The "CIV Classification," a New Proposal for the Architectural Grading of Vulvar Lichen Sclerosus

Expert opinion on characteristics of vulval lichen sclerosus: initial identification of important clinical features through an international electronic Delphi consensus study

BACKGROUND

Lichen sclerosus (LS) is a chronic inflammatory condition that mainly affects genital skin. It causes distressing symptoms that impact daily quality of life, as well as progressive anatomical changes and a potential risk of cancer. Vulval LS is often misdiagnosed and treatment delayed. If nonexperts can be supported to identify clinical features of LS, they may diagnose the condition sooner and commence timely treatment or refer a patient for assessment and confirmatory biopsy.

OBJECTIVES

To reach international expert consensus on clinical diagnostic features for vulval LS.

METHODS

Between March and May 2023, a four-stage electronic Delphi consensus exercise was conducted. In the first three rounds, participants were asked to rate the importance of a list of clinical features. Responses from round 1 were summarized and presented in rounds 2 and 3, along with additional features suggested by participants. Any items rated as 'very important/critical' or 'not important' that met the definition of consensus were removed from subsequent rounds. In round 4, items that were rated 'important but not critical' were ranked in order of their importance. Consensus was defined a priori, and all rounds were conducted anonymously.

RESULTS

In total, 47 participants from 14 countries completed round 1, with 42 (89%) retained by round 3 when consensus was determined. Round 4 was completed by 36 (77%) participants. Participants completing all four rounds predominantly included healthcare professionals (n = 28/36; 78%) and patient support group representatives (n = 7/36; 19%). In round 1, 21 diagnostic features were rated. Participants suggested an additional 10 features, which were subsequently added to the round 2 survey. After three rounds, consensus was achieved for five diagnostic features: whiteness, itch, changes in anatomy, burying of the clitoral area and improvement in response to topical steroids. There were also 12 features rated as 'important but not critical' and participants subsequently ranked them in the fourth round.

CONCLUSIONS

Experts agreed on 5 critical diagnostic features for vulval LS in adults and an additional 12 features that may also be important. Future research should assess these clinical features for diagnostic validity through a multicentre diagnostic test accuracy study.

A systematic review of outcome measures evaluating treatment efficacy in vulval lichen sclerosus and evaluation of patients' priorities

Vulval lichen sclerosus (VLS) is an inflammatory skin disease characterised by itching, apareunia, loss of vulval architecture and scarring. Heterogeneity in outcome reporting precludes comparison between treatments. This study aimed to systematically review outcome measures used to evaluate the efficacy of VLS treatments and present patients' treatment priorities. This review followed the PRISMA guidelines using a registered protocol (PROSPERO: CRD42022356738). Multiple databases were searched, along with grey literature on Clinicaltrials.gov, European Union Clinical Trials and International Standard Randomised controlled trial (RCT) registries. All RCTs assessing any treatment for VLS were eligible for inclusion. A total of 775 patients were assessed across 21 RCTs. The assessment tools reported outcomes in the following domains: patient-reported symptoms assessed with one validated scale in 12 studies and seven non-validated scales in nine studies; sexual function with validated female sexual function index and female sexual distress scale in two studies and two non-validated scales in two studies; quality of life with three validated scales in three studies and clinician-reported objective outcomes with two validated scales in three studies and six non-validated scales in fourteen studies. Histological changes were assessed in 10 studies and tissue biomechanics in one study. We also carried out an online survey completed by 809 women with VLS to assess their research and disease treatment priorities and identified validated outcome measures to assess these. There is high variability in assessing treatment outcomes for VLS. We identified validated assessment tools which could be implemented in VLS studies to evaluate the effectiveness of treatments.

Treatment-induced anogenital melanosis is a very frequent finding in patients with vulvar lichen sclerosus

Background

Pigmented lesions such as melanosis have rarely been reported in patients with vulvar lichen sclerosus (VLS) that is typically characterized by hypopigmented lesions.

Objective

We aimed to analyze systematically anogenital melanosis in a large cohort of VLS patients.

Methods

We analyzed the clinical data of 198 female patients with VLS. The anogenital lesions of all patients were professionally photographed in a standardized position and illumination. Severity classification of architectural findings followed an easy-to-use clinical score. A modified Melasma Area and Severity Index and an image analysis software were used to evaluate the area and intensity of pigmentation.

Results

According to the clinical score, 79 (198/39.9%) patients showed grade 1 disease, 78 (198/39.4%) grade 2, 37 (198/18.7%) grade 3, and 4 (198/2%) grade 4 disease. About 111 (56.1%) of the 198 patients had anogenital melanosis with a median modified Melasma Area and Severity Index of 3.6 (0.4-14). Univariate analysis revealed that anogenital melanosis was positively correlated with the use of topical estrogens (P = .0018) and negatively correlated with the use of pulsed high-dose corticosteroids plus low-dose methotrexate (PHDC-LDM, P = .021). On multivariable analysis, the use of topical hormone therapy turned out to be a strong independent predictor for the presence of anogenital melanosis (odds ratio: 4.57, 95% confidence interval: 1.66-12.57, P = .0033), whereas PHDC-LDM use was an independent predictor for the absence of anogenital melanosis (odds ratio: 0.35, 95% confidence interval: 0.15-0.84, P = .018).

Limitations

The study includes the retrospective monocentric design.

Conclusion

Anogenital melanosis is a very frequent and so far, under-reported clinical finding in VLS patients. It is likely caused by the use of topical estrogens employed for VLS treatment. In contrast, patients with more severe disease and PHDC-LDM treatment appear to develop less likely anogenital melanosis.

Outcome Measures in Adult Vulvar Lichen Sclerosus: A Systematic Review

OBJECTIVES

Core outcome domains (CODs) for treatment of adult vulvar lichen sclerosus (VLS) have recently been established through a Delphi study. A number of measuring tools are available for evaluating VLS. The aim of this study is to identify available standardized measurement tools for the major CODs for VLS that have recently been defined, namely, physical findings and quality of life (QoL) specific to VLS.

MATERIALS AND METHODS

A systematic search through September 8, 2023, for measuring tools applicable to VLS regarding physical findings and QoL including sexual function or sexual well-being and self-image was performed.

RESULTS

Thirty-five studies were included in the systematic review describing 26 tools covering the following 6 outcome domains: QoL-general health, QoL-lichen sclerosus specific, symptoms, clinical signs, emotional impact, and sexual functioning.

CONCLUSIONS

In current research, there is no uniformity in use of measurement tools for evaluating VLS. The established CODs to evaluate treatment of VLS are applicable for evaluating disease course as well. A comprehensive study to reach consensus regarding measurement of physical findings, QoL-lichen sclerosus specific, sexuality, and self-image taking the predetermined CODs and other factors such as age into account is needed.

Is there a role for platelet rich plasma injection in vulvar lichen sclerosus? A self-controlled pilot study

BACKGROUND

Owing to the evidence that as many as 30-40% of patients with vulvar lichen sclerosus (VLS) fail to report a remission of symptoms with first-line corticosteroid treatment (TCS), especially as what regards dyspareunia, we aimed to analyze patients' satisfaction following vulvar injection of autologous platelet-rich plasma (PRP). This is intended as an adjunctive treatment, to be used following TCS, and appears to promote tissue repair. It may also possibly have immunomodulatory proprieties.

MATERIALS AND METHODS

Patients with VLS were considered eligible for this pilot study if, despite having been treated with a 3-month TCS regimen, they reported a persistence of symptoms. PRP was produced in a referral center using a manual method and a standardized protocol. Each patient received three treatments 4 to 6 weeks apart.

RESULTS

A total of 50 patients with a median age of 53 years [IQR 38-59 years] were included in the study. 6 months after the last injection of PRP all patients were either satisfied or very satisfied with the treatment (100%; 95% CI 93-100%). Median NRS scores for itching, burning, dyspareunia and dysuria were significantly reduced (p < 0.05) and FSFI, HADS and SF-12 questionnaires revealed a significant improvement in sexual function, psychological wellbeing and quality of life (p < 0.05). The number of patients reporting the need for maintenance TCS treatment was reduced by 42% (p < 0.001) and an improvement in vulvar elasticity and color was reported in all patients.

CONCLUSION

Following standard medical therapy, PRP may be effective not only in improving symptoms, but also in restoring function.

Fat Grafting in Vulvar Lichen Sclerosus: Long Term Follow-Up

OBJECTIVE

The rationale for the use of autologous fat grafting in the treatment of vulvar lichen sclerosus (VLS) consists in reduction of inflammation, regeneration of tissues, volume increase, and pain fiber control. The main outcome of this study was the evaluation of patients' satisfaction after treatment. Secondary outcomes included modifications in symptoms, psychosexual wellbeing, vulvar hydration, and histology after surgery.

METHODS

Eligible for this study were women aged 18-85 years with a histological diagnosis of VLS who underwent at least one autologous vulvar fat grafting at the authors' center, between 2010 and 2019. In 2021, all women underwent a clinical reevaluation, comprehensive of vulvoscopy, vulvar biopsy, and handing out of validated questionnaires.

RESULTS

Overall, 88.7% of patients declared themselves very satisfied/satisfied with the procedure. All symptoms were improved postsurgery; in particular, the difference was statistically significant for pruritus, burning, and dyspareunia ( p < .05). Sexual function was also improved at time of reevaluation, as were depressive and anxiety symptoms ( p < .05). No cases of vulvar intraepithelial neoplasia or cancer occurred during follow-up and vulvar architecture remained stable, although patients reported a significantly reduced need for topical steroids ( p < .0001). Lastly, in postoperative biopsies, inflammatory infiltrate was stable or reduced, and the distribution of elastic fibers was comparable or restored in most patients.

CONCLUSIONS

Patient satisfaction with fat grafting is detectable up to 11 years after surgery, and as such, it may represent a valid therapeutic option in selected cases of VLS.