnosis, and treatment. However, there have been great advances in our understanding of autoimmunogenic targets in disease formation and progression. In addition, there has been recent investigation of potential non-steroid-based treatments, including platelet-rich plasma therapy and energy-based modalities such as the fractional CO2 laser, photodynamic therapy, and high intensity focused ultrasound. Refinement of surgical techniques for restoring vulvar anatomy and treating clitoral phimosis, introital stenosis, and vulvar granuloma fissuratum is leading to improved patient outcomes. This review summarizes current perspectives on the pathogenesis, symptomatology, diagnosis, and treatment for vulvar lichen sclerosus.
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Affiliation(s)
- Jill M Krapf
- The George Washington University, Washington, DC, USA.,The Centers for Vulvovaginal Disorders, Washington, DC, USA
| | - Leia Mitchell
- The Centers for Vulvovaginal Disorders, Washington, DC, USA
| | - Michelle A Holton
- Department of Emergency Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Andrew T Goldstein
- The George Washington University, Washington, DC, USA.,The Centers for Vulvovaginal Disorders, Washington, DC, USA
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Abstract
To determine if vestibulovaginal sclerosis and lichen sclerosus (LS) are 2 distinct entities. Biopsies obtained from the vagina or vulvar vestibule that contained abnormal subepithelial collagen were reviewed. Cases were categorized either as LS or vestibulovaginal sclerosis based on presence or absence of basal layer degeneration and lymphocytic infiltrate. Clinical data collected included examination findings, biopsy site and indication, previous vulvovaginal surgery, medications at time of biopsy, vulvar LS, treatment, and response. There were 15 cases with a mean age of 62 yr (range: 32-86 yr); 12 (80%) specimens were from vestibule and 3 from vagina. Nine cases were categorized as LS because of lymphocytic infiltrate in combination with basal layer degeneration, of these 8 had LS elsewhere on vulvar skin. Six cases were classified as vestibulovaginal sclerosis and had an absent or sparse lymphocytic infiltrate and essentially normal epithelium; none of these had vulvar LS. While vestibulovaginal sclerosis and lichen sclerosus are distinguishable clinically and histopathologically, further studies are needed to determine if vestibulovaginal sclerosis is a subset of LS or a different condition.
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Affiliation(s)
- Tania Day
- Department of Maternity and Gynecology, John Hunter Hospital (T.D., K.B.) Faculty of Health and Medicine, University of Newcastle (T.D., J.S.) Anatomical Pathology, Pathology North, Hunter New England (J.S.), Newcastle, NSW Dermogynaecology Clinic, Mercy Hospital for Women, Heidelberg (G.D.) Vulvar Disorders and Dermatology Clinic, Royal Women's Hospital, Melbourne (R.P.), Vic., Australia
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Marnach ML, Torgerson RR. Vulvovaginal Issues in Mature Women. Mayo Clin Proc 2017; 92:449-454. [PMID: 28259230 DOI: 10.1016/j.mayocp.2016.10.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/04/2016] [Accepted: 10/07/2016] [Indexed: 11/20/2022]
Abstract
Mature women often present with symptomatic vulvovaginal atrophy and vulvar dermatoses, causing noncoital pain, dyspareunia, and sexual changes. Diagnosis of these conditions can be challenging, and long-term management is required to decrease morbidity and enhance quality of life. Vaginal estrogen therapies remain safe and effective for treating symptomatic vulvovaginal atrophy. A vulvar biopsy is easy to perform and generally well tolerated when indicated for the diagnosis of lichen simplex chronicus, lichen sclerosus, and lichen planus. Therapy with moderate- to high-potency corticosteroids is effective for these frequently debilitating conditions.
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Affiliation(s)
- Mary L Marnach
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
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Halonen P, Jakobsson M, Heikinheimo O, Riska A, Gissler M, Pukkala E. Lichen sclerosus and risk of cancer. Int J Cancer 2017; 140:1998-2002. [PMID: 28124469 DOI: 10.1002/ijc.30621] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/20/2016] [Accepted: 01/13/2017] [Indexed: 12/14/2022]
Abstract
Malignant potential of lichen sclerosus (LS) has been suspected, but evidence is sparse. We used the population-based Finnish Cancer Registry data to further study this connection. We identified all women with the diagnosis of LS (n = 7,616) listed in the Finnish Hospital Discharge Registry from 1970 to 2012. The cohort was followed through the Finnish Cancer Registry for subsequent cancer diagnoses until 2014. Standardized incidence ratios (SIRs) were calculated for different cancers by dividing the observed numbers of cancers by expected ones. The expected numbers were based on national cancer incidence rates. During the follow-up period, we found 812 cancers among patients with LS (SIR: 1.13, 95% CI 1.05-1.21). LS was associated with an increased risk of vulvar (182 cases, SIR: 33.6, 95% CI 28.9-38.6) and vaginal cancer (4 cases, SIR: 3.69, 95% CI 1.01-9.44). The risk of cancers of the uterine cervix and lung was significantly decreased. LS is associated with an increased risk for vulvar and vaginal cancer. These data are important when designing the care of women diagnosed with LS.
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Affiliation(s)
- Pia Halonen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maija Jakobsson
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Riska
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Gissler
- Information Services Department, THL National Institute for Health and Welfare, Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institute, Stockholm, Sweden
| | - Eero Pukkala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland.,Faculty of Social Sciences, University of Tampere, Finland
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Burger MPM, Obdeijn MC. Complications after surgery for the relief of dyspareunia in women with lichen sclerosus: a case series. Acta Obstet Gynecol Scand 2016; 95:467-72. [PMID: 26799364 DOI: 10.1111/aogs.12852] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/12/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The objective of this study was to analyse complications after surgical intervention on the vulva, especially with grafting of the vaginal epithelium, for the relief of dyspareunia in women with lichen sclerosus. MATERIAL AND METHODS A case series of 23 women with histologically confirmed lichen sclerosus who underwent vulvar surgery because of disabling sexual dysfunction. Surgical care was provided in a university hospital (tertiary referral center) between 2008 and 2012. The interventions were posterior vestibuloplasty (perineoplasty), dehooding of the glans clitoridis and anterior vestibuloplasty with grafts of vaginal epithelium. RESULTS A posterior vestibuloplasty was performed in all 23 women. Short-term complications included postoperative infection with subtotal dehiscence of the advanced vaginal epithelium (n = 1), and reactivation of lichen sclerosus with the formation of bullae due to the postoperative discontinuation of dermatosteroid use (n = 1). The long-term complications included localized pain (n = 3); although the relation with the surgical intervention was unclear. Four women underwent dehooding of the glans clitoridis, all without complications. Anterior vestibuloplasty with a free full-thickness graft of vaginal mucosa was performed in five women. One woman underwent a second operation because of contraction and keratinization of the graft. The importance of estrogens for the condition of the graft was unclear. CONCLUSIONS After reconstructive vulvar surgery in women with lichen sclerosus, issues such as infection, reactivation of the disease and pain require attention. The use of vaginal grafts in the repair of the anterior vestibule is a novel approach and deserves further exploration.
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Affiliation(s)
- Matthé P M Burger
- Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Miryam C Obdeijn
- Department of Plastic, Reconstructive and Hand Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Extensive anogenital lichen sclerosus with vaginal stenosis: A case report. JOURNAL OF DERMATOLOGY & DERMATOLOGIC SURGERY 2015. [DOI: 10.1016/j.jssdds.2013.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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van den Einden LCG, van der Avoort IAM, de Hullu JA. Prevention, identification and treatment of vulvar squamous (pre)malignancies: a review focusing on quality of care. Expert Rev Anticancer Ther 2014; 13:845-59. [DOI: 10.1586/14737140.2013.811059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Bhargava K, Lewis FM. Lichen sclerosus occurring on vaginal mucosa secondary to uterine prolapse. J OBSTET GYNAECOL 2013; 33:319-20. [DOI: 10.3109/01443615.2012.738720] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Barchino-Ortiz L, Suárez-Fernández R, Lázaro-Ochaita P. [Vulvar inflammatory dermatoses]. ACTAS DERMO-SIFILIOGRAFICAS 2011; 103:260-75. [PMID: 22176862 DOI: 10.1016/j.ad.2011.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 07/12/2011] [Accepted: 08/27/2011] [Indexed: 12/27/2022] Open
Abstract
Vulvar skin disease is a common reason for consultation. The vulva, like the rest of the skin, can be affected by numerous diseases of various etiologies, but its particular anatomic and physiologic characteristics create additional diagnostic and therapeutic difficulties. The study of vulvar disease is emerging as a new branch of dermatology. In this article, we examine the characteristics of the normal vulva, and perform a brief, structured review of vulvar inflammatory dermatoses, which comprise a heterogeneous group of diseases in which a broad, multidisciplinary approach is essential.
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Affiliation(s)
- L Barchino-Ortiz
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España.
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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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