Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review

Signs and symptoms of vulvovaginal atrophy (VVA) in clinical practice - the possible involvement of thyroid autoimmunity in genitourinary syndrome of menopause (GSM)

BACKGROUND

Thyroid autoimmune disorders (ADs) are common in midlife women and can impact various aspects of health, including sexual function. The effect of thyroid autoimmunity on the clinical manifestations of vulvovaginal atrophy (VVA) remains unclear.

OBJECTIVE

To explore the relationship between thyroid ADs and VVA signs and symptoms in a sample of postmenopausal women.

METHODS

Cross-sectional study including postmenopausal women not using systemic hormone therapy. VVA signs were assessed using the vaginal health index (VHI) and vulvar health index (VuHI); VVA symptoms were rated on a four-point severity scale.

RESULTS

Among 112 women enrolled, 28 had thyroid ADs. A significantly higher percentage of women with thyroid ADs showed vaginal atrophy (75 vs. 45.2%, p < .05). A greater proportion of women with thyroid ADs exhibited vulvar atrophy or both vaginal and vulvar atrophy, though these differences were not statistically significant. Women with thyroid ADs reported significantly higher scores for dryness, burning/itching, irritation/inflammation, and dyspareunia compared to those without it. A higher percentage of women with thyroid ADs experienced severe dyspareunia (45 vs. 20.6%, p < .05), severe burning/itching (33.3 vs. 9.1%, p < .05), and severe stress urinary incontinence (17.9 vs. 3.6%, p < 0.05).

CONCLUSIONS

This study suggests that thyroid ADs may contribute to genital aging, with an apparent greater involvement in vaginal signs of atrophy. Women with thyroid ADs reported more severe VVA symptoms, but specific symptomatological clusters should be investigated in larger samples. Our data support the need to explore further the role of thyroid disorders in VVA.

Clinical presentations and complications of lichen sclerosus: A systematic review

Lichen sclerosus (LS) is a chronic, inflammatory dermatosis most commonly characterized by changes in skin pigmentation and pruritus, with associated dyspareunia and genital architectural changes. There are a variety of complications associated with LS, which further worsen a patient's health-related quality of life. A systematic review was conducted to summarize the literature regarding clinical features of LS, as well as LS-associated complications. In total, 900 studies were included, which represented 17,011 clinical presentations and 2,795 complications of LS in women, and 5,745 clinical presentations and 769 complications of LS in men. In both sexes, the majority of reported cases (77% in females, 99% in males) localized to the genitals. In women, presentations were spread amongst loss of normal architecture (14%), pigmentary changes (21%) and pruritus (18%), whereas in men a greater portion of cases presented with architectural alterations (34%), as well as pigmentary changes (15%) and urogenital symptoms (15%). Other classes of LS-associated presentations included textural changes, atrophy, pain/burning/discomfort, erosions/ulcerations/excoriations, bleeding/bruising/purpura, defecatory symptoms and bullae. A small portion of cases found in the literature presented with asymptomatic LS. LS-associated complications included skin neoplasms, urogenital issues and sexual dysfunction, including dyspareunia.

Efficacy and safety of 5-aminolevulinic acid photodynamic therapy in refractory genital lichen sclerosus

BACKGROUND

Genital lichen sclerosus (GLS) is a chronic inflammatory skin disease affecting the genital and anal areas. Treatment of refractory remains a challenge in clinical practice.

OBJECTIVE

This study aimed to evaluate the efficacy and safety of 5-aminolevulinic acid photodynamic therapy (5-ALA PDT) for refractory GLS.

METHODS

Thirty-five patients with histopathologically confirmed GLS (including 32 females and 3 males) were treated with 5-ALA PDT. Lesion pretreatment was performed to enhance photosensitizer penetration, and fluorescence diagnosis was used for precise point-to-point treatment. Efficacy and safety were systematically evaluated by assessing treatment outcomes, symptom improvement, side effects and maintenance of efficacy over a 6-month follow-up period.

RESULTS

After treatment, most patients experienced significant relief of pruritus, improved skin elasticity and color, and reduced lesion area. After 6 treatment sessions, 11 patients (31.43 %) achieved complete resolution of pruritus, with 3 patients (8.57 %) achieving complete remission after 3 sessions. Cattaneo scores decreased significantly after treatment and during follow-up (P < 0.05). Adverse reactions were mainly mild pain, which could be relieved by ice compression or oral analgesics.

CONCLUSIONS

5-ALA PDT shows significant efficacy and good safety for refractory GLS, improving the clinical symptoms and signs of patients, and warrants wider clinical application.

Regional Variations in the Incidence of Lichen Sclerosus in Sweden: Insights from a Nationwide Register Study (2001-2021)

Background: Lichen Sclerosus (LSc) is a chronic inflammatory skin condition predominantly affecting the anogenital regions, with a well-recognised potential for malignancy. This study examines the incidence, demographic characteristics, and regional distribution of LSc in Sweden over a 20-year period. The analysis is based on data from the Swedish National Patient Register (NPR), with a focus on cases diagnosed in specialist care settings. Methods: A nationwide register-based study was conducted using data from the NPR, identifying cases of LSc diagnosed between 1 January 2001 and 1 January 2021. Data analysis explored incidence by region, sex, age, and diagnostic care setting. A total of 154,424 patients with LSc were included, and the control group consisted of the general Swedish population without known LSc. Results: The mean annual incidence of LSc was 0.81 per 1000 individuals across Sweden, with higher rates in females (1.14 per 1000) compared to males (0.47 per 1000). Incidence varied significantly across regions, with Blekinge, Kalmar, and Gotland exhibiting the highest rates. This study analysed the distribution of LSc diagnoses across medical specialties, finding that 29.8% of cases were managed by dermatology and venereology, while 17.2% were handled by gynaecology and obstetrics. The analysis of marital status revealed that the proportion of married and divorced LSc patients was significantly lower than the national averages for men and women. Conclusions: This study highlights significant regional variations in LSc incidence. Future research should investigate whether environmental factors, genetic predisposition, socioeconomic disparities, or variations in healthcare access contribute to the variations in incidence. Such insights could lead to more targeted public health strategies for managing LSc across different regions.

AI-powered visual diagnosis of vulvar lichen sclerosus: A pilot study

BACKGROUND

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin condition associated with significant impairment of quality of life and potential risk of malignant transformation. However, diagnosis of VLS is often delayed due to its variable clinical presentation and shame-related late consultation. Machine learning (ML)-trained image recognition software could potentially facilitate early diagnosis of VLS.

OBJECTIVE

To develop a ML-trained image-based model for the detection of VLS.

METHODS

Images of both VLS and non-VLS anogenital skin were collected, anonymized, and selected. In the VLS images, 10 typical skin signs (whitening, hyperkeratosis, purpura/ecchymosis, erosion/ulcers/excoriation, erythema, labial fusion, narrowing of the introitus, labia minora resorption, posterior commissure (fourchette) band formation and atrophic shiny skin) were manually labelled. A deep convolutional neural network was built using the training set as input data and then evaluated using the test set, where the developed algorithm was run three times and the results were then averaged.

RESULTS

A total of 684 VLS images and 403 non-VLS images (70% healthy vulva and 30% with other vulvar diseases) were included after the selection process. A deep learning algorithm was developed by training on 775 images (469 VLS and 306 non-VLS) and testing on 312 images (215 VLS and 97 non-VLS). This algorithm performed accurately in discriminating between VLS and non-VLS cases (including healthy individuals and non-VLS dermatoses), with mean values of 0.94, 0.99 and 0.95 for recall, precision and accuracy, respectively.

CONCLUSIONS

This pilot project demonstrated that our image-based deep learning model can effectively discriminate between VLS and non-VLS skin, representing a promising tool for future use by clinicians and possibly patients. However, prospective studies are needed to validate the applicability and accuracy of our model in a real-world setting.

What Is New in Morphea-Narrative Review on Molecular Aspects and New Targeted Therapies

Morphea, also known as localized scleroderma, is an autoimmune chronic connective tissue disease. It is characterized by excessive collagen deposition in the dermis and/or subcutaneous tissue. The etiopathogenesis of this disease is not fully understood, with endothelial cell damage, immunological disorders, extracellular matrix disorders and factors such as infection, trauma and other autoimmune diseases being considered. As medicine advances, there is increasing evidence that genetic factors play a significant role in disease risk and progression. In addition to environmental factors and genetic predisposition, epigenetic factors may be potential triggers for morphea. Epigenetics studies changes that affect gene expression without altering the DNA sequence, such as microRNAs, long non-coding RNAs or DNA methylation. Understanding the pathogenesis of this disease is key to identifying potential new treatments. There are anecdotal reports of good therapeutic effects following the use of biological drugs such as tocilizumab, a humanized IgG monoclonal antibody; abatacept, a recombinant soluble fusion protein; JAK inhibitors, such as tofacitinib and baricitinib; and a drug used successfully in cancer treatment, imatinib, a tyrosine kinase receptor inhibitor. In this article, we aim to review up-to-date knowledge on the pathogenesis of morphea, with particular emphasis on genetic and epigenetic factors. In addition, we present the new options of morphea treatment based on several case series treated with new drugs that are potential targets for the development of therapies for this disease.

The relationship between the vaginal and vulvar microbiomes and lichen sclerosus symptoms in post-menopausal women

Lichen sclerosus is a chronic inflammatory condition of unknown etiology that affects the genital and extragenital skin, which can lead to sexual dysfunction and has been associated with vulvar cancer. The vaginal microbiome has a critical role in gynecologic health, but little is known about the microbiome in lichen sclerosus. This study investigated the vaginal and vulvar microbiomes of 27 post-menopausal women with lichen sclerosus. The most abundant genera detected in the vaginal microbiome were Lactobacillus, Gardnerella, and Anaerococcus, while Lactobacillus, Anaerococcus, and Staphylococcus were the most abundant in the vulvar microbiome. The vaginal samples clustered into two main groups, Lactobacillus dominant (n = 6, > 50% microbiome Lactobacillus) and polymicrobial (n = 21) with no dominant genus. The vulvar samples were mainly polymicrobial (n = 25). Actinomyces, Anaerococcus, and Ezakiella in the vaginal microbiome and Actinomyces and Ezakiella in the vulvar microbiome were significantly associated with lichen sclerosus symptoms (adjusted p < 0.05). In this population of post-menopausal women with lichen sclerosus the majority have diverse, non-Lactobacillus dominant microbiomes, which is considered less optimal for gynecologic health based on studies of pre-menopausal women. Actinomyces, Ezakiella, and Anaerococcus were associated with lichen sclerosus symptoms. Understanding the role of these bacteria in lichen sclerosus pathogenesis will be an essential future investigation.

Treatment of lichen sclerosus with hydroxychloroquine: a Mayo Clinic experience

BACKGROUND

There is a dearth of studies investigating the efficacy of hydroxychloroquine in the treatment of either anogenital lichen sclerosus or extragenital lichen sclerosus, a condition that, if left untreated, could lead to a greater degree of scarring and malignant transformation.

OBJECTIVE

This study aims to analyze the demographic characteristics, clinicopathological features, treatment response, and outcomes of patients diagnosed with either anogenital or extragenital lichen sclerosus who received hydroxychloroquine therapy.

METHODS

A retrospective analysis was conducted involving 70 patients diagnosed with lichen sclerosus who underwent treatment with hydroxychloroquine at our institution between 2018 and 2023.

RESULTS

Among the cohort, 67 patients were female, and 3 were male. Extragenital lichen sclerosus was diagnosed in 23 patients, with 16 exhibiting concomitant morphea overlap. Itching was the predominant clinical presentation (67%). A notable proportion of patients (36%) had a connective tissue disorder, prompting hydroxychloroquine therapy. Among the 30 patients treated solely for lichen sclerosus, 21 demonstrated response and 9 had no response. From a broader comparison of response to hydroxychloroquine, the overall anogenital response rate was 84.6% as opposed to 50% in extragenital lichen sclerosus. The median time to initial response was 4 months. Adverse effects, predominantly mild, were observed in 10 (14.3%) patients.

LIMITATION

This study is constrained by its retrospective nature and reliance on data from a single center, resulting in a limited sample size.

CONCLUSION

Hydroxychloroquine demonstrates promise as a therapeutic option for anogenital lichen sclerosus because of its favorable response rates and low incidence of adverse effects. However, further investigations, including larger-scale or prospective studies, are imperative to ascertain its definitive efficacy.

Treatment-induced anogenital melanosis is a very frequent finding in patients with vulvar lichen sclerosus

Background

Pigmented lesions such as melanosis have rarely been reported in patients with vulvar lichen sclerosus (VLS) that is typically characterized by hypopigmented lesions.

Objective

We aimed to analyze systematically anogenital melanosis in a large cohort of VLS patients.

Methods

We analyzed the clinical data of 198 female patients with VLS. The anogenital lesions of all patients were professionally photographed in a standardized position and illumination. Severity classification of architectural findings followed an easy-to-use clinical score. A modified Melasma Area and Severity Index and an image analysis software were used to evaluate the area and intensity of pigmentation.

Results

According to the clinical score, 79 (198/39.9%) patients showed grade 1 disease, 78 (198/39.4%) grade 2, 37 (198/18.7%) grade 3, and 4 (198/2%) grade 4 disease. About 111 (56.1%) of the 198 patients had anogenital melanosis with a median modified Melasma Area and Severity Index of 3.6 (0.4-14). Univariate analysis revealed that anogenital melanosis was positively correlated with the use of topical estrogens (P = .0018) and negatively correlated with the use of pulsed high-dose corticosteroids plus low-dose methotrexate (PHDC-LDM, P = .021). On multivariable analysis, the use of topical hormone therapy turned out to be a strong independent predictor for the presence of anogenital melanosis (odds ratio: 4.57, 95% confidence interval: 1.66-12.57, P = .0033), whereas PHDC-LDM use was an independent predictor for the absence of anogenital melanosis (odds ratio: 0.35, 95% confidence interval: 0.15-0.84, P = .018).

Limitations

The study includes the retrospective monocentric design.

Conclusion

Anogenital melanosis is a very frequent and so far, under-reported clinical finding in VLS patients. It is likely caused by the use of topical estrogens employed for VLS treatment. In contrast, patients with more severe disease and PHDC-LDM treatment appear to develop less likely anogenital melanosis.

Growing up with juvenile vulvar lichen sclerosus: the experiences and care needs of adult women with lichen sclerosus since childhood - a qualitative exploration

BACKGROUND

Vulvar lichen sclerosus (VLS) is a chronic remitting condition that affects the genital skin of females of all ages. Although qualitative studies have been conducted that have focused on women with VLS in mid-life or beyond, less is known about the experiences of individuals with VLS from childhood or adolescence onward.

OBJECTIVES

To gain an understanding of the experiences of women with a history of juvenile VLS (JVLS) with regard to the impact of the disease on their personal lives, and their experiences and needs regarding care and guidance.

METHODS

A qualitative study was conducted consisting of 27 in-depth face-to-face interviews with adult women with a histologically confirmed history of JVLS, striving for maximum variation and saturation. Interviews were audio recorded and transcribed verbatim. A thorough thematic content analysis was performed.

RESULTS

Three main themes were identified. Theme 1 was named 'Varying impact of living with JVLS': women experienced diverse emotional and physical impacts, from shame and denial to complete acceptance, from restrictions in daily functioning to no limitations; they felt hindered by their own lack of knowledge about JVLS and generally expressed positivity in sharing their experiences with people close to them. Theme 2 was entitled 'Finding one's way in care and guidance': while navigating care and guidance, women often felt hindered by knowledge gaps among healthcare professionals (HCPs), lack of continuity in care and guidance, lack of life phase-adjusted and future-oriented information provision, inadequate guidance around life events and insufficient monitoring of determinants of treatment adherence. Theme 3 was named 'Need for patient-tailored care involving appropriate and compassionate care and guidance': patients stressed the need for age-appropriate and life phase-adjusted information, guidance around life events and compassionate contact with knowledgeable HCPs aware of the determinants of treatment adherence and influencing factors.

CONCLUSIONS

Age-appropriate, life phase-adjusted, individually tailored care for women diagnosed with VLS in childhood or adolescence is needed. Care and guidance from childhood onward should encompass a standard of care adapted to the individual as their needs change over time. This involves taking interpersonal differences into account, including differences in support network and coping strategies. These findings demonstrate the need to improve awareness and knowledge about JVLS/VLS among HCPs, especially primary care providers, and among the general public.

Nonsclerotic Lichen Sclerosus of Vulva: A Clinicopathologic Analysis

The International Society of the Study of Vulvovaginal Diseases (ISSVD) recently defined nonsclerotic lichen sclerosus (NSLS) as a scenario wherein the clinical findings are consistent with lichen sclerosus (LS), but no microscopic evidence of dermal sclerosis is found and recognized 4 histologic subcategories. Herein, we present an institutional experience with NSLS, with an emphasis on frequency, application of the ISSVD categories in routine practice, and clinicopathologic correlation. The authors reviewed clinical and pathologic findings for consecutive vulvar biopsies in which LS was a clinical and/or pathologic consideration. Cases were classified as classical/sclerotic LS (CLS), NSLS (per ISSVD criteria), and "unclassified," the latter of which were cases not classifiable as NSLS or CLS, despite a clinical impression or LS or LS being a significant clinical consideration (ie, "clinical LS"). In clinical LS cases, CLS and NSLS were diagnosed histologically in 61% (182/298) and 15% (44/298), respectively, whereas the remainder were histologically unclassified. The latter group was microscopically heterogeneous, devoid of a consistent pathologic profile, and generally showed absence, focality, minimality, ambiguity, or infrequency of features that would have allowed their categorization into one of the NSLS categories. Among the 4 categories for the categorizable NSLS cases, the "lichenoid dermatitis" pattern (61.4%) was the commonest, followed by dermal fibrosis with acanthosis (22.7%), dermal fibrosis without acanthosis (9.1%), and hypertrophic lichenoid dermatitis (6.8%). The clinical response rates to topical therapies for the NSLS and unclassified groups were 71% and 62%, respectively (P=0.4). Our findings highlight the significance of clinicopathologic correlation in the diagnosis of NSLS. In the setting of clinical LS, some histologic evidence to support that impression is found in most cases when the ISSVD system for diagnosis and classification of biopsies is applied. However, a subset of clinical LS cases are not pathologically classifiable as either CLS or any of the NSLS categories; these display nonspecific histologic features and require future study.

Blue diode laser as supportive therapy for the management of vulvar lichen sclerosus

Vulvar lichen sclerosus is a chronic inflammatory condition characterized by the thinning and atrophy of the skin and mucosa surrounding the vulva and anus. This study evaluates the efficacy of a treatment protocol utilizing blue-diode laser photobiomodulation in managing vulval lichen sclerosus symptoms in a cohort of 12 female patients. The treatment protocol consisted of laser sessions 3 times a week for 2 weeks and follow-up sessions over a 16-week period. Objective and subjective parameters were assessed before treatment, at the end of treatment, and at 4-month follow-up visits. Results demonstrated significant reductions in subjective symptoms, such as itching and pain, as well as improvements in objective signs, including erythema and fissures. No side effects were observed, indicating the safety and tolerability of laser treatment. These findings suggest that photobiomodulation can be an effective therapeutic option for patients with vulval lichen sclerosus, with future research aimed at refining treatment protocols and evaluating its long-term benefits.

The Association between Cardiovascular Risk Factors and Lichen Sclerosus: A Systematic Review and Meta-Analysis

Background/Objective: Lichen sclerosus is a chronic inflammatory skin disease that affects people of all ages and sexes. Evidence of cardiovascular risk factors in lichen sclerosus has been continuously reported; however, the definitive association remains inconclusive. This meta-analysis aimed to summarize the association between cardiovascular risk factors and lichen sclerosus. Methods: Electronic databases, including MEDLINE and EMBASE, were systematically searched from inception to May 2024 to identify the literature reporting the association between cardiovascular risk factors and lichen sclerosus. A random-effects model was used for the meta-analysis. Results: We included 16 eligible studies: nine case-control studies, six retrospective cohort studies, and one cross-sectional study. A total of 432,457 participants were included. Lichen sclerosus was significantly associated with type 2 diabetes mellitus with an odds ratio of 2.07 (95% CI: 1.21-3.52). Although not statistically significant, a trend of increasing risk in hypertension, dyslipidemia, obesity, and metabolic syndrome was observed among lichen sclerosus patients, with odds ratios of 1.56 (95% CI: 0.90-2.70), 1.44 (95% CI: 0.94-2.23), 5.84 (95% CI: 0.37-92.27), and 1.36 (95% CI: 0.52-3.54), respectively. Conclusions: Lichen sclerosus was associated with diabetes mellitus and potentially correlated with hypertension, dyslipidemia, obesity, and metabolic syndrome. Population-based prospective observational studies are required to further elucidate these findings and assess the impact of these associations.

Study of 138 vulvar lichen sclerosus patients and the malignant risk transformation

Objective

To report the prevalence of malignant transformation of vulvar lichen sclerosus (VLS) and possible risk factors.

Methods

This is a cohort study with data analysis from medical records of 138 patients with histological diagnosis of VLS registered at the Vulvar Pathology Outpatient Clinic of the University Hospital, between 2007 and 2017. Predominance of risk factors was performed using logistic regression analysis. The variables studied were the length of follow-up, age, regular or irregular follow up; presence of symptoms (dyspareunia, pruritus and/or vulvar burning); histology characteristics, the presence of epithelial hyperplasia; and the presence of autoimmune diseases.

Results

There were 138 patients included in the study, and among them five progressed to malignant transformation. The patients had a median age of 59 years and 83% were symptomatic. The most frequent symptom was itching with 72%. Autoimmune diseases were present in 11.6%, the most prevalent being thyroid disease. All five case of malignant transformation (0.6%) had an irregular follow up. The logistic regression analysis was used among the studied variables, and no statistical significance was found among them (p ≥ 0.05). The relationship between hyperplasia and the clinical outcome of malignant transformation, in which non-significant but acceptable p value close to 0.05 was observed.

Conclusion

The prevalence of malignant transformation in patients with VLS was 0.6%, and common factors were the lack of adherence to medical treatments and the loss of follow-up.

Patient satisfaction and sexual issues in vulvar lichen sclerosus treatment: a monocentric certified dysplasia unit survey analysis

OBJECTIVE

Vulvar lichen sclerosus (VLS) is an underestimated chronic disease. It can cause significant symptom burden and sexual dysfunction. This study aimed to evaluate patient satisfaction and current challenges in the management of VLS in a certified dysplasia unit, particularly during the COVID-19 pandemic.

METHODS

This survey analyzed patients who had been diagnosed with VLS and treated at our DKG-certified dysplasia unit. The study was conducted during the COVID-19 pandemic in the Department of Gynecology and Obstetrics at the University of Aachen. The questionnaire contained 43 questions on general treatment, diagnostic delays, disease education, psychologic and sexual issues, and specific questions regarding the COVID-19 pandemic. The questionnaires were distributed between January 2021 and September 2023.

RESULTS

This study included 103 patients diagnosed with VLS, who were treated at our certified dysplasia unit. Overall, 48% of the patients were satisfied with the success of the therapy. Most participants reported psychologic problems (36.8%), fear of cancer (53.3%), or sexual restrictions (53.3%). Among the patients, 38% were bothered by the regular application of topical cortisone. However, 72% were willing to undergo treatment for more than 24 months. The COVID-19 outbreak in March 2020 had a significant negative impact on general VLS care from the patient's perspective (3.83/5 before vs. 3.67/5 after; p = 0.046). There was a general request for booklets to inform and educate the patients about their disease. Furthermore, the respondents demanded a telephone hotline to answer the questions and wished for follow-up visits via e-mail to cope better with their current situation.

CONCLUSION

This study highlights the need for more effective treatments for VLS and an increased awareness of psychologic and sexual distress. To ensure patient well-being and satisfaction, it is imperative to offer individualized care with adequate disease education in a team of specialists from various disciplines.

Treatment algorithm for the comprehensive management of severe lichen sclerosus in boys based on the pathophysiology of the disease

INTRODUCTION

It is estimated that approximately one out of 200 boys has the diagnosis of lichen sclerosus (LS), previously referred to as BXO (balanitis xerotica obliterans). Severe progressive disease is rare however, mismanagement of urethral tissues may contribute to progression of LS.

STUDY DESIGN

The current literature regarding the management of severe lichen sclerosus was reviewed alongside our management of seven patients with ages ranging from six to ten years of age with severe lichen sclerosus who required surgical intervention. These patients were identified out of a busy pediatric practice that saw 5507 patients during the four-year span. Based on the pathophysiology of lichen sclerosus, urethral anatomy, and our management an algorithm was developed for medical and surgical management.

RESULTS

All patients received initial medical treatment with topical steroids. Three patients underwent urethral mobilization and serial biopsy. One of these patients with severe disease required a second distal urethral mobilization. Three patients were treated with circumcision, and one is responding well to topical steroids after complex reconstruction. None developed postoperative urethral disease.

DISCUSSION

Lichen sclerosus affects squamous epithelium but can extend to unaffected tissue if traumatized via the Koebner phenomenon. There are no randomized control trials for the management of the disease. Thus, appropriate early management with avoidance of urethral dilation or incision may prevent extension down the urethra that can lead to severe stricture disease. Several authors identified this as one of the worst forms of stricture diseases to manage. Based on the pathophysiology of the disease and our 4-year experience treating patients, we propose an algorithm for management of severe lichen sclerosus in boys. The diagnosis of lichen sclerosus in boys requires a high level of suspicion, and early biopsies should be obtained if suspected. If identified before circumcision or meatotomy, initial treatment should be medical. If the patient fails topical steroid therapy, circumcision and biopsy are the initial recommended surgical approach. Optimally, a biopsy with the first meatotomy establishes the diagnosis. If the disease persists, urethral mobilization may represent a curative treatment as it advances healthy urethra and allows complete removal of distal squamous epithelium instead of traumatic repeated dilations or incisions.

CONCLUSION

This paper summarizes the available literature on the management of severe LS and provides a flow diagram based on the pathophysiology of the disease and our experience sever cases.

Lichen Sclerosus-Incidence and Comorbidity: A Nationwide Swedish Register Study

Background: Data on the incidence and comorbidity of Lichen sclerosus (LS), based on validated nationwide population-based registries, remains scarce. Objective: To explore the incidence and association of comorbidities with LS in Sweden, emphasizing its potential links to malignancies and autoimmune disorders. Methods: A population-based retrospective open cohort study was conducted using the National Patient Register to identify all individuals diagnosed with LS (ICD-10 code L90.0) from 1 January 2001 to 1 January 2021. The study included 154,424 LS patients and a sex and age matched control group of 463,273 individuals to assess the incidence and odds ratios for various cancers and premalignant conditions. Results: The incidence of LS in Sweden was 80.9 per 100,000 person per year, with higher incidence in females (114.4) than in males (47.2). LS patients showed an increased odds ratio for vulvar cancer (OR = 8.3; 95% CI = 7.5-9.0), penile cancer (OR = 8.9; 95% CI = 7.3-11.0), prostate cancer (OR = 1.2; 95% CI = 1.1-1.2), testicular cancer (OR = 1.4; 95% CI = 1.1-1.7), bladder cancer (OR = 1.1; 95% CI = 1.1-1.2), breast cancer (OR = 1.4; 95% CI = 1.3-1.4), leukoplakia of the vulva (OR = 253.5; 95% CI = 221.9-289.6), and leukoplakia of the penis (OR = 5.1; 95% CI = 4.9-5.4). Conclusions: This study underscores the significantly increased association of various cancers and premalignant conditions in LS patients, highlighting the critical need for efficacious treatment and diligent follow-up. The association between LS and autoimmune diseases further necessitates comprehensive investigation to understand the underlying mechanisms and clinical management implications. Future research is essential to confirm these findings and elucidate the role of LS in cancer development.

Advances in the pathogenesis of vulvar lichen sclerosus

Vulvar lichen sclerosus (VLS) is a chronic non-neoplastic skin lesion characterized by vulvar itching, pain, atrophy, whitening of the skin and mucous membranes, and gradual atrophy and disappearance of the labia minora, which can eventually lead to vulvar scarring, causing functional impairment and seriously affecting the patient's physical and mental health. VLS can occur at any age, however, its pathogenesis and etiology are not fully understood. Considerable progress has been made in related research on genetic susceptibility factors, autoimmune disorders, collagen metabolism abnormalities, and their triggering factors in disease formation and progression. This article reviews the etiology of vulvar lichen sclerosus.

WNL we never looked: vulvar carcinoma incidence after screening cutoff

The incidence of vulvar carcinoma increases with age, though elderly women receive less aggressive cancer therapies and fewer strategies aimed at cancer prevention. Furthermore, elderly women dual enrolled in Medicaid-Medicare experience poor survival rates for vulvar carcinoma. Herein, we provide recommendations for the prevention of and guidelines for the multidisciplinary care of vulvar carcinoma. Prevention of vulvar carcinoma can be categorized into primary, secondary, and tertiary prevention. Primary prevention consists of vaccination, secondary prevention consists of screening, and tertiary prevention is aimed at the management of premalignant and early-stage lesions.

The Potential Coexistence of Autoimmune Thyroid Diseases and Pediatric Vulvar Lichen sclerosus

INTRODUCTION

Vulvar lichen sclerosus (VLS), a chronic inflammatory skin disorder, often coexists with autoimmune thyroid disease (AITD). VLS presents with subtle symptoms including vulvar itching and discomfort. Clinically, a "Figure 8" pattern involving the labia minora, clitoral hood, and perianal region is often observed. It is prevalent both in pre-pubertal girls and women aged 40-60, and the link between VLS and AITD remains unclear, with proposed causes including autoimmune, hormonal or genetic factors, and environmental triggers. This study addresses the lack of research on the association in children, aiming to investigate the largest group of underage girls to date.

AIM

This study aimed to investigate the coexistence of thyroid autoimmune diseases in girls diagnosed with vulvar lichen sclerosus (VLS) and to assess the presence of antibodies for specific thyroid autoimmune diseases.

MATERIALS AND METHODS

Our study was conducted from July 2020 to February 2021, involving a sample of 55 girls aged 2-18 years old, all free from systemic diseases. The study group comprised 20 girls previously diagnosed with vulvar lichen sclerosus (VLS), while the control group included 35 girls without VLS. Legal guardians completed questionnaires detailing the medical history of their children. Blood samples were collected from all participants and subjected to biochemical analysis. The presence of human IgG antibodies against thyroid peroxidase and IgG antibodies against thyroglobulin was assessed using the immunoenzymatic method with commercially available ELISA kits.

RESULTS

In the study group, common symptoms included itching, soreness, burning sensation, excoriation, and erythema or pallor of the skin and perineal mucosa. An evaluation of anti-thyroglobulin and anti-thyroid peroxidase antibodies revealed no statistical significance between the study and control groups (anti-TG p = 0.379, anti-TPO p = 0.96). Family history of autoimmune diseases showed no significant correlation with anti-thyroid antibodies in girls. Although no significant relation between VLS occurrence and antibody levels was found, it emphasizes the need for multidisciplinary medical care. Further research with larger patient groups is necessary.

Exploring the potential prompting role of cervical human papilloma virus detection in vulvar lesions: a cross-sectional study in China

Introduction

The etiology and clinical presentation of vulvar carcinomas, especially vulvar lesions, are not fully understood. Because the vulva and cervix are anatomically connected, human papillomavirus (HPV) is the main cause of cervical lesions. Thus, this study explored the potential characteristics and effects of specific HPV infection types across vulvar lesions and concurrent cervical lesions.

Methods

This retrospective, cross-sectional study analyzed patients with cervical HPV or cytological results and concurrent vulvar biopsy who were seen in our hospital colposcopy clinic in Shanxi Province, China, between 2013 and 2023. Data on age, menopause status, vulvar manifestations, and cytology and HPV infection testing results were collected. Attributable fractions and multinominal logistic models were used to evaluate HPV genotyping and clinical characteristics across vulvar lesions.

Results

Among the 1,027 participants, 83 (8.1%) had vulvar intraepithelial neoplasia (VIN) of high grade or worse (VIN2+), and 127 (12.4%) had non-neoplastic epithelial disorders of the vulva (NNEDV). A total of 175 patients had either VIN2+ or cervical intraepithelial neoplasia (CIN) lesions of grade 2 or worse (CIN2+). The most common HPV genotypes for VIN2+ or concurrent VIN2+/CIN2+ were HPV16, HPV52, and HPV58, although attributable fractions differed among lesions. Patients with normal cytological or histopathological result were more likely to have NNEDV detected, while abnormal cervical diagnosis was associated with higher detection of VIN2+. Multinominal logistic modeling showed that age and HPV16 infection were risk factors for VIN2+ or concurrent VIN2+/CIN2+; however, only vulvar presentation with depigmentation was a risk factor for NNEDV. Among patients with low-grade CIN1/VIN1, compared with those who were HPV16 negative, those who were HPV16 positive were at 6.63-fold higher risk of VIN2+/CIN2+ [95% confidence interval (CI): 3.32, 13.21]. Vulvar depigmentation was also associated with increased risk of NNEDV (odds ratio: 9.98; 95% CI: 3.02, 33.04).

Conclusions

Chinese women may be at specific, high risk for HPV infection types associated with VIN or CIN. The use of cervical cell HPV detection along with vulvar presentation during cervical cancer screening may also contribute to vulvar lesion detection.

Lichen Sclerosus of the Labial Mucosa: A Case Report and Literature Review

Lichen sclerosus (LS) is an uncommon, chronic, inflammatory mucocutaneous disorder found predominantly in females with unknown etiology. It presents as a white sclerotic plaque commonly located on the anogenital area. Extragenital LS is less prevalent, and LS affecting the oral mucosa is extremely rare, with only 39 biopsy-confirmed cases reported in the literature. Due to its several mimicking conditions, histological examination is usually required for a definitive diagnosis, particularly in patients with oral LS. Current evidence-based treatment recommendations for oral LS are unavailable; however, most cases tend to improve after treatment with topical or intralesional corticosteroids. We report a case of a 58-year-old female referred from the otolaryngology department for evaluating an asymptomatic whitish sclerotic plaque on the lower lip mucosa that had existed for 1 year. Following a punch biopsy, the patient was diagnosed with LS of labial mucosa. The condition improved after 2 months of treatment with topical and intralesional corticosteroids. The present case report raises awareness in recognizing oral LS and contributes to knowledge of this rare disorder.

Vulvar Lichen Sclerosus: Navigating Sex Hormone Dynamics and Pioneering Personalized Treatment Paradigm

Vulvar lichen sclerosus (VLS) is a frequently overlooked inflammatory disorder affecting the skin and mucous membranes of the vulva. With a propensity for atrophy, severe scarring, functional impairment, and malignant evolution, VLS is a disease that recurs frequently; early diagnosis, rapid treatment, and ongoing patient follow-up are essential. Potent topical corticosteroids (TCSs) are now widely recognized as the most effective treatment for achieving remission in VLS, but considering the potential complications of long-term treatment with potent TCSs, understanding the evolution of VLS during puberty becomes particularly crucial in determining the necessity for aggressive or more conservative therapeutic interventions. Emerging treatments, including PRP (platelet-rich plasma), stem cell therapy, and energy-based lasers like fractional CO2 and Nd-YAG, are being investigated to identify more effective VLS treatments than ultrapotent topical corticosteroids. However, more research is needed to assess the efficacy and safety of these new medicines. Topical clobetasol 0.05% ointment daily for 4-12 weeks is the gold standard for treating VLS. This article is a narrative review of the English-language medical literature from 2017 to November 2023, following three main sections concerning VLS: studies of the evolution amid pubertal hormonal changes; studies of the outcomes of personalized conventional therapies; and studies addressing the spectrum of innovative modalities for VLS.

Comorbidity in patients with Lichen sclerosus: a retrospective cohort study

Lichen sclerosus (LS) is a chronic lymphocyte mediated inflammatory mucocutaneous disease of unknown aetiology with a predilection for the anogenital region, and affecting both sexes. The disease is characterized by pain, intolerable itching and scarring. In late stages of LS, disfiguring scarring can drastically alter the structural anatomical architecture of the genitals. The association between genital LS and different malignant tumours is a concern that needs to be further investigated. An association between LS and several autoimmune diseases has been confirmed in recent studies. All registered citizens of Region Jönköping, Sweden were included in the present study. Patients diagnosed with LS (n = 5680) between 2001 and 2021 were identified using ICD-10 code L90.0 and selected as cases. All other individuals (n = 362 568) served as controls. Odds ratios (ORs) for the selected comorbidity were calculated and adjusted for age and sex. The cumulative incidence of LS for the entire population over a 20-year period was 1.54% (15.4 per 1000 people). The cumulative incidences over a 20-year period for females and males were 2.13% and 0.97%, respectively. This study confirmed the association between LS and vulvar cancer (OR = 17.4; 95% CI 12.1-25.3), penis cancer (OR = 9.1; 95% CI 4.3-18.9), prostate cancer (OR = 2.0; 95% CI 1.6-2.4) and breast cancer (OR = 1.6; 95% CI 1.4-1.8). LS was also associated with Crohn´s disease (OR = 2.0; 95% CI 1.6-2.6) and diabetes mellitus type 1 (OR = 1.9; 95% CI 1.6-2.1). The present study revealed novel important data regarding the association of LS with cancer and autoimmune diseases, emphasising the importance of sufficient treatment and follow-up of patients with LS. However, future studies are needed to confirm these results and the potential role of LS in the development of cancer.

Patterns of pediatric and adolescent female genital inflammation in China: an eight-year retrospective study of 49,175 patients in China

Background

Genital inflammation is one of the most frequent clinical complaints among girls, which was easily overlooked by the general public. This study aimed to investigate the patterns and epidemiological characteristics of pediatric and adolescent female genital inflammation in China.

Methods

A retrospective observational study (2011 to 2018) was conducted among all female patients under the age of 0-18 years at the Department of Pediatric and Adolescent Gynecology of The Children's Hospital, Zhejiang University School of Medicine. Data were collected from the electronic medical records. The abnormal vaginal discharge of patient was collected for microbiological investigation by bacterial and fungal culture. Descriptive analysis was conducted to evaluate the genital inflammation pattern and epidemiological characteristics, including age, season, and type of infected pathogens.

Results

A total of 49,175 patients met the eligibility criteria of genital inflammation and 16,320 patients later came to the hospital for follow-up over the study period. The number of first-visit increased gradually from 3,769 in 2011 to 10,155 in 2018. The peak age of the first visit was 0-6 years old. Non-specific vulvovaginitis, lichen sclerosis, and labial adhesion were the top three genital inflammation. Among the top five potential common pathogens of vaginal infection, the prevalence of Haemophilus influenzae cases was the highest (31.42%, 203/646), followed by Streptococcus pyogenes (27.74%, 176/646), Candida albicans (14.09%, 91/646), Escherichia coli (8.51%, 55/646), and Staphylococcus aureus (6.35%, 41/636). The specific disease categories and pathogens of genital inflammation vary by age groups and season.

Conclusion

Our study summarizes the pattern of pediatric and adolescent female genital inflammation over an 8-year period in China, emphasizing the need for more public awareness, healthcare services and research in this field.

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.

Risk of Lichen Sclerosus and Lichen Planus in Patients Receiving Immune Checkpoint Inhibitors

INTRODUCTION

Immune checkpoint inhibitors (ICIs) are recommended for various types of cancer. On the other hand, these ICIs may cause immune-related adverse events (irAEs). Lichen sclerosus (LS) and lichen planus (LP) are two distinct phenotypes of irAEs that occur in a subset of patients treated with ICIs. These adverse effects have a detrimental effect on the patient's quality of life and treatment phases; however, the clinical evaluation and assessment of LS and LP remain uncertain. This study aims to assess and evaluate the risk of LS and LP associated with the use of ICIs via a systematic review of the literature and the USA FDA Adverse Events FAERS database.

METHOD

The study searched electronic databases such as PubMed, Medline, Cochrane, and Google Scholar for case reports on immune-checkpoint-inhibitor-associated lichen sclerosus and lichen planus published in English between inception and 31 December 2021. The FDA's adverse event reporting system (FAERS) database was also analyzed.

RESULTS

Thirty-eight case reports and two retrospective studies with a total of 101 patients, in addition to the FAERS data, were evaluated. More cases involved lichen planus (78.9%) than lichen sclerosis (21%). Nivolumab and pembrolizumab were most frequently reported with LS and LP, among other ICIs. Thirty-six out of thirty-eight patients with LS or LP experienced complete remission, while two patients experienced partial remission. Most of the cases had an excellent response to corticosteroids (92.1%), while the remainder had moderate (5.2%) and poor (2.6%) responses. Additionally, the reporting odds ratio (ROR) of the FAERS database indicated a favorable association for ICIs, the risk of LP, and LS. A stronger association was uniquely found between nivolumab and pembrolizumab.

CONCLUSION

There have been published case reports for these adverse events. Healthcare providers should be aware of the possibility of lichen sclerosis and lichen planus developing in patients receiving ICIs which could necessitate hospitalization or discontinuation. Regulatory agencies are advised to monitor the risks as a potential safety signal.

Living with vulval lichen sclerosus: a qualitative interview study

BACKGROUND

Vulval lichen sclerosus (VLS) is a chronic inflammatory condition predominantly affecting the anogenital skin. Symptoms can be distressing and affect quality of life and everyday activities. Very little research has been undertaken to explore the experience of living with VLS from the perspective of people with the condition.

OBJECTIVES

To understand individuals' experiences of VLS and its impact on their lives.

PARTICIPANTS AND METHODS

Semi-structured remote (telephone or video) interviews were conducted with a purposive sample of 20 women living in the UK with VLS recruited via online support groups and social media. Data collection and analysis was informed by social constructionist grounded theory, using a constant comparison method.

RESULTS

We developed three themes to interpret the experience of living with VLS: missed opportunities (participants experienced delayed diagnosis, lack of information and disempowering encounters with healthcare professionals); learning to live with a long-term condition (the amount of work involved in learning how to self-manage the disease and the impact on everyday life); a secret life (experiences of the condition were often shrouded in secrecy, and there was stigma associated with a vulval skin condition resulting in them feeling isolated and lonely).

CONCLUSIONS

Patients attending healthcare appointments with vulval complaints should be examined and LS should be considered as a diagnosis. Healthcare professionals' awareness and knowledge of VLS needs to be improved and they should avoid language which is blaming or minimizing of patients' experiences. VLS is a chronic condition and patients need to be supported in self-management. Support groups may be a source of support and information but can also be challenging when hearing others' difficult experiences. Wider public health educational activities are needed to change societal attitudes towards female genitals and tackle the stigma around vulval conditions. What is already known about this topic? Vulval lichen sclerosus (VLS) can have a profound impact on quality of life and self-identity but is relatively underexplored from the perspective of those living with the condition. What does this study add? In-depth findings about the experiences of living with VLS including ongoing issues with timely diagnosis, learning to live with a long-term condition and the secrecy and stigma about the condition. The needs of women with symptoms of and diagnoses of VLS are not being met sufficiently by the healthcare system. What are the clinical implications of this work? Healthcare professionals should consider addressing knowledge gaps in vulval conditions including VLS to prevent delayed diagnosis and avoid the use of certain terminology which can minimize patients' experiences. Patients with vulval complaints should be examined and LS should be considered as a diagnosis. Regular follow-up would reflect its chronic nature and could provide patients with reassurance and confidence in self-management. Wider public health activities are needed to change societal attitudes and tackle stigma around vulval conditions.

Photodynamic therapy combined with fire needle for a case of bullous lichen sclerosus

In this work, we treated a case of stubborn bullous lichen sclerosus with photodynamic therapy(PDT) combined with fire needle. After 3 sessions of PDT ,pretreated with fire needle, most of the patient's skin lesions subsided and symptoms improved significantly. We found that photodynamic therapy is a potential treatment modality for lichen sclerosus with significant efficacy. Combined with fire needle pretreatment, which may not only promote the transdermal absorption of the drug, but also play a synergistic effect.

Clinical study on multi-focused laser in the treatment of vulvar lichen sclerosus

Objective

To investigate the clinical effect of Multi-focused (MF) laser in the treatment of vulvar lichen sclerosus (VLS).

Methods

In this single-center, randomized controlled trial, we compared the effect of fractionated MF laser with other treatments on patients with biopsy-proven VLS. Patients with VLS were enrolled in this study and randomly divided into three groups. Patients in the experimental group were treated with a CO2 laser, control group 1 was treated with radiofrequency, and control group 2 was treated topically with glucocorticoids and soaking with Chinese patent medicine. The pruritus degree, skin elasticity, skin color, lesion scope, and total score were compared before treatment, at one month after treatment, and three months after treatment.

Results

One month after treatment, the pruritus degree, skin elasticity, skin color, lesion scope, and total score decreased in the experimental group, and the differences were statistically significant (P &lt; 0.05). In control group 1, the differences in pruritus degree, skin color, and total score were statistically significant (P &lt; 0.05), but the differences in skin elasticity and lesion scope were not statistically significant (P &gt; 0.05). In control group 2, the differences in pruritus degree and total score were statistically significant (P &lt; 0.05), but the differences in skin elasticity, skin color, and lesion scope were not statistically significant (P &gt; 0.05). At one month after the end of treatment, the differences in pruritus degree, skin elasticity, skin color, lesion scope, and total score among the three groups were not statistically significant. At three months after the end of treatment, the differences in the scores of the five indicators were statistically significant.

Conclusion

For the three treatment methods for VLS, topical corticosteroids + traditional Chinese medicine can quickly relieve itching symptoms in patients, but it cannot significantly improve skin elasticity, skin color, and lesion scope, and VLS easily relapses after treatment. Radiofrequency can improve itching symptoms and skin color but has poor effects on the change of skin elasticity and lesion scope. Multi-focused laser treatment can alleviate the degree of pruritus, improve skin color and elasticity, and narrow the lesion scope, and VLS will not relapse within three months after treatment.

Does treatment of lichen sclerosus improve overactive bladder symptoms?

INTRODUCTION AND HYPOTHESIS

Lichen sclerosus (LS) is a chronic disease which mainly affects the vulvar area in women. A few studies have shown a possible relationship between LS and overactive bladder (OAB) symptoms, but no studies have investigated whether OAB symptoms improve after initiating treatment of LS. The aim of this study was to investigate whether the treatment of LS also improves OAB symptoms in women newly diagnosed with LS.

METHODS

This was a prospective cohort pilot study based on questionnaires from women newly diagnosed with LS and with symptoms of OAB. Women above the age of 18 who were newly diagnosed with LS were included. The women completed two questionnaires on OAB at inclusion and after 3 months. The questionnaires consisted of the validated questionnaires OAB-q (33 questions, maximum score 198) and ICIQ-OAB (8 questions, maximum score 56). All women initiated treatment with local steroid by the time of the LS diagnosis.

RESULTS

A total of 40 women were included, and 13 women dropped out during the data collection time. Comparing month 0 to month 3 for the remaining 27 women, a mean difference at 28.8 points was observed for OAB-q and a mean difference of 5.7 points was observed for ICIQ-OAB. Both results showed a statistically significant difference after 3 months (p < 0.05). A total of 92.6% (25/27) of the women improved their symptoms.

CONCLUSION

Treatment with local steroid might improve OAB symptoms in women newly diagnosed with LS.

Transcriptional Activity of Some Genes Involved in Apoptosis in Patients with Vulvar Lichen Sclerosus

Lichen sclerosus of the vulva is a common, but poorly studied disease. We assessed the level of transcriptional activity of APAF1, BAX, BCL2, BIRC5, CCND1, DAPK1, MCL1, and MYC genes encoding products that control apoptosis in the samples of tissues affected by vulvar lichen sclerosus and adjacent control tissues (n=24). Analysis of transcriptional activity was performed by real-time PCR using specific primers and SYBR Green intercalating dye. After the total group was divided by the presence of the concomitant gynecological diseases, a significant increase in the transcriptional activity of the CCND1 gene was revealed in patients with concomitant uterine fibroids. This may indicate the possible role of the activation of mitosis during tumor initiation.

Influence of Photodynamic Therapy on Lichen Sclerosus with Neoplastic Background

Background: Lichen sclerosus is the most common nonmalignant vulvar disease with morbidity in postmenopausal age. The first line of treatment is corticosteroid therapy. In case of insufficiency, tacrolimus or pimecrolimus can be provided. Photodynamic therapy (PDT) can be used as alternative way of treatment while symptoms recurrent despite other methods. Methods: the analyzed population of 182 women with diagnosis of lichen sclerosus treated using PDT was divided into three groups: patients with neoplastic disease or intraepithelial neoplasia; those with a positive family history of neoplastic disease; and a control group with no neoplastic disease and no familial history of neoplastic diseases. Results: Reduction of vulvar changes was assessed in the whole vulva in the groups as 21.9%, 21.2% and 21.8%, respectively. The most frequent symptom, itching, was reported to decrease in all groups, 39.3%, 35.5% and 42.5%, respectively. Improvement of quality of life was assessed in 91.3% of the whole group, stabilization of lichen sclerosus in 7.1% and progression in 1.6%. Conclusions: Photodynamic therapy gives positive results in most cases. Improvement after PDT is observed in objective vulvoscopic assessment and in subjective patients’ opinions. Neoplastic disease in the past can influence the effectiveness of PDT.

Effects of Fractional CO2 Laser Treatment on Patients Affected by Vulvar Lichen Sclerosus: A Prospective Study

Background: Fractional carbon dioxide (CO₂) lasers are today considered the most effective and efficient treatment for many vulvovaginal disorders, providing mini-invasive procedures without side effects. Previous studies demonstrated the efficacy of fractional CO₂ lasers in vulvar lichen sclerosus (VLS), a chronic skin disorder characterized by itching and painful lesions. Complications include pain, sexual and/or urinary dysfunction, with a negative quality of life, and an increased risk of squamous cell carcinoma. A definitive VLS treatment is still lacking. Objectives: This is a prospective, single-center study aimed at evaluating the effect of fractional microablative CO₂ laser treatment on women affected by VLS. Materials and methods: Patients with histologically confirmed VLS underwent three fractional microablative CO₂ laser treatments, 4 weeks apart, on the genital affected areas. Clinical and VLS-related symptoms, side effects, and patient satisfaction index were assessed and recorded for all the patients using the visual analog scale (VAS). Results: Data from a total of 70 patients were included, paired at different time points and analyzed. VLS-related symptoms and other relevant parameters (pH, vaginal introitus discomfort, dyspareunia, vaginal dryness, itching, and burning) showed a statistically significant improvement (p < 0.001) after the first laser treatment and kept improving after second and third sessions. According to VAS, the two most common symptoms, vaginal introitus discomfort and dyspareunia, went from (mean ± standard deviation) 8.2 ± 2.3 and 8.3 ± 2.2, respectively, at baseline, to 3.6 ± 2.6 and 3.8 ± 2.6, respectively, 1 month after the last treatment. Vaginal dryness, itching, and burning were significantly improved as well. Most patients declared to be very satisfied with the results of the treatment. A total of 62.8% of the women expressed a satisfaction score ≥8 on a scale from 0 to 10. Conclusions: Fractional microablative CO₂ laser treatment seems to be safe and effective to treat VLS and improve VLS-related symptoms.

Photodynamic Therapy in the Treatment of Vulvar Lichen Sclerosus: A Systematic Review of the Literature

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disease involving the genital skin and mucous membrane. Patients exhibit focal atrophy and destructive scarring, with an increased risk of malignant transformation. Due to objective symptoms as well as subjective complaints, patients with VLS experience emotional distress, lowered mood, and sexual dysfunction, which is reflected in impaired health-related quality of life. Thus, the necessity of implementing appropriate therapy at the earliest possible stage of the disease in order to avoid serious complications is highlighted. We presented the systematic review of available literature, performed with MEDLINE, Cinahl, Central, Scopus, and Web of Science databases. We identified a total of twenty relevant studies which indicate that photodynamic therapy (PDT) is a valuable therapeutic modality in the treatment of VLS.

Fractional CO2 laser treatment as adjunctive therapy to topical steroids for managing vulvar lichen sclerosus

Objectives

Uncontrolled vulvar lichen sclerosus (VLS) is often associated with distressful symptoms of genital itch, irritation, and pain and can lead to a pathological process including anatomical changes, scarring, and an elevated risk of cancer in the genital area. First‐line topical corticosteroid as monotherapy is frequently not adequate to fully suppress disease activity and control symptoms. This study evaluated the efficacy of fractional CO₂ laser treatments as adjunctive therapy where recalcitrant VLS had been improved, but not adequately controlled, with topical corticosteroid treatment. Outcomes were evaluated up to 12 months after a series of CO₂ laser treatments delivered via a fractional handpiece.

Materials and Methods

Women with a diagnosis of VLS supported by histologic findings on biopsy and/or clinical signs on physical examination received up to five monthly laser treatments. Subjects maintained existing topical corticosteroid and any exogenous hormone treatment during the study. Investigators assessed severity (0 = not present, 1 = mild, 2 = moderate, or 3 = severe) of clinical signs and architectural changes present before adjunctive study interventions and at follow‐up visits. Subjects reported the presence of clinical symptoms and impact on quality of life on 4‐ or 5‐point Likert scales. The validated Female Sexual Function Index (FSFI) was used to assess changes in sexual function. Four subjects were biopsied before adjunctive laser treatment and at follow‐up.

Results

Twelve females, 11 postmenopausal, with a mean age of 57 ± 10 years received three to five monthly CO₂ laser treatments. Significant improvement in all prominent clinical signs and architectural changes were reported at the 3‐ and 6‐month follow‐ups after the treatment series. Significant improvement was maintained at the 12‐month follow‐up, with 89% of subjects showing at least one‐point improvement in elasticity compared to baseline; 86% in lichenification; 88% in sclerosis; and 80% in whitening and parchment‐like skin. Labial fusion and the extent of disease improved in 50% of patients. Ulcerations present in three subjects at baseline resolved after treatment. Subjects reported 86% improvement in dyspareunia and 83% in skin tearing. Quality of life improved significantly after treatment (p < 0.01). The 6‐month follow‐up FSFI showed significant improvement in sexual function compared to baseline (p < 0.05), with a mean point improvement of 4.5. Histology findings after treatment showed some positive improvement, as a decrease in dermal hyalinized zone thickness. There were no treatment complications or adverse events related to the treatment.

Conclusions

Fractional CO₂ laser treatment outcomes showed improvement in predominant clinical signs and architectural changes in VLS recalcitrant to topical corticosteroid treatment. Adjunctive laser treatment relieved symptoms and improved quality of life as well as sexual function. Fractional CO₂ laser treatment may provide an advanced treatment modality for the management of recalcitrant VLS with improved patient care and sustainable outcomes. Further study in a larger population and with CO₂ laser treatment to both vulvar tissue and the vaginal canal should be explored.

Lichen sclerosus of the vulva

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.

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.

Treatment Options in Vulvar Lichen Sclerosus: A Scoping Review

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. The aim of this review is to focus on first-line, second-line, and maintenance therapies as well as follow-up of women with VLS. With numerous controversies, we decided to conduct a scoping review on this subject. A review protocol was developed, and the Knowledge Resource Services website was used to run a search of articles pertaining to VLS with keywords "Vulvar," "Vulval," and "Lichen Sclerosus." The search was limited to published data from the last 10 years, i.e., July 2009 onward, and researches published in English language. A total of 338 articles pertaining to VLS were obtained. Out of this, 62 were original articles related to management of VLS. Effective treatments such as high-potency topical steroids are now the standard of care and first-line treatment. Follow-up may be done every three to six months for the first two years and then at least yearly to ensure adequacy of treatment and encourage compliance. Long-term follow-up in specialist clinics is recommended for women who have persistent complaints, thickened skin, or history of neoplastic lesion. Monitoring young patients yearly is recommended as there are chances of recurrence.

Vulvar lichen sclerosus in women of reproductive age

Vulvar lichen sclerosus (vLS) is an inflammatory skin condition that predominantly affects the vulvar and perianal regions. Approximately 50% of cases present prior to menopause; however, there is a paucity of data on vLS in women of reproductive age as well as during their pregnancies. A retrospective review was performed at two tertiary referral centers to better describe cases of vLS in women of reproductive age. Thirty-three patients with a mean age of 40 years met inclusion criteria. In this group, vulvar pruritus was the most common presenting symptom (52%); 61% had biopsy-proven vLS, 42% had at least one autoimmune condition, 21% had comorbid depression or anxiety, 33% were given an incorrect diagnosis prior to vLS, and 42% had documented nonadherence to topical steroids. Among the eight patients who became pregnant, four had cesarean deliveries and 63% were symptomatic during pregnancy. When treating a woman who presents with vulvar pruritus or skin changes, vLS should be considered.

Microablative fractional radiofrequency as a therapeutic option for vulvar lichen sclerosus: a pilot study

OBJECTIVES

To assess the clinical response to and the histomorphometric effects of microablative fractional radiofrequency (MFR) in women with symptomatic vulvar lichen sclerosus (VLS).

METHODS

This was a pilot study on the use of MFR for the treatment of VLS. Upon recruitment and at each treatment session, all participants were examined and each of their symptoms were rated on a visual analog scale. After the procedure, the participants completed a satisfaction questionnaire. We compared the morphometric findings of vulvar biopsies performed at enrollment and after the last treatment session. The participants were divided into three groups according to previous treatment with corticosteroids: G1, no previous treatment; G2, treated for up to 5 years; and G3, treated for >5 years.

RESULTS

This study included 26 women. After two to three sessions, most participants in all groups became either "asymptomatic" or "much better" than before treatment and were "very satisfied" or "satisfied" with the intervention. Pruritus and burning sensation were the most frequently reported symptoms. Nearly 40% of the participants in all groups reported complete remission of symptoms. The improvement was rated as moderate or higher by 80%, 76%, and 66% of the women in groups 1, 2, and 3, respectively. The improvement of symptoms persisted for 11 months (range, 7-16 months), on average, after the treatment. Type III collagen concentration significantly increased and was associated with important symptom improvement. Tissue trophism and vascularization also increased but did not reach statistical significance, probably because of the small number of cases.

CONCLUSIONS

MFR may be an effective and safe treatment for symptomatic VLS.

Cold Atmospheric Pressure Plasma (CAP) as a New Tool for the Management of Vulva Cancer and Vulvar Premalignant Lesions in Gynaecological Oncology

Vulvar cancer (VC) is a specific form of malignancy accounting for 5–6% of all gynaecologic malignancies. Although VC occurs most commonly in women after 60 years of age, disease incidence has risen progressively in premenopausal women in recent decades. VC demonstrates particular features requiring well-adapted therapeutic approaches to avoid potential treatment-related complications. Significant improvements in disease-free survival and overall survival rates for patients diagnosed with post-stage I disease have been achieved by implementing a combination therapy consisting of radical surgical resection, systemic chemotherapy and/or radiotherapy. Achieving local control remains challenging. However, mostly due to specific anatomical conditions, the need for comprehensive surgical reconstruction and frequent post-operative healing complications. Novel therapeutic tools better adapted to VC particularities are essential for improving individual outcomes. To this end, cold atmospheric plasma (CAP) treatment is a promising option for VC, and is particularly appropriate for the local treatment of dysplastic lesions, early intraepithelial cancer, and invasive tumours. In addition, CAP also helps reduce inflammatory complications and improve wound healing. The application of CAP may realise either directly or indirectly utilising nanoparticle technologies. CAP has demonstrated remarkable treatment benefits for several malignant conditions, and has created new medical fields, such as “plasma medicine” and “plasma oncology”. This article highlights the benefits of CAP for the treatment of VC, VC pre-stages, and postsurgical wound complications. There has not yet been a published report of CAP on vulvar cancer cells, and so this review summarises the progress made in gynaecological oncology and in other cancers, and promotes an important, understudied area for future research. The paradigm shift from reactive to predictive, preventive and personalised medical approaches in overall VC management is also considered.

Putative precancerous lesions of vulvar squamous cell carcinoma

Precursor lesions of vulvar squamous cell carcinoma (VSCC) can be divided into two major biologic and prognostic groups: HPV-associated and HPV-independent VSCC. These two pathways are categorized as usual vulvar intraepithelial neoplasia (uVIN) with progression to basaloid or warty VSCC and differentiated vulvar intraepithelial neoplasia (dVIN) with progression to the more common keratinizing VSCC. While the HPV-dependent pathway to squamous cell carcinoma is well-understood, the development of squamous cell carcinoma from HPV-independent lesions is less clear. The majority of HPV-independent lesions fall into the dVIN category, and mutations in TP53 have been implicated as the driver behind their development. Other less common HPV-independent precursor lesions, termed differentiated exophytic vulvar intraepithelial lesion (DEVIL) and vulvar acanthosis with altered differentiation (VAAD), have also been characterized as precursors to keratinizing and verrucous VSCC. Inflammatory conditions of the vulva such as lichen sclerosus and lichen simplex chronicus also put patients at risk for developing VSCC. We herein evaluate the available evidence and biologic basis for these VSCC precursor lesions, among other speculated entities, and discuss their clinical, diagnostic, and prognostic features.