MEDICAL TREATMENT :
Topical steroids (eg, medium-strength betamethasone 0.1% ointment) are applied twice daily until symptoms are controlled, usually in 10-14 days. Use episodically as necessary thereafter. If unsuccessful, high-potency steroids (eg, clobetasol 0.05%) can be used in a similar fashion with return to a less potent steroid once a response is obtained.
Topical medium-strength corticosteroids (eg, 0.1% triamcinolone) can be applied twice daily and decreased to once daily when symptoms resolve.
For patients with lichen sclerosus and coexistent squamous hyperplasia, therapy is as for lichen sclerosus. It may occasionally be necessary to excise hyperplastic or fissured areas of lichen sclerosus unresponsive to medical therapy, but patients must realize that recurrence rates after excision are high. This applies even after skin grafting, when lichen sclerosus may recur in the grafted skin.
Difficult cases refractory to the usual therapies require consultation with a dermatologist and, on occasion, a plastic surgeon. Multidisciplinary management is helpful in such patients. For pruritus unresponsive to topical steroids, triamcinolone (Kenalog-10) may be injected locally at 1-cm grids. Because a retinoid has been shown to reduce connective tissue degeneration in lichen sclerosis, these agents are worth considering in resistant cases. Therapy with oral etretinate and tretinoin has been shown to be helpful. In view of adverse drug effects, topical therapy is preferable, and tretinoin has been used locally with good results.
Encouraging results have been reported in small numbers of patients treated with 1% topical pimecrolimus (Elidel) administered twice daily for 3 months. Pimecrolimus is a topical macrolide immunosuppressant that inhibits T-cell activity and is US Food and Drug Administration approved for eczema (Goldstein, 2004).
A preliminary report from China suggested that focused ultrasound therapy may be efficacious and recommended further studies (Li, 2004).
Surgical Care: Surgery is reserved for patients in whom biopsy has identified associated vulvar intraepithelial neoplasia or invasive SCC. When introital stenosis is causing symptoms, vaginoplasty may be indicated. Simple vulvectomy has little or no place in the treatment of this disease because symptoms are not always relieved, signs recur, and cancer returns. The operation has significant physical and psychosexual complications.
DRUG THERAPY : The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Corticosteroids -- Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. Steroid creams are grouped according to anti-inflammatory activity as low- (eg, hydrocortisone 1%), medium-, or high-potency agents. Ointments are indicated for management of thick, chronic dermatitis. Inflamed skin requires lotions or creams.
- HYDROCORTISONE
- CLOBETASOL
- TRIAMCINOLONE
2. HORMONE THERAPY : MAY IMPROVE INFLAMMATORY REACTIONS
- PROGESTERONE