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In Brief: Vulvar lichen planus is best treated with high-potency creams

In Brief

Vulvar lichen planus is best treated with high-potency creams

Lichen planus is a relatively uncommon inflammatory condition that affects the skin, nails, mouth, and vagina, usually around midlife. One of its most troubling manifestations is erosive lichen planus of the vulva (ELPV), an often painful condition that usually starts with itchy patches on the vulva (the tissues surrounding the vagina and urethra) and in the vagina. With time, scarring develops, causing the labial and clitoral tissues to shrink and the urethral and vaginal openings to narrow. Women frequently have trouble urinating, pain with intercourse, and bleeding after intercourse. No one knows what causes ELPV, though there’s some evidence that an autoimmune mechanism is at work.

There have been few studies of ELPV and no randomized trials of therapies, which has made it difficult for clinicians to advise women about the course of the disease and the best way to treat it. But new research is changing that picture. According to a study in the March 2006 Archives of Dermatology, the best way to relieve or eliminate symptoms is with strong topical corticosteroid drugs, alone or in combination with antifungal or antibacterial preparations. The research also suggests a possible link between ELPV and the development of a form of skin cancer.

In this study, British dermatologists monitored 114 women diagnosed with ELPV for an average of six years. They gathered information about symptoms, diagnosis, and response to various treatments, including surgery, oral medications, and topical corticosteroids. Most of the women were diagnosed with ELPV during perimenopause or postmenopause — on average, about five years after symptoms began. More than half also had lichen planus lesions in the mouth, a condition called vulvovaginal-gingival syndrome.

The most frequently used first-line treatment was 0.05% clobetasol propionate (Temovate), an ultrapotent corticosteroid cream. (Ultrapotent corticosteroid creams are stronger than those used for less-difficult-to-treat skin conditions.) Clinicians usually prescribe twice-daily applications for three months. Of the women who used Temovate, 94% improved and 71% became symptom-free during treatment. A combined product consisting of a high-potency corticosteroid cream with antifungal and antibacterial drugs was at least as effective or more so. On the other hand, oral medications such as methotrexate, cyclosporine, and certain antimalarial drugs were not useful.

Seven women in the study showed precancerous cellular changes, and three developed squamous cell carcinoma (SCC) — in one case, in the mouth; in the other two, in the anogenital area. This is a small number and may be due to chance. But there have been several reports of SCC with lichen planus of the vulva. Studies have also found that SCC is a problem in skin scarred by a similar disorder called lichen sclerosus. It’s not clear whether a delay in treatment leads to such problems or if effective therapy can reduce the risk; further study is clearly needed.

There is no cure for this condition. Even after successful treatment with an ultrapotent corticosteroid cream such as Temovate — others include diflorasone (Maxiflor) and halobetasol (Ultravate) — women with ELPV will need maintenance therapy. This often involves fewer applications of a strong corticosteroid cream and the addition of a lower-potency one. In general, women with vulvar problems should wear cotton underwear, avoid scented detergents and body soaps, and pat dry with a towel after bathing (rather than rub dry or dry with a hair dryer).

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Last updated:	August 21, 2006