Lichen Sclerosus and Lichen Planus in Women and Girls

The Barriers and Perceived Benefits to Vulvar Self-Examination in the Management of Vulvar Lichen Sclerosus

OBJECTIVES

It is common practice to advise people with vulvar lichen sclerosus to perform vulvar self-examination (VSE) to optimize topical therapy and detect changes that may represent active disease, scarring, and/or squamous cell carcinoma development. The aim of this study was to better understand people's willingness and potential barriers to performing VSE.

MATERIALS AND METHODS

A cross-sectional survey was undertaken of all patients with vulvar LS presenting to a tertiary referral vulvar dermatology clinic in Australia, from June 2022 to January 2023. Patients who did not speak and read English were excluded. Ethics approval was obtained.

RESULTS

Seventy-eight (66%) of 118 eligible patients completed the survey. Fifty-three (68%) of patients had examined their vulva at least once. Forty-one (49%) had been recommended VSE by a medical practitioner. All those recommended VSE had performed VSE at least once. In contrast, only 10 (27%) of the 37 patients not recommended VSE by a health professional had ever performed VSE. Seventy-nine percent of all patients reported that they were very likely or likely to perform VSE if it was recommended.Patients with higher education level and tampon use were more likely to perform VSE. Self-reported back problems were associated with being less likely to perform VSE.

CONCLUSIONS

More widespread VSE may result in earlier detection of the complications of vulvar lichen sclerosus. Most women would perform VSE if recommended by a health care provider; however, currently only half are receiving this advice. Further research should be performed to determine whether VSE affects clinical outcomes.

EuroGuiderm guideline on lichen sclerosus-introduction into lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness. It may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are redness and oedema, typically followed by whitening of the genital skin; sometimes fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS, highlight important aspects in the care of LS patients (part 1), generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

Is there a role for platelet rich plasma injection in vulvar lichen sclerosus? A self-controlled pilot study

BACKGROUND

Owing to the evidence that as many as 30-40% of patients with vulvar lichen sclerosus (VLS) fail to report a remission of symptoms with first-line corticosteroid treatment (TCS), especially as what regards dyspareunia, we aimed to analyze patients' satisfaction following vulvar injection of autologous platelet-rich plasma (PRP). This is intended as an adjunctive treatment, to be used following TCS, and appears to promote tissue repair. It may also possibly have immunomodulatory proprieties.

MATERIALS AND METHODS

Patients with VLS were considered eligible for this pilot study if, despite having been treated with a 3-month TCS regimen, they reported a persistence of symptoms. PRP was produced in a referral center using a manual method and a standardized protocol. Each patient received three treatments 4 to 6 weeks apart.

RESULTS

A total of 50 patients with a median age of 53 years [IQR 38-59 years] were included in the study. 6 months after the last injection of PRP all patients were either satisfied or very satisfied with the treatment (100%; 95% CI 93-100%). Median NRS scores for itching, burning, dyspareunia and dysuria were significantly reduced (p < 0.05) and FSFI, HADS and SF-12 questionnaires revealed a significant improvement in sexual function, psychological wellbeing and quality of life (p < 0.05). The number of patients reporting the need for maintenance TCS treatment was reduced by 42% (p < 0.001) and an improvement in vulvar elasticity and color was reported in all patients.

CONCLUSION

Following standard medical therapy, PRP may be effective not only in improving symptoms, but also in restoring function.

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.

Lichen sclerosus: The 2023 update

Lichen sclerosus (LS) is an underdiagnosed inflammatory mucocutaneous condition affecting the anogenital areas. Postmenopausal women are predominantly affected and, to a lesser extent, men, prepubertal children, and adolescents. The etiology of LS is still unknown. Hormonal status, frequent trauma and autoimmune diseases are well-known associations for LS, yet infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype. Furthermore, there is a distinct expression of tissue remodeling associated genes as well as microRNAs. Oxidative stress with lipid and DNA peroxidation provides an enabling microenvironment to autoimmunity and carcinogenesis. Circulating IgG autoantibodies against the extracellular matrix protein 1 and hemidesmosome may contribute to the progression of LS or simply represent an epiphenomenon. The typical clinical picture includes chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. In addition to genital scarring, and sexual and urinary dysfunction, LS may also lead to squamous cell carcinoma. Disseminated extragenital LS and oral LS are also reported. The diagnosis is usually clinical; however, a skin biopsy should be performed in case of an unclear clinical picture, treatment failure or suspicion of a neoplasm. The gold-standard therapy is the long-term application of ultrapotent or potent topical corticosteroids and, alternatively, topical calcineurin inhibitors such as pimecrolimus or tacrolimus. Collectively, LS is a common dermatological disease with a so far incompletely understood pathogenesis and only limited treatment options. To foster translational research in LS, we provide here an update on its clinical features, pathogenesis, diagnosis and (emerging) treatment options.

Laser Therapy for Recalcitrant Vulvar Lichen Sclerosus: A Review of the Literature

Vulvar lichen sclerosus (LS) is a chronic vulvar dermatosis potentially impacting quality of life and sexual function. While most women with LS respond to topical corticosteroids and/or calcineurin inhibitors, some require additional therapy. Systemic therapies have been used successfully in oral and vulvovaginal lichen planus with minimal data in the setting of LS. Likewise, while vaginal laser therapy has shown potential benefit for genitourinary syndrome of menopause, there is a paucity of data in the setting of LS. We review retrospective and prospective studies along with randomized controlled trials utilizing vulvovaginal laser for LS therapy.

Presenting Symptoms and Diagnosis of Vulvar Lichen Sclerosus in Premenopausal Women: A Cross-Sectional Study

OBJECTIVES/PURPOSE

Presenting symptoms of vulvar lichen sclerosus (LS) specific to premenopausal women are not well reported in the literature and may differ from those in postmenopausal women. This study aimed to characterize the presentation of vulvar LS among premenopausal women.

MATERIALS AND METHODS

An observational web-based study was conducted in premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating characteristics of symptoms, timing of diagnosis, alternate diagnoses, and presence of concomitant autoimmune conditions.

RESULTS

Of the 956 responses received, 503 met inclusion criteria of biopsy-confirmed LS and premenopausal status. Average age of symptom onset was 27 years, and average age of diagnosis was 32 years, with a 4-year delay in diagnosis. Symptoms most present were dyspareunia (68%) and tearing with intercourse or vaginal insertion (63%). Symptoms that affect the individual most were also dyspareunia (44%) and tearing with intercourse or vaginal insertion (39%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%) and tearing with intercourse or vaginal insertion (26%). Most common skin changes included hypopigmentation (81%), vulvar fissures (72%), and labial resorption (60%), with fissures affecting the individual the most (48%). Sixty-six percent of the respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). Hypothyroidism was the most common concurrent autoimmune condition (10%).

CONCLUSIONS

Vulvar LS affects premenopausal women, commonly presenting with dyspareunia and tearing with intercourse. This condition should be considered and evaluated in premenopausal women presenting with vulvar symptoms and sexual pain.

Benign "lumps and bumps" of the vulva: A review

Vulvar dermatology represents a challenge for many providers. Given that the vulva is both a gynecologic and dermatologic organ, patients with cutaneous lesions involving the vulva may present to primary care, gynecology, or dermatology. Particularly within dermatology, the vulva remains understudied, which can lead to anxiety among providers regarding appropriate next steps in the diagnosis and management of vulvar lesions. Thus, the purpose of this review is to highlight commonly encountered anatomic variants and benign neoplasms of the vulva, distinguish them from key pathologic mimickers, and provide guidance to practicing dermatologists on what may constitute normal vulvar variations.

The "CIV Classification," a New Proposal for the Architectural Grading of Vulvar Lichen Sclerosus

OBJECTIVES

The purpose of this cross-sectional study was to prepare a reliable and easy-to-use architectural classification for vulvar lichen sclerosus (VLS) aimed at defining the morphological patterns of this condition.

MATERIALS AND METHODS

An expert panel composed by 7 physicians with expertise in clinical care of vulvar conditions outlined the architectural criteria for the definition of VLS severity (phimosis of the clitoris, involvement of the interlabial sulci, narrowing of the vulvar introitus), identifying 5 grades to build up a classification. Thirteen physicians with 2-30 years expertise in vulvar diseases (nonexpert group) were asked to evaluate 3-5 pictures from 137 patients. Each physician individually assigned a grade to each case, according to the previously mentioned criteria. Interrater reliability was analyzed by means of intraclass correlation coefficient (ICC). The reliability concerning the 2 classifications of each rater was analyzed by means of κ statistic. Intraobserver and interobserver reliability in vivo was analyzed by means of κ index.

RESULTS

This study provides a new classification of VLS, based on defined anatomical criteria and graded into mutually exclusive progressive classes.The ICC analysis showed a substantial interrater reliability of the classification, ICC = 0.89 (0.87-0.91), both in the expert panel and in the nonexpert group (ICC = 0.92 and 0.87, respectively). An "almost perfect" intraobserver and interobserver reliability was achieved among physicians in vivo (κ = 0.93).

CONCLUSIONS

Our classification showed a high reliability. It is easy to use, and it can be applied in clinical practice and eventually, in the evaluation of regenerative and cosmetic surgery.

Diagnosis and Management of Vulvovaginal Lichen Planus

Importance

Genital lichen planus is a debilitating disorder that lacks definitive recommendations regarding diagnosis and treatment.

Objective

The aim of this study was to present best practices from available evidence for the diagnosis and treatment of genital lichen planus.

Evidence Acquisition

We conducted a narrative review of the literature on genital lichen planus by searching PubMed using the following search terms: "vulvar lichen planus" OR (vulvar diseases[mesh] OR vulva[mesh]) AND lichen planus[mesh] OR vulvar[ti] AND "lichen planus"[ti]. We included all languages and years in the search.

Results

The search resulted in 273 citations that we reviewed for relevancy and selected 60 as the foundation for this review that focuses on genital sites. Diagnosis can be made without biopsy, and when a biopsy is taken, the pathologic findings may be nonspecific. Topical ultrapotent corticosteroids are most commonly used as first-line treatment of genital lichen planus.

Conclusions and Relevance

When patients present with genital lichen planus, a complete review of systems and a thorough physical examination should be performed because of the prevalence of extragenital sites. Treatment of genital disease should start with a topical, ultrapotent steroid, and follow-up visits should occur to ensure improvement and to monitor for adverse drug reactions and malignancy.

Lichen sclerosus among women in the United States

Background

Vulvar lichen sclerosus (LS) is a chronic dermatosis for which the true prevalence is not well established. LS remains an underrecognized and undertreated disease, and treatment patterns and differences among various specialties that care for patients with LS are largely unknown.

Objective

This study sought to determine the prevalence of diagnosed vulvar LS, demographic characteristics, and diagnostic and treatment patterns in the United States.

Methods

A database comprising >21.7 million women with commercial insurance in the United States was analyzed, and the largest cohort of patients with LS in the United States to date was identified.

Results

We found that obstetricians/gynecologists are diagnosing and managing approximately half of women with LS, and regardless of specialty, the majority of providers are appropriately prescribing high-potency topical steroids.

Conclusion

Our results suggest that LS may truly be underrecognized and underdiagnosed, especially in younger women.

Vulvar Lichen Sclerosus: Current Perspectives

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.

Fact or Fiction? Adipose-Derived Stem Cells and Platelet-Rich Plasma for the Treatment of Vulvar Lichen Sclerosus

OBJECTIVE

The aim of the study was to summarize and review the evidence for the efficacy and safety of adipose-derived stem cells (ADSCs) and platelet-rich plasma (PRP) for the treatment of vulvar lichen sclerosus (LS).

MATERIALS AND METHODS

PubMed/MEDLINE, Ovid, Web of Science, and clinicaltrials.gov were searched from inception up to May 7, 2018.

RESULTS

Seven observational studies were identified, with a total of 98 patients. Both ADSCs and PRP were reported to improve symptoms, quality of life measures, as well as clinical and histological signs of vulvar LS. There is a strong risk of biased estimates of treatment effect.

CONCLUSIONS

Current evidence is weak for ADSCs and/or PRP as treatment for vulvar LS. Further research is needed before recommending this therapy.

Dermoscopy of Inflammatory Genital Diseases: Practical Insights

Diagnosis of genital inflammatory disorders may be difficult for several reasons, such as their similar appearance, possible misdiagnosis with infectious and malignant conditions, and peculiar anatomic conditions that may lead to modification of clinical features. Dermoscopy could be included as a part of the clinical inspection of genital diseases to support diagnosis, as well as to ideally avoid unnecessary invasive investigation. Practical guidance for the use of dermoscopy in the assessment of the main inflammatory genital diseases is provided, namely for lichen sclerosus, lichen planus, psoriasis, lichen simplex chronicus, and plasma cell mucositis.

Vulvo-vaginal lichen planus: A focussed review for the clinician

Vulvo-vaginal lichen planus is a condition which imposes a significant burden of symptoms and sequale. There is a paucity of knowledge and evidenced-based management with significant diagnostic delay prior to appropriate treatment being common. There remains great variability in clinician practice in the context of limited knowledge. This clinical review presents current evidence on the clinicopathological features, practical assessment and management options. Learning points include characterization of this chronic, burdensome clinical entity that has no standardized diagnostic or management protocols. We provide practical clinical conclusions based on current knowledge and identify areas for future research to improve patient outcomes.

Lichen sclerosus of the oral mucosa: clinical and histopathological findings. Review of the literature and a case report

OBJECTIVES

Lichen sclerosus (LS) is a rare, chronic mucocutaneous disease that most frequently affects the female genital area. Oral manifestations are seldom detected; only 36 well-documented and histopathologically verified oral LS cases have been published.

MATERIALS AND METHODS

Here we describe one patient affected by oral (LS) and review of the literature 1957-2017.

RESULTS

Findings in our review suggest a female to male ratio of 1.64:1. It is most commonly diagnosed at the age of 10-29 years (46%). Oral LS can appear as symptomless, irregular-shaped, porcelain-white and flat lesions situated asymmetrically. Lesion is commonly sole, well-demarcated area and its size varies from 2 mm (small macula) to 7 cm (large plaque). The most common sites in the oral cavity include the labial mucosa, lips and gingiva. The histopathological criteria include atrophy and sometimes hyperkeratosis of the epithelium, hydropic degeneration of basal cells, hyalinization of the lamina propria, lymphocyte infiltration beneath the zone of hyalinization and scantiness of elastin. Surgical excision is an effective treatment for small lesions; intralesional triamcinolone or corticosteroid injections are used for larger lesions.

CONCLUSIONS

Oral LS may be under-recognized due to its asymptomatic nature and rarity.

Lichenoid vulvar disease: A review

Vulvar dermatoses are common, potentially debilitating conditions that can be seen by a variety of medical specialists. Lichenoid vulvar diseases, namely lichen sclerosus (LS), lichen planus (LP), and lichen simplex chronicus (LSC), can all negatively impact patients' quality of life and LS and LP also have an association with squamous cell carcinoma. It is essential that dermatologists are familiar with the unique features of each of these conditions to ensure the appropriate management and follow up. Herein, we provide an update on the epidemiology, clinical presentation, histopathology, and treatment of patients with vulvar LS, LP, and LSC.