Dermasilk Briefs in Vulvar Lichen Sclerosus: An Adjuvant Tool

A systematic review of outcome measures evaluating treatment efficacy in vulval lichen sclerosus and evaluation of patients' priorities

Vulval lichen sclerosus (VLS) is an inflammatory skin disease characterised by itching, apareunia, loss of vulval architecture and scarring. Heterogeneity in outcome reporting precludes comparison between treatments. This study aimed to systematically review outcome measures used to evaluate the efficacy of VLS treatments and present patients' treatment priorities. This review followed the PRISMA guidelines using a registered protocol (PROSPERO: CRD42022356738). Multiple databases were searched, along with grey literature on Clinicaltrials.gov, European Union Clinical Trials and International Standard Randomised controlled trial (RCT) registries. All RCTs assessing any treatment for VLS were eligible for inclusion. A total of 775 patients were assessed across 21 RCTs. The assessment tools reported outcomes in the following domains: patient-reported symptoms assessed with one validated scale in 12 studies and seven non-validated scales in nine studies; sexual function with validated female sexual function index and female sexual distress scale in two studies and two non-validated scales in two studies; quality of life with three validated scales in three studies and clinician-reported objective outcomes with two validated scales in three studies and six non-validated scales in fourteen studies. Histological changes were assessed in 10 studies and tissue biomechanics in one study. We also carried out an online survey completed by 809 women with VLS to assess their research and disease treatment priorities and identified validated outcome measures to assess these. There is high variability in assessing treatment outcomes for VLS. We identified validated assessment tools which could be implemented in VLS studies to evaluate the effectiveness of treatments.

EuroGuiderm guideline on lichen sclerosus-Treatment of 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 usually a whitening of the genital skin, sometimes preceded by redness and oedema; 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 (part 1), highlight important aspects in the care of LS patients, 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.

Clinical Use of Non-Suture Silk-Containing Products: A Systematic Review

AIMS

The purpose of this systematic review is to determine how various innovative non-suture silk and silk-containing products are being used in clinical practice, and compare patient outcomes following their use.

METHODS

A systematic review of PubMed, Web of Science, and Cochrane was completed. A qualitative synthesis of all included studies was then performed.

RESULTS

Our electronic search identified 868 silk-related publications, which yielded 32 studies for full-text review. After exclusion, nine studies from 2011 to 2018 were included for qualitative analysis. A total of 346 patients were included which consisted of 37 males and 309 females. The mean age range was between 18-79 years old. The follow-up among studies ranged between one to twenty-nine months. Three studies addressed the application of silk in wound dressings, one on the topical application of silk-derived products, one on silk-derived scaffold in breast reconstruction, and three on silk underwear as adjunct for the treatment of gynecological conditions. All studies showed good outcomes alone or in comparison to controls.

CONCLUSION

This systematic review concludes that silk products' structural, immune, and wound-healing modulating properties are advantageous clinical assets. Nevertheless, more studies are needed to strengthen and establish the benefit of those products.

Use of Bombyx mori silk fibroin in tissue engineering: From cocoons to medical devices, challenges, and future perspectives

Silk fibroin has become a prominent material in tissue engineering (TE) over the last 20 years with almost 10,000 published works spanning in all the TE applications, from skeleton to neuronal regeneration. Fibroin is an extremely versatile biopolymer that, due to its ease of processing, has enabled the development of an entire plethora of materials whose properties and architectures can be tailored to suit target applications. Although the research and development of fibroin TE materials and devices is mature, apart from sutures, only a few medical products made of fibroin are used in the clinical routines. <40 clinical trials of Bombyx mori silk-related products have been reported by the FDA and few of them resulted in a commercialized device. In this review, after explaining the structure and properties of silk fibroin, we provide an overview of both fibroin constructs existing in the literature and fibroin devices used in clinic. Through the comparison of these two categories, we identified the burning issues faced by fibroin products during their translation to the market. Two main aspects will be considered. The first is the standardization of production processes, which leads both to the standardization of the characteristics of the issued device and the correct assessment of its failure. The second is the FDA regulations, which allow new devices to be marketed through the 510(k) clearance by demonstrating their equivalence to a commercialized medical product. The history of some fibroin medical devices will be taken as a case study. Finally, we will outline a roadmap outlining what actions we believe are needed to bring fibroin products to the market.

Diagnosis and management of cutaneous and anogenital lichen sclerosus: recommendations from the Italian Society of Dermatology (SIDeMaST)

Lichen sclerosus (LS) is a disabling chronic inflammatory disease of skin and genital mucous membrane causing itch, pain, dysuria and restriction of micturition, and significant sexual dysfunction and dyspareunia both in women and men. If left untreated, LS is associated with a high degree of sclerosis and scarring, as well as with an elevated risk of cancer in the genital area. Although a central role of autoimmunity is suggested, the pathogenesis of LS is still not clearly understood and the disease remains difficult to treat. The goals of treatment of LS are to alleviate symptoms and discomfort, prevent anatomical changes and prevent malignant transformation. This guideline has been developed by an Italian group of experts. It summarizes evidence-based and expert- based recommendations. The highest level of evidence favors the use of topical high potency corticosteroids; second and third lines' treatments include topical calcineurin inhibitors and topical retinoids, respectively. Surgical treatment has become the treatment of choice in male genital LS with persistent phimosis not responsive to medical treatment. The aim of this paper is to offer evidencebased and easily applicable recommendations for the management of LS.

Proposition of a severity scale for lichen sclerosus: The "Clinical Lichen Sclerosus Score"

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin disease of the anogenitalarea leading to itch, burning, sexual dysfunction and impaired quality of life. An unmet need in the context of LS is a practical, easily assessable grading scale to classify disease severity and to allow intra- and interindividual comparisons. The objectives of this study were i) to assess the prevalence and severity of 23 items proposed by a recent Delphi consensus group in patients with adult VLS. ii) to develop a clinical severity scale and, iii) to test the interrater reliability of this novel severity scale. A retrospective assessment of the prevalence and severity of 23 items in 143 patients was performed by using patient records and photo documentation to develop a novel clinical severity scale (i.e. the "Clinical Lichen Sclerosus Score" = CLISSCO) for VLS. Thereafter, the CLISSCO was validated by 16 raters. We found that the items proposed by the consensus group vary markedly in frequency and severity. Following selection of the most relevant items, the CLISSCO was developed consisting of 3 "Symptoms", 3 "Signs" and 6 "Architectural changes" rated on a 0-4 point Likert-scale. The intraclass correlation coefficient was excellent for each item, the applicability of the CLISSCO considered user-friendly by the raters. We conclude that the CLISSCO proved to be a user-friendly, reliable tool to assess disease severity in VLS. However, further studies are needed to validate its applicability and value in daily practice and clinical research.

The role of clothing on participation of persons with a physical disability: A scoping review

Determining ways to facilitate participation of persons with a physical disability is crucial and clothing may play a central role. This review aims to synthesize and examine the role of clothing on participation of persons with a physical disability. Six research databases and grey literature were searched following Arksey & O'Malley's six steps, including multiple expert consultations. English and French articles contributing to how clothing affects participation were included and tabulated based on the International Classification of Functioning, Disability and Health. Fifty-seven articles and 88 websites were included. A variety of stakeholder perspectives, diagnoses, and types of clothing were represented. Clothing mostly influences mobility and self-care, as well as various personal factors. Forty-nine percent of articles reported essential clothing design features to consider. Clothing is an important and complex environmental factor that interacts with all health domains, including participation. Future research should consider intersectoral initiatives.

Vulvar pruritus-Causes, Diagnosis and Therapeutic Approach

BACKGROUND

In Germany, 17-23% of the population suffers from chronic itching of the skin; in 5-10% of cases, the female genitalia are affected, specifically, the vulva. Vulvar pruritus is thus a common symptom that often markedly impairs the affected women's quality of life.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in MEDLINE/PubMed for articles on the pathogenesis, diagnosis, and treatment of vul- var pruritus. The search terms were (in German and English) "vulvärer Juckreiz," "pruritus vulvae," and "genital itch," alone and in combination with "Behandlung," "Therapie," or "treat- ment."

RESULTS

The most common cause of vulvar pruritus is vulvo- vaginal candidiasis followed by chronic dermatoses, such as lichen sclerosus and vulvar eczema. Especially in refractory cases, an invasive or preinvasive lesion such as squamous epithelial dysplasia (VIN, vulvar intraepithelial neoplasia) should be borne in mind in the differential diagnosis. Rarer causes include infection, atrophy, and vulvodynia. The essen- tial elements of treatment are topical/oral antimycotic drugs and high-potency glucocorticoids, along with consistently ap- plied, basic moisturizing care and the avoidance of potential triggering factors.

CONCLUSION

As vulvar pruritus has multiple causes, standard- ization of its diagnostic evaluation and treatment would be l efficacy and to meet the diverse needs of women who suffer from this condition.

Development of the Adult Vulvar Lichen Sclerosus Severity Scale-A Delphi Consensus Exercise for Item Generation

Through expert international consensus, 24 items are proposed for inclusion in a future validated adult vulvar lichen sclerosus severity scale.

Supplemental digital content is available in the text.

Objective

To generate a list of items through international expert consensus consisting of both symptoms and clinical signs for inclusion in an adult vulvar lichen sclerosus severity scale.

Methods

This study was carried out as a three-stage Delphi consensus exercise. After an extensive literature review, any items used to determine disease severity in previous clinical trials were compiled into a survey. The Delphi participants were recruited from the International Society for the Study of Vulvovaginal Disease most of whom were gynecologists and in practice for more than 20 years. Participants were asked to rate the importance of these items. Consensus was defined as 75% agreeing that an item was very important or essential toward determining disease severity. Participants were also asked to indicate preferred method of measurement for these items.

Results

Of approximately 400 members of the International Society for the Study of Vulvovaginal Disease, 66 participated in the study. Of the 14 symptoms presented, 7 reached consensus for inclusion. Of the 23 signs presented, 11 reached consensus for inclusion and 1 reached consensus for exclusion. Of the six architectural changes presented, all six reached consensus for inclusion. No consensus was reached regarding method of measurement for any of the symptoms and signs that reached consensus for inclusion.

Conclusion

International consensus was reached for a variety of items for use in an adult vulvar lichen sclerosus severity scale that will be further developed and tested. Ideally, this scale will be used in clinical practice and in research to allow for high-quality trials.

[Lichen sclerosus : Symptoms, diagnosis, therapeutic procedures]

Lichen sclerosus is a chronic, inflammatory dermatosis that usually affects the anogenital area. Early diagnosis and subsequent long-term anti-inflammatory treatment may reduce symptoms and signs and the risk of a mutilating course and the development of carcinomas.

Vulvar Lichen Sclerosus et Atrophicus

Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis characterized by ivory-white plaques or patches with glistening surface commonly affecting the vulva and anus. Common symptoms are irritation, soreness, dyspareunia, dysuria, and urinary or fecal incontinence. Anogenital lichen sclerosus (LS) is characterized by porcelain-white atrophic plaques, which may become confluent extending around the vulval and perianal skin in a figure of eight configuration. Thinning and shrinkage of the genital area make coitus, urination, and defecation painful. LS is not uncommon in India and present as an itchy vulvar dermatosis which a gynecologist may mistake for candidal vulvovaginitis. There is often a delay in diagnosis of VLS due to its asymptomatic nature and lack of awareness in patients as well as physicians. Embarrassment of patients due to private nature of the disease and failure to examine the genital skin properly are the other reasons for delay in diagnosis. There is no curative treatment for LS. Various medications available only relieve the symptoms. Chronic nature of the disease affects the quality of life. Proper and regular follow-up is required as there are chances of the development of squamous cell carcinoma.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.