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Vulvar Lichen Sclerosus from Pathophysiology to Therapeutic Approaches: Evidence and Prospects. Biomedicines 2021; 9:biomedicines9080950. [PMID: 34440154 PMCID: PMC8394941 DOI: 10.3390/biomedicines9080950] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Vulvar lichen sclerosus (VLS) is a chronic, distressing, inflammatory disease with an enormous impact on quality of life. Treatment goals are relieving symptoms, reversing signs and preventing anatomical changes. Despite the availability of numerous therapeutic options, treatment outcome may not be entirely satisfactory and a definitive cure does not exist. This may be due to the fact that the exact VLS etiopathogenesis remains unknown. The objectives of this paper were to review the most up-to-date knowledge on VLS etiopathogenesis and to consider the available therapies through the lens of a plausible pathogenetic model. An electronic search on both VLS etiopathogenesis and its treatment was performed using the National Library of Medicine PubMed database. Based on current knowledge, it is conceivable that various, heterogeneous environmental factors acting on a genetic background trigger an autoimmune, Th-1 response, which leads to a chronic inflammatory state. This, in turn, can determine both tissue and micro-vascular injury and activation of signaling pathways involved in fibroblast and collagen metabolism. This pathogenetic sequence may explain the effectiveness of anti-inflammatory treatments, mostly topical corticosteroids, in improving VLS clinical-pathological changes. Further deepening of the disease pathways will presumably allow key mediators to become new therapeutic targets and optimize the available treatments.
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Corazza M, Toni G, Valpiani G, Morotti C, Borghi A. Does longer duration of corticosteroid treatment improve clearance in vulvar lichen sclerosus? Results from a single centre, comparative, open label study. Dermatol Ther 2021; 34:e14955. [PMID: 33835646 PMCID: PMC8459264 DOI: 10.1111/dth.14955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/08/2021] [Accepted: 04/06/2021] [Indexed: 11/27/2022]
Abstract
A complete clearance of vulvar lichen sclerosus (VLS) is achieved in a minority of patients treated with a standard 12-week duration corticosteroid treatment. The aim of this pragmatic, retrospective, open label, comparative trial was to assess the effectiveness, in terms of complete clearance, of a 24-week treatment with mometasone furoate 0.1% ointment (MMF) and to compare it with a 12-week therapy. We included VLS patients treated with MMF administered for five consecutive days/week for 24 weeks (group A). The following were assessed: (a) clearance in Global Subjective Score (GSS), Global Objective Score (GOS) or both, (b) changes of these parameters and dyspareunia at treatment completion compared to baseline, (c) safety profile. All these assessments were compared with the same outcomes recorded among VLS patients who had previously undergone a 12-week MMF treatment (group B). Twenty-nine patients were included in group A and 32 in group B. The rates of patients who achieved the clearance of GSS, GOS or both parameters did not significantly differ between groups A and B. The groups did not differ in any of the effectiveness outcomes assessed. A 24-week duration corticosteroid treatment does not seem to provide significant therapeutic benefits in comparison with standard 12-week courses, especially considering the occurrence of complete clearance.
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Affiliation(s)
- Monica Corazza
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Giulia Toni
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Giorgia Valpiani
- Research Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Chiara Morotti
- Research Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Alessandro Borghi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
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Vulvar leukoplakia: therapeutic options. MENOPAUSE REVIEW 2020; 19:135-139. [PMID: 33100949 PMCID: PMC7573333 DOI: 10.5114/pm.2020.99570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/10/2020] [Indexed: 11/20/2022]
Abstract
Vulvar leukoplakia is not a histological diagnosis and involves several diseases. Most commonly, these are vulvar lichen sclerosus and squamous cell hyperplasia of the vulva. These two conditions have similar aetiology, clinical presentation and treatment but different histopathological changes. They both lead to significant impairment of quality of life, risk of malignancy, as well as recurrence after treatment. Treatment of these conditions includes topical corticosteroids as a first-line therapy, but they have their side effects and not all patients are receptive to this therapy. This requires the use of alternative therapeutic options such as topical calcineurin inhibitors, topical and systemic retinoids, other steroid creams, various destructive techniques and, as a last resort, surgical removal of affected tissues. Surgical treatment should be avoided, despite the malignant potential, because of recurrence risk in both diseases New therapeutic approaches are coming into effect in gynaecological practice due to potential risks of the above-mentioned methods. Platelet-rich plasma therapy, ablative and non-ablative laser treatment, and new topical medicines, are some of the new options applied to improve the efficacy of treatment avoiding the side effects of conventional medications. A number of them are still in their initial phase of application and time will tell their effectiveness.
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Borghi A, Odorici G, Scuderi V, Valpiani G, Morotti C, Corazza M. Measuring perceived benefit and disease-related burden in patients affected with vulvar lichen sclerosus after a standard topical corticosteroid treatment. Results from a cohort study using Pictorial Representation of Illness and Self-measure and Dermatology Life Quality Index. Dermatol Ther 2020; 33:e14334. [PMID: 32974986 DOI: 10.1111/dth.14334] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/08/2020] [Accepted: 09/18/2020] [Indexed: 12/01/2022]
Abstract
Improvement in suffering after treatment has been poorly investigated in women affected with vulvar lichen sclerosus (VLS). We performed an observational study on a cohort of VLS patients for assessing the effect of a 12-week topical corticosteroid treatment on their VLS-related burden, as measured with Pictorial Representation of Illness and Self-Measure (PRISM) and Dermatology Life Quality Index (DLQI). Demographics and disease-related subjective and objective scores (at baseline, T0, and at the control visit, T1) were recorded. The PRISM and DLQI were administered at T0 and T1. We assessed the variation of PRISM and DLQI at T1 compared to baseline and the relevance of several variables on these changes. Sixty-three patients were included. A significant improvement was found in both PRISM and DLQI after treatment. A higher coefficient of variations was observed for PRISM and DLQI as compared to subjective and objective scores. Improvement of global subjective score after treatment was the sole variable associated with PRISM and DLQI variations. The corticosteroid treatment led to a significant decrease in the impact of VLS on patients' well-being, in terms of suffering and quality of life impairment. PRISM seems a reliable instrument for integrating clinicians' and patients' perspectives for a comprehensive VLS management.
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Affiliation(s)
- Alessandro Borghi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Giulia Odorici
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Valeria Scuderi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Giorgia Valpiani
- Research Innovation Quality and Accreditation Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Chiara Morotti
- Research Innovation Quality and Accreditation Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Monica Corazza
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
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Corazza M, Virgili A, Toni G, Valpiani G, Morotti C, Borghi A. Pictorial Representation of Illness and Self-Measure to assess the perceived burden in patients with chronic inflammatory vulvar diseases: an observational study. J Eur Acad Dermatol Venereol 2020; 34:2645-2651. [PMID: 32597539 DOI: 10.1111/jdv.16637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/06/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Chronic inflammatory vulvar diseases can have a huge detrimental impact on patient welfare. A few studies have addressed this issue so far, mainly measuring patients' quality of life or sexual dysfunction. OBJECTIVE To assess the burden of suffering in patients with chronic inflammatory vulvar diseases using the Pictorial Representation of Illness and Self-Measure (PRISM), a visual, non-verbal instrument. We also assessed (i) the concordance between PRISM and the Dermatology Life Quality Index (DLQI), (ii) whether some variables, both patient-related and disease-related, affect the patient's suffering and quality-of-life impairment. METHODS We evaluated for inclusion in this cross-sectional study all patients who attended our Vulva Unit over a 9-month period with histologically proven lichen sclerosus (LS), lichen planus (LP), lichen simplex chronicus (LSC), eczema, plasma cell vulvitis and psoriasis (at least five for each disease). Demographics and disease-related subjective and objective scores were recorded. The PRISM and DLQI were administered. RESULTS We included 87 patients affected with LS, 13 with LSC and seven with LP. Median PRISM values (0-273 mm) ranged from 95 to 120 mm, depending on the disease, and median DLQI scores (0-30) were five for all three groups. Neither PRISM nor DLQI scores differed significantly among the three groups. Moderate coherence was found between PRISM and DLQI (ρ = 0.5455, P < 0.001). Global subjective score was the only variable significantly associated with the degree of suffering and quality-of-life impairment. CONCLUSIONS Pictorial Representation of Illness and Self-Measure proved to be a valuable, highly reliable tool for measuring the perceived burden in these patients. In spite of a moderate correlation, PRISM resulted more sensitive in capturing patient distress than DLQI.
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Affiliation(s)
- M Corazza
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - A Virgili
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - G Toni
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - G Valpiani
- Research Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - C Morotti
- Research Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - A Borghi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
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Pergialiotis V, Bellos I, Biliou EC, Varnava P, Mitsopoulou D, Doumouchtsis SK. An arm-based network meta-analysis on treatments for vulvar lichen sclerosus and a call for development of core outcome sets. Am J Obstet Gynecol 2020; 222:542-550.e6. [PMID: 31697910 DOI: 10.1016/j.ajog.2019.10.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/20/2019] [Accepted: 10/22/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of the present systematic review is to evaluate the available medical treatments for vulvar lichen sclerosus, using an arm-based network meta-analysis protocol. DATA SOURCES We searched Medline (1966-2019), Scopus (2004-2019), Cochrane Central Register of Controlled Trials CENTRAL (1999-2019), Clinicaltrials.gov (2008-2019) databases, and Google Scholar (2004-2019) database along with the reference list of all included studies. STUDY ELIGIBILITY CRITERIA All observational, randomized, and single-arm studies that evaluated medical treatments for vulvar lichen sclerosus were considered eligible for inclusion in the present systematic review. STUDY APPRAISAL A network meta-analysis was carried out in R 3.4.3 using the pcnetmeta package, which uses a Bayesian hierarchical model (based in Markov chain Monte Carlo convergence simulation). RESULTS Sixteen studies were included in this present meta-analysis, which recruited 954 women with vulvar lichen sclerosus. Their quality was evaluated with the JADAD, Cochrane risk of bias, and risk of bias in nonrandomised studies of interventions-I tools. Clobetasol treatment ranked as the best treatment for disease remission after evaluating rank probabilities (40% chance of ranking first compared with tacrolimus [38%]). However, the density plot revealed partial overlapping with tacrolimus. The lowest probability of experiencing a relapse was observed with pimecrolimus (15% [2-48%]); however, the density plot revealed significant overlapping with mometasone furoate, testosterone, and clobetasol. CONCLUSION Robust evidence concerning the superiority of potent steroids at least over calcineurin inhibitors is still lacking in the field of vulvar lichen sclerosus. On the other hand, the gross heterogeneity in terms of selected population, duration of treatment, administered regimen, outcome reporting, and selection of outcome measures leaves several fields unanswered.
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Affiliation(s)
- Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece; Third Department of Obstetrics and Gynecology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Eirini-Chrysovalantou Biliou
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiota Varnava
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Mitsopoulou
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece
| | - Stergios K Doumouchtsis
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece; Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals National Health Service Trust, London, United Kingdom; St George's University of London, London, United Kingdom
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Corazza M, Maietti E, Toni G, Virgili A, Borghi A. Combining topical tretinoin with mometasone furoate in the treatment of vulvar lichen sclerosus: Results of dermoscopic assessment. Dermatol Ther 2018; 31:e12735. [PMID: 30334327 DOI: 10.1111/dth.12735] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/13/2018] [Accepted: 08/29/2018] [Indexed: 11/29/2022]
Abstract
The main purpose of the present study was to compare the dermoscopic changes on vulvar lichen sclerosus (VLS) induced by two different 12-week treatment protocols, namely mometasone furoate 0.1% ointment plus tretinoin 0.05% cream in short-contact therapy (group A) versus the same corticosteroid plus emollient (group B). All dermoscopic images captured before and after treatment were assessed. Each dermoscopic variable selected for the study purpose was arbitrarily graded according to a 4-point scale by dermatologists blinded to both the time at which the images were captured and treatment allocation. Seventeen patients in group A and 15 in group B were included. The vessel mean dermoscopic scores increased significantly after treatment, whereas the scores of (a) patchy, structure-less, whitish areas, (b) whitish background, (c) comedo-like openings, and (d) purpuric blotches decreased. At the control visit, the two protocols did not differ significantly for any of the dermoscopic parameters, both in terms of mean score change and in the number of patients showing changes. Although the complementary action of the two molecules may suggest a therapeutic benefit, the association of tretinoin in short contact therapy with a potent corticosteroid did not induce significant changes in the dermoscopic features of VLS compared with the same corticosteroid alone.
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Affiliation(s)
- Monica Corazza
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Elisa Maietti
- Center for Clinical Epidemiology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Giulia Toni
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Annarosa Virgili
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Alessandro Borghi
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
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Development of the Adult Vulvar Lichen Sclerosus Severity Scale-A Delphi Consensus Exercise for Item Generation. J Low Genit Tract Dis 2018; 22:66-73. [PMID: 29095746 PMCID: PMC5768225 DOI: 10.1097/lgt.0000000000000361] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Ren L, Zhao Y, Huo X, Wu X. MiR-155-5p promotes fibroblast cell proliferation and inhibits FOXO signaling pathway in vulvar lichen sclerosis by targeting FOXO3 and CDKN1B. Gene 2018; 653:43-50. [DOI: 10.1016/j.gene.2018.01.049] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/12/2018] [Indexed: 12/11/2022]
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Borghi A, Virgili A, Minghetti S, Toni G, Corazza M. Clearance in vulvar lichen sclerosus: a realistic treatment endpoint or a chimera? J Eur Acad Dermatol Venereol 2017; 32:96-101. [DOI: 10.1111/jdv.14516] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/28/2017] [Indexed: 11/27/2022]
Affiliation(s)
- A. Borghi
- Dipartimento di Scienze Mediche; Sezione di Dermatologia e Malattie Infettive; Università degli Studi di Ferrara; Ferrara Italy
| | - A. Virgili
- Dipartimento di Scienze Mediche; Sezione di Dermatologia e Malattie Infettive; Università degli Studi di Ferrara; Ferrara Italy
| | - S. Minghetti
- Dipartimento di Scienze Mediche; Sezione di Dermatologia e Malattie Infettive; Università degli Studi di Ferrara; Ferrara Italy
| | - G. Toni
- Dipartimento di Scienze Mediche; Sezione di Dermatologia e Malattie Infettive; Università degli Studi di Ferrara; Ferrara Italy
| | - M. Corazza
- Dipartimento di Scienze Mediche; Sezione di Dermatologia e Malattie Infettive; Università degli Studi di Ferrara; Ferrara Italy
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Corazza M, Virgili A, Toni G, Borghi A. Mometasone furoate in the treatment of vulvar lichen sclerosus: could its formulation influence efficacy, tolerability and adherence to treatment? J DERMATOL TREAT 2017; 29:305-309. [DOI: 10.1080/09546634.2017.1360990] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Monica Corazza
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Annarosa Virgili
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Giulia Toni
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Alessandro Borghi
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
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Borghi A, Minghetti S, Toni G, Virgili A, Corazza M. Combined therapy in vulvar lichen sclerosus: does topical tretinoin improve the efficacy of mometasone furoate? J DERMATOL TREAT 2017; 28:559-563. [DOI: 10.1080/09546634.2016.1277178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Alessandro Borghi
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Sara Minghetti
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Giulia Toni
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Annarosa Virgili
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
| | - Monica Corazza
- Dipartimento di Scienze Mediche, Sezione di Dermatologia e Malattie Infettive, Università degli Studi di Ferrara, Ferrara, Italy
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Lyseng-Williamson KA. Mometasone furoate 0.1 % ointment and hydrogel: a guide to their use in corticosteroid-responsive dermatoses. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0339-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Krapf JM, Goldstein AT. Vulvar Dermatoses: Diagnosis, Management, and Impact on Sexual Function. CURRENT SEXUAL HEALTH REPORTS 2016. [DOI: 10.1007/s11930-016-0090-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Affiliation(s)
- F.M. Lewis
- Frimley Health NHS Trust and St John's Institute of Dermatology; Guy's and St Thomas’ NHS Trust; Great Maze Pond London SE1 9RT U.K
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