HOUSTON — Controlling the intense pruritus of vulvar lichen sclerosus is important, not only for patients' quality of life, but also to reduce their risk of developing cancer, according to several experts at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital.
It is estimated that between 3% and 5% of untreated patients with vulvar lichen sclerosus will develop vulvar carcinoma in the following 10–20 years, said Dr. Raymond H. Kaufman, professor emeritus in obstetrics, gynecology, and pathology at Baylor College of Medicine, Houston. That compares to an annual incidence of vulvar carcinoma of 1 in 150,000 (0.0006%) in the general population. “There is an increased risk [in patients with lichen sclerosus], and even though it is small, these patients should be warned,” he said. “Generally, it's the noncompliant patients, or the scratchers, who are most at risk.” In fact, between 50% and 80% of patients with vulvar cancer have a history of lichen sclerosus, he said.
“This condition is itchy, itchy, itchy,” agreed Dr. Libby Edwards, a dermatologist who has a private practice in Charlotte, N.C. Poor control can also result in excoriations and secondary infections in many patients, she said in an interview.
A review by Dr. Kaufman found that in 88% of his patients, the clinical appearance of the vulvar skin was white and crinkled, with thickening of the skin in 38%, fissures in 30%, and phimosis in 23%. “The labia minora may fuse with the labia majora, and the tissue is easily traumatized,” said Dr. Kaufman. “Areas of ecchymosis are very common and can cause anxieties about melanoma.”
Both experts noted that testosterone cream, once thought to be an effective treatment for lichen sclerosus, is now considered no better than placebo. Dr. Kaufman recommends clobetasol ointment 0.05%, twice daily for 2 months, at bedtime for the next 2 months, and then every other day for 2 months—with a maintenance regimen of once or twice weekly or according to symptoms.
Dr. Edwards said she also recommends starting treatment with clobetasol ointment twice daily but reevaluates monthly. “Without monthly follow-up, patients often stop using the medication because their symptoms go away, and I want to monitor them for improvement and possible side effects with this very potent steroid.” When the skin texture becomes normal, she reduces the dosage to once daily three times per week. When patients are on this regimen, she said, follow-up visits are necessary only at 6-month intervals to assess for recurrence, side effects, or signs of cancer.
For those patients who do not respond to clobetasol, Dr. Kaufman recommends Elidel 1% or Protopic 0.1% cream twice a day, but he advises caution because these creams can cause significant vulvar irritation. In such cases, it may be necessary to titrate the dosage down to once a day or even every other day until the patient becomes more comfortable, he said.
Advanced disease can cause loss of the labia minora and scar the clitoral hood. Photos courtesy Dr. Libby Edwards