Lichen Sclerosus

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Effective treatment of lichen sclerosus will control symptoms, minimize scarring, and allow for early detection of malignant change. As a result of compelling data from clinical trials, treatment recommendations have changed recently. The current recommended and accepted treatment for all forms of lichen sclerosus is the potent topical corticosteroid ointment, clobetasol propionate (19,20). One RCT comparing clobetasol, testosterone, progesterone, and petroleum jelly showed higher rates of symptom control with clobetasol (75%) (21). Clobetasol 0.05% gel or cream provides rapid symptomatic improvement in over 90% of women treated. It also reverses some of the histological changes and is effective in long-term disease control. The medication should be applied once daily (22), and treatment typically lasts two to three months. The dose should be tapered gradually and then used only when symptoms recur, typically fewer than once or twice per week. There is some evidence that lichen sclerosus of the vulva may be treated with long-term maintenance therapy (23). The patient should be advised that this therapy is not curative and recurrence is likely.

If lesions recur, re-treatment may be necessary. Potential side effects include cutaneous atrophy or adrenal suppression but, in practice, these complications are rare. There is anectodal suggestion that intralesional injections of triamcli-none every three to six months may be appropriate alternative therapy (24).

In the past, androgens and progesterones have been used widely. Andro-genic side effects are common and include clitoral enlargement, hirsutism, amenorrhoea, increased libido, and voice changes (25). Side effects of progesterone include changes in vaginal discharge. Placebo-controlled trials have demonstrated that testosterone (26) is no more effective in the treatment of lichen sclerosus. Clinical trials have also indicated that prednisolone is not an effective treatment (27).

Surgical therapies, such as excision followed by skin grafting, vaginoplasty, and vulvectomy, have been used for treatment of lichen sclerosus; however, there are no data proving their effectiveness. Surgical treatments are associated with a recurrence rate and surgery is not currently recommended in the absence of vulvar intraepithelial neoplasia (VIN) or malignancy (27). In contrast, surgical intervention is always necessary in the case of lichen sclerosus complicated by malignant disease. In severe cases, with extensive Assuring and scar formation, surgical correction may be considered. Topical steroids post-operatively may help prevent recurrence. Other ablation techniques include cryotherapy (28) and laser therapy (29). These have not been investigated, recurrence rates are high, and there can be significant post-procedural discomfort, resulting in limited use of these therapeutic modalities.

Photodynamic therapy (PDT) with topical 5-aminolaevulinic acid and argon laser light has been reported to result in clinical improvement (30).

Several studies (31,32), including a placebo-controlled trial (31), showed some efficacy of systemic retinoids for treatment of lichen sclerosus; however, there are many intolerable and potentially harmful side effects. There is no evidence demonstrating the effectiveness of topical retinoids and clinical use is unlikely because these drugs cause severe skin irritation.

Case studies have demonstrated the efficacy of treating anogenital lichen sclerosus with low-dose PUVA (33), as well as with PUVA cream photoche-motherapy (34). It has been postulated that radiation suppresses collagen synthesis and induces collagenase activity, leading to softening of sclerotic skin plaques.

Tacrolimus is also a promising agent for treating lichen sclerosus. There have been multiple RCTs indicating the efficacy of this drug in generalized disease. Case reports demonstrate treatment success specifically with genital lesions (35,36); however, further investigation is necessary at this time.

Lifetime risk of developing squamous cell carcinoma in the affected area is approximately 4% (37). At the minimum, patients should have yearly follow-up to monitor for malignancy. Clinicians should advise patients to return sooner if they notice any growth or ulceration. Any erosions, ulcers, and hyperkeratotic or erythematous areas should be evaluated with biopsy.

There is debate as to whether asymptomatic patients should be treated and this decision should be based on each individual case. Treatment may prevent disease progression and, possibly, malignant transformation. This, however, must be considered in the context of the multiple disadvantages to long-term therapy. Regardless of treatment decision, all patients should have long-term follow-up.

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