The treatment of vulval lichen sclerosus in prepubertal girls: a critically appraised topic

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.

Comparison of lichen sclerosus in boys and girls: A systematic literature review of epidemiology, symptoms, genetic background, risk factors, treatment, and prognosis

BACKGROUND

Studies concerning pediatric lichen sclerosus are limited, and, to date, there have been no studies comparing the course of lichen sclerosus in boys and girls. We sought to examine all publications on boys and girls with lichen sclerosus and assess and compare epidemiology, symptoms and signs, genetic background, risk factors, treatment, and prognosis.

METHODS

A systematic search was performed in the Embase, Medline, Cochrane, and Web of Science databases. Inclusion criteria were information on children ages 0-18 years and a clinical or histologic diagnosis of lichen sclerosus. Literature from 1985 to 2021 was reviewed.

RESULTS

A total of 1780 articles were retrieved from the search, of which 90 articles were eligible for inclusion. Boys and girls present similarly on many aspects; nonetheless, treatment and follow-up are approached differently.

CONCLUSIONS

Though the clinical approach is often different, lichen sclerosus in boys and girls demonstrates many similarities. More research is needed, especially on follow-up, to gain a better understanding of the course of lichen sclerosus and establish an advanced management plan for children.

Paediatric lichen sclerosus et atrophicus: A retrospective analysis of 38 paediatric patients

BACKGROUND

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory cutaneous disease.

AIM

To evaluate the characteristics of paediatric LSA patients in Turkey.

MATERIAL AND METHODS

Data for patients aged <18 years who were diagnosed with LSA by a paediatric dermatologist were retrospectively reviewed. Patient demographic characteristics, clinical features, disease duration, the vitamin D level, accompanying diseases, presence of atopy, therapeutic approach and treatment response were recorded.

RESULTS

The study included 38 patients, of whom 35 (92.1%) were female and 3 (7.9%) were male. Mean age at onset of disease was 6.4 ± 3.3 years in females versus 3.1 ± 2.6 years in males. Mean diagnostic delay was 20.6 ± 28.9 months in females and 2 ± 1.7 months in males. In 28 (80%) patients the time from onset of lesions to diagnosis was ≥3 months. The majority (76.3%) of the patients were asymptomatic, whereas five had itching, two had itching and burning, and two had pain. Among the females, 12 (34.3%) and 23 (65.7%) presented with isolated extragenital and anogenital involvement + extragenital lesions, respectively. All three males had isolated extragenital involvement. The most commonly recommended treatments were topical calcineurin inhibitors and calcipotriol/betamethasone ointment. Accompanying diseases were as follows: alopecia areata (n = 2); atopic dermatitis (n = 2); vitiligo (n = 2); ulcerative colitis and juvenile idiopathic arthritis (n = 1); Hashimoto's thyroiditis (n = 1). Among the 28 patients whose vitamin D level was measured, 24 (85.7%) had vitamin D deficiency.

CONCLUSION

LSA can be asymptomatic in the majority of affected children. Diagnostic delay was noted in 80% of the study's LSA patients, highlighting the lack of awareness of the condition among parents and clinicians.

Pediatric Vulvar Lichen Sclerosus-A Review of the Literature

Vulvar lichen sclerosus (VLS) is a chronic inflammatory condition affecting the anogenital region, which may present in a prepubertal or adolescent patient. The most popular theories are its autoimmune and genetic conditioning, although theories concerning hormonal and infectious etiology have also been raised. The most common presenting symptoms of VLS is vulva pruritus, discomfort, dysuria and constipation. In physical examination, a classic “Figure 8” pattern is described, involving the labia minora, clitoral hood, and perianal region. The lesions initially are white, flat-topped papules, thin plaques, or commonly atrophic patches. Purpura is a hallmark feature of VLS. The treatment includes topical anti-inflammatory agents and long-term follow-up, as there is a high risk of recurrence and an increased risk of vulvar cancer in adult women with a history of lichen sclerosus. This article reviews vulvar lichen sclerosus in children and provides evidence-based medicine principles for treatment in the pediatric population. A systematic search of the literature shows recurrence of VLS in children. Maintenance regimens deserve further consideration.

Pediatric vulvar malignancies: rare but important to know

Malignancies of the vulva in the pediatric population are exceptionally rare, which makes it difficult to gain any insight into their clinicopathologic profile. In this review, we summarize all published cases of a vulva malignancy in pediatric patients (≤21 years) reported in the English language literature for the 50-year period between 1970 and 2020. We estimate that less than 100 malignancies have been reported in total, approximately 50% of which were rhabdomyosarcomas. Invasive squamous cell carcinomas, yolk sac tumors, Ewing sarcoma/primitive neuroectodermal tumors (ES/PNET) and melanomas each represented approximately 10% of reported cases. For rhabdomyosarcoma, the alveolar and embryonal subtypes were reported with equal frequency, with both representing 70% of cases combined. The average patient age was 9.8 years. 48% and 35% were Intergroup Rhabdomyosarcoma Study clinical groupings I and III respectively. Managements were generally multimodal, and overall outcomes for the group were favorable. For invasive squamous cell carcinoma, the patients were all in their teenage years, with an average age at diagnosis of 15.2 years. A small subset of cases were associated with human papillomavirus and immunosuppression, and it is possible that immunosuppression has a role in vulvar squamous carcinogenesis in this population. One case was associated with lichen sclerosus. The patients with yolk sac tumors ranged in age from less than 1 year to 20 years (mean 12) and 67% of cases were stage I at presentation. An insufficient number of cases have been reported to define their prognosis, although some cases were notably aggressive. The few reported cases of melanoma are distinctive only because they were all associated with lichen sclerosus, suggestive of some role for the latter in their pathogenesis. The average age of patients reported with ES/PNET was 15 years (range 3.3 to 20). At least half of the reported cases were advanced stage at presentation, and patient outcomes were notably poor: 62.5% were dead of disease at follow-up. Pediatric vulvar malignancies are rare and are mostly comprised of 5 entities. Their accurate pathologic classification is necessary to facilitate optimal management.

Lichen Sclerosus in Prepubertal Girls: An Uncommon but Treatable Cause of Lower Urinary Tract Symptoms

Lichen sclerosus (LS) is a chronic inflammatory dermatosis commonly visualized in the anogenital region with porcelain-white atrophic patches that extend to the perianal region in a figure-of-eight configuration. While LS is known to increase lower urinary tract symptoms and incontinence in postmenopausal women, the age distribution is bimodal and literature on the LS impact in prepubertal girls remains limited. There is an association with autoimmune conditions and the pathogenesis is thought to be autoimmune with an underlying genetic predisposition. Lack of familiarity among pediatric urology providers may lead to a significant diagnostic and treatment delay, resulting irreversible genital skin changes.

The long-term clinical consequences of juvenile vulvar lichen sclerosus: A systematic review

BACKGROUND

Vulvar lichen sclerosus (VLS) occurring in children and adolescents may have repercussions throughout life.

OBJECTIVE

We sought to assess the evidence available on the long-term consequences of juvenile VLS.

METHODS

Multiple databases were searched for studies containing long-term follow-up information on children or adolescents up to age 18 years with VLS. Articles were classified by level of evidence and the specific aspects of VLS studied.

RESULTS

In all, 37 studies met the inclusion criteria, giving information on the long-term consequences of VLS, of which 13 were cohort studies and 24 were case reports or series. These publications show that signs and symptoms persist after puberty and beyond, scarring and permanent architectural changes occur, treatment is effective with regard to symptoms, and long-term quality of life is affected. Findings suggest a possible relationship with risk of malignancy. The included publications had low-level evidence.

LIMITATIONS

Meta-analysis was not possible because the studies had different focuses. Very few patients were followed into adulthood.

CONCLUSIONS

There is low-level evidence suggesting long-term repercussions of juvenile VLS. Studies following children and adolescents with VLS into adulthood are needed to better understand the course of this disease and its repercussions on adult vulvar health.

Evaluation of vulvar leukoplakia photodynamic therapy efficiency by fluorescent diagnostics method with local «Alasens®» photosensitizer application

PURPOSE

Using continuous-pulse irradiation mode application for performing photodynamic therapy sessions to introduce a new method, and conclude results of clinical research focused on vulvar leukoplakia photodynamic therapy efficiency in combination with topical aqueous «Alasens®» solution administration.

METHOD

Seventy patients (average age of 61 years) diagnosed with vulvar leukoplakia disease (2018 ICD-10-CM Diagnosis Code N90.4) were examined. The following values represent doses of combined mode photodynamic therapy session: 12 J/cm² pulse radiation dose; 3.5 J/cm² continuous radiation dose. Non-invasive spectroscopic and visual control of drug accumulation in real time was carried out by fluorescence diagnostic method before and after each therapy session.

RESULTS

Single-therapy session efficiency was estimated by a fluorescent signal reduction in the pathological region after irradiation, and the direct correlation between photosensitizer photobleaching and disease regression was registered. Photodynamic therapy course included three procedures, with each session applied in 24 -h intervals, and when necessary, an additional course of therapy was applied 60 days afterward. Significant post-treatment results took effect after 2-3 courses with symptom presence reduced or fully regressed depending on the initial severity of the disease. Additionally, side effects and sequelae remained absent in all cases.

CONCLUSION

The result of methods applied during the clinical research period indicate strong potential in utilizing such promising technology to contribute to the possible prevention of malignant transformation and the treatment of vulvar leukoplakia.