Management of vulvar lichen sclerosus

The major treatment goals are resolution of symptoms (eg, pruritus, pain) and signs of active disease (eg, fissuring, ecchymoses, scale/hyperkeratosis). Improvement in skin atrophy and hypopigmentation varies. Existing atrophic anatomical changes and scarring do not improve with medical treatment. Disabling or disfiguring adhesions and scarring may improve with surgery and physical therapy.

UVA1: ultraviolet A1; PDT: photodynamic therapy.

* For most patients, we prescribe once-nightly application of the topical corticosteroid. Refer to UpToDate content on the management of vulvar lichen sclerosus for alternative regimens.

¶ Supplemental, targeted intralesional corticosteroid injections may be helpful for thick, hypertrophic plaques because topical corticosteroids may not penetrate adequately. The possibility of vulvar squamous cell carcinoma should also be considered when thick plaques fail to respond to therapy.

Δ Repeat (or initial) biopsy may be indicated.

◊ We typically continue the same superpotent topical corticosteroid if there was a partial response and switch to a different superpotent topical corticosteroid if there was no sign of response.

§ Efficacy data for these treatments are limited. Refer to UpToDate content on the management of vulvar lichen sclerosus for discussions of these treatments.

¥ Most of our patients continue life-long, twice-weekly topical maintenance therapy. However, some patients with well-controlled disease are able to taper to less-frequent application (eg, once weekly).

‡ Self-examination involves looking for signs of active disease or malignancy. Findings concerning for malignancy include hyperkeratotic plaques, erosions, or ulcers that do not improve with treatment.

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Management of vulvar lichen sclerosus