The efficacy and safety of deucravacitinib compared to methotrexate, in patients with vulvar lichen planus who have failed topical therapy with potent corticosteroids: a study protocol for a single-centre double-blinded randomised controlled trial

BACKGROUND

Vulvar lichen planus (VLP) is a chronic vulvar dermatosis that is difficult to treat and can severely impair quality of life in the absence of adequate treatment. There is a lack of high-quality evidence to direct therapy for VLP. This randomised controlled trial will be the first double-blinded study comparing systemic treatments in VLP and aims to investigate the safety and efficacy of deucravacitinib compared to methotrexate, in patients with VLP who have failed treatment with potent topical corticosteroids.

METHODS

A total of 116 women aged ≥ 18 years with moderate to severe VLP (Genital Erosive Lichen Planus (GELP) score ≥ 5) will be recruited. All participants will initially be treated with Diprosone® OV daily, and their outcome will be assessed using the GELP score. At 8 weeks' follow-up, responders (GELP < 5) will be continued on Diprosone® OV. Non-responders (GELP ≥ 5) will be randomised 1:1 in a blinded fashion to receive (i) methotrexate 10 mg weekly + placebo tablet twice daily + folic acid 5 mg weekly or (ii) deucravacitinib 6 mg twice daily + placebo tablet weekly + folic acid 5 mg weekly. The primary endpoint is the difference in the mean change of GELP scores from baseline to week 32 between deucravacitinib and methotrexate groups.

DISCUSSION

High-quality evidence guiding the management of women with VLP is lacking. Once completed, this will be the first double-blinded RCT to compare systemic treatments in VLP. The results of this study will provide valuable, high-quality data to guide second-line therapy options for VLP that is recalcitrant to potent topical corticosteroids.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12623000682640. Registered on 26 June 2023.

Evaluation of genital self-image and sexual dysfunction in women with vulvar lichen planus or lichen sclerosus

INTRODUCTION

Vulvar lichen planus (LP) and vulvar lichen sclerosus (LS) are chronic inflammatory diseases that affect women's sexual health. In this study, our aim was to investigate sexual function, anxiety level and genital self-image in vulvar LP and vulvar LS patients.

METHODS

This study was conducted on a total of 178 women who presented to the gynecology clinic between February 2019 and January 2020. The patients were divided into the following groups: group 1, vulvar LP (n = 21); group 2, vulvar LS (n = 59); group 3, fungal vulvitis controls (n = 48); and group 4, healthy controls (n = 50). The validated Female Sexual Function Index (FSFI), Beck Anxiety Index (BAI), and Female Genital Self-Image Scale (FGSIS) questionnaires were assessed in all women.

RESULTS

There were no significant differences among the groups with respect to age, parity, menopausal status, body mass index (BMI), vaginal intercourse past 1 month, marital status or educational status (p > .05). There were statistically significant differences between the vulvar LP and vulvar LS groups compared to control groups in terms of FSFI total scores and subscores (p < .001). When FGSIS and BAI scores were analyzed, significant statistical differences were found among the study groups (p < .001). A positive correlation was found between the FSFI and FGSIS scores in patients with vulvar LP and LS. Additionally, a negative correlation was found between the FSFI and BAI scores in patients with vulvar LP and LS.

CONCLUSIONS

Our study showed that sexual function, genital self-image and anxiety level were associated in vulvar LP and vulvar LS patients. Vulvar LP and vulvar LS patients with worse genital self-image have more sexual problems and anxious conditions.

Meet the expert: Topical management of vulvar dermatoses

Vulvar dermatoses are often debilitating chronic skin conditions associated with pain and pruritus. In oncologic patients, cancer treatments can precipitate and exacerbate vulvar dermatoses. Cytotoxic chemotherapy, hormonal therapies, and local pelvic radiation therapy can lead to vulvar symptoms, and cancer treatment-induced vulvar conditions include graft-versus-host-disease and radiation dermatitis. There have also been reports of lichen sclerosus development or exacerbation secondary to hormonal therapy and immune checkpoint inhibitors, attributed to proposed hormonal and immunologic pathogenesis of lichen sclerosus. Early recognition and treatment of these conditions can significantly improve quality of life. In this review, we summarize the clinical features and management characteristics of six types of common vulvar dermatoses that may present in the oncologic patient.

Total acquired vulval synechia: an unusual presentation

An unusual case of Acquired Total vulval synechia due to vulvar Lichen planus is reported in an 18-year-old girl, which is an extremely rare condition. It has a potential for producing extensive scarring and narrowing of introitus resulting in dyspareunia and rarely carcinoma of vulva. Successful surgical management of total vulvar synechiae in patient suffering from Lichen Planus is being reported.