Lichen Planus

Little data support the efficacy of any specific therapy for vulvar lichen planus. Typically, vulvar lesions of lichen planus are treated with a potent topical corticoid cream such as clobetasone. Intralesional corticosteroids are used for refractory disease. Antihistamines are also helpful in treating pruritis. Generally, systemic steroids are reserved for severely symptomatic disease (38); upon discontinuation, oral steroid dosages must be tapered.

There have been reports indicating the value of vaginal suppositories in treatment of this disease (39); 25 mg hydrocortisone suppositories intravaginally twice daily for two months resulted in improvement in 16 of 17 women in one series.

Oral and topical retinoids have proven effective for generalized disease and there have been some reports of success of these agents with vulvar disease (40). However, data are too few to make any conclusive recommendations regarding use of these agents. Additionally, topical retinoids cause significant irritation and may worsen lesions.

Griseofulvin has been reported in one case series to be efficient in managing patients with vulvar disease. However, subsequent study failed to reproduce these results (38). Small studies have shown cyclosporin to be effective in treatment of severe disease (38). Cyclosporine acts by suppressing proliferating T cells and inhibiting lymphokine production. Side effects of this powerful drug can be severe, and include nephrotoxicity. It is essential to monitor the renal function of patients taking this drug every two weeks (16).

Oral or topical dapsone may be effective in chronic, recalcitrant cases. An uncontrolled case series demonstrated the efficacy of the drug, particularly when used in conjunction with oral corticosteroids. The exact mechanism of action is unknown but is believed to be anti-inflammatory, possibly through alterations of neutrophil function (16). Rarely, dapsone has been associated with hemolytic anemia or agranulocytosis. During therapy, complete blood count (CBC) should be measured regularly; most advise monitoring liver and renal function, as well. Before initiating the therapy, a glucose-6-phosphate dehydrogenase (G-6-PD) screen is recommended, as G-6-PD deficiency is a contraindication to drug use.

Recent studies have also shown topical tacrolimus 0.1% ointment to be effective in treating erosive vulvar lichen sclerosus (41). A more recent retrospective series investigating topical tacrolimus therapy demonstrated symptom control and clinical improvement in 94% of patients (42).

There have also been case studies demonstrating the use of PUVA cream phototherapy in genital lichen planus (36). At present, however, data are limited.

Surgical methods of treatment include excision, cryotherapy, and carbon dioxide laser. Blunt dissection may be performed with addition of potent topical steroids in the postoperative period (38).

As with lichen sclerosus, these patients should be monitored regularly because of an increased risk of developing vulvar malignancy (38).

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