Vulvar lichen sclerosus:clinical aspects and guideline to management

Lichen sclerosus is the second most frequently encountered non-neoplastic disorder of the vulva. For this reason, gynecologists, dermatologists and primary care physicians should have a good understanding of the disease and its treatment. Most patients present with significant pruritus and, on examination, will be found to have white patches or plaques extending from the vestibule to the labia majora. A wrinkled surface is often present and atrophy, purpura, fissures, erosions and excoriations may be noted. Tissue damage, in the form of absorption of the labia minora and burying of the clitoris, occurs in chronic cases. Lichen sclerosus is an autoimmune disease and as such may be associated with vitiligo, alopecia areata and autoimmune thyroid disease. The two most important conditions to consider in differential diagnosis of the vulvar changes are vitiligo and erosive lichen planus. Women with vulvar lichen sclerosus are at risk for the development of superimposed squamous cell carcinoma and for this reason any thickened area or ulceration that does not heal quickly with therapy should be biopsied. The treatment of choice is the topical application of an ultrapotent topical steroid such as clobetasol proprionate 0.05% ointment. Daily therapy should be carried out for approximately 3 months. At that point, nearly all women will be free of symptoms. Younger patients are also likely to experience noticeable improvement in damaged tissue but this is much less likely to be true in older patients. Relapse is common and most patients will require some level of maintenance therapy. There is no longer any place for the use of topical testosterone ointment in the treatment of vulvar lichen sclerosus.