Genital verrucous carcinoma is associated with lichen sclerosus: a retrospective study and review of the literature

Cutaneous Verrucous Carcinomas: A Review

Verrucous carcinoma (VC) is a relatively rare locally aggressive, slow-growing, well-differentiated squamous cell carcinoma with minimal metastatic potential and is most frequent in the mucosa. Although rarely reported on the skin, cutaneous verrucous carcinomas (CVC) can appear anywhere, most commonly on the feet. However, clinical and pathologic diagnosis of CVC has been confusing and challenging. It can easily be mistaken for benign or more malignant conditions such as giant condyloma acuminata, keratoacanthoma, and pseudoepithelioma-like hyperplasia or squamous cell carcinoma, resulting in inappropriate management. In this review, we describe the different aspects associated with CVC, including its pathogenesis and clinicopathologic features. The available evidence for the differential diagnosis and treatment of CVC is discussed, and specific management recommendations are made. After the treatment, careful follow-up examinations of the excised area should be performed at regular intervals.

Cutaneous Horn of the Glans

Cutaneous horn is a protuberance constituted by compact keratinous material, with a hard consistence similar to a horn, which occurs more frequently in photoexposed areas. The authors describe a case of cutaneous horn on the glans considered a rare location. Verrucous carcinoma was the histopathological diagnosis of the base of the horn and lichen sclerosis, the precursor lesion.

Anogenital Verrucous Carcinoma-A case report

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Verrucous carcinoma (VC) is a variant of squamous cell carcinoma.

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Anogenital VC is a rare condition, which clinically presents as common genital warts.

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Early recognition of VC and radical excision is crucial due to local destruction of tissue.

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Recurrence of VC is not uncommon.

Introduction

Verrucous carcinoma is an uncommon variant of low-grade squamous cell malignancy with a low malignant potential but a high risk of recurrence.

Presentation of case

We report a case of a Human Papilloma Virus negative local verrucous carcinoma in the perianal area of a 45-year old otherwise healthy female. The tumor presented clinically as a persistent genital wart not responding to usual dermatologic local therapy. The patient was referred to the Department of Plastic Surgery and Breast Surgery after primary excision in a private practice setting of a general surgeon. Three months later, further excision revealed local lichen sclerosus inflammatory changes in close proximity to the excision scar.

Discussion

Due to the low occurrence of verrucous carcinoma in the perianal area, no guidelines are available for the management of this disease. Conflicting reports on the ethiology and the nomenclature and classifications of verrucous carcinomas exist.

Conclusion

Avoid pitfalls in the diagnosis of a rare variant of squamous cell cancer with a high recurrence ratio: Common genital warts not responding to ordinary local antimitotic Podophyllotoxin treatment require biopsy to exclude verrucous carcinoma. Follow-up is recommended at a 3–6 months interval due to the relative high risk of relapse.

Lichen Sclerosus-Presentation, Diagnosis and Management

BACKGROUND

Lichen sclerosus is a chronic inflammatory skin disease. It is thought to be underdiagnosed and undertreated. If it is not treated, lichen sclerosus is associated with a greater degree of scarring and an elevated risk of cancer in the genital area.

METHODS

This review is based on pertinent articles published up to October 2015 that were retrieved by a selective search in PubMed, Embase, and the Cochrane Library and on the European S3 guideline for lichen sclerosus.

RESULTS

Lichen sclerosus is mainly found in the anogenital area but can also be generalized. Extragenital involvement is reportedly present in 6% to 20% of patients. Neighboring mucous membranes, such as the vaginal or oral mucosa, are not typically affected. The disease is more common in women than in men, and occurs more often in adults than in children. About 10% of patients have other family members with the same condition. Anogenital lichen sclerosus often causes itching and pain. Functional impairment due to fissures and scars can arise over the course of the condition. The treatment of first choice is the local application of high-potency corticosteroids as early as possible (1/A). For boys and men in whom the condition does not remit after steroid treatment, circumcision is indicated (3/D).

CONCLUSION

Anogenital itching and clinical features such as erythema, white skin changes (such as hyperkeratosis and sclerosis), and fissures should arouse suspicion of lichen sclerosus. The diagnosis should be confirmed with a skin biopsy, and early, thorough treatment should be initiated. In this way, a mutilating disease course can be averted, and the risk of cancer can be lessened.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

Treatment of male genital lichen sclerosus with clobetasol propionate and maintenance with either methylprednisolone aceponate or tacrolimus: a retrospective study

OBJECTIVE

To assess the efficacy of clobetasol propionate 0.05% cream in male patients suffering from genital lichen sclerosus (GLS), as well as the efficacy of methylprednisolone aceponate 0.1% cream and tacrolimus 0.1% ointment as maintenance therapy.

METHODS

The study was conducted retrospectively. At baseline, male patients with GLS (n = 41) were treated with clobetasol propionate 0.05% cream applied twice daily for 8 weeks. Visual Analog Scale (VAS) score for pruritus, Investigator's Global Assessment (IGA) score and Dermatology Life Quality Index (DLQI) were recorded at baseline, week 8 and week 20. At week 8, patients responsive to treatment (n = 37) were further treated with methylprednisolone aceponate 0.1% cream twice weekly (n = 17) or tacrolimus 0.1% ointment once daily (n = 20), as maintenance therapy until week 20.

RESULTS

VAS, IGA and DLQI median scores were significantly decreased from baseline to week 8 (p < 0.001). At week 20, patients treated with methylprednisolone aceponate 0.1% cream presented no significant difference in median IGA score (p = 0.865), median DLQI score (p = 0.853) or median VAS score (p = 0.474) compared with patients treated with tacrolimus 0.1% ointment.

CONCLUSIONS

Clobetasol propionate 0.05% cream is effective as first-line treatment in male GLS. The data suggest that there is no difference between methylprednisolone aceponate 0.1% cream and tacrolimus 0.1% ointment in preventing the relapses.

Systematic review and meta-analysis of randomized controlled trials on topical interventions for genital lichen sclerosus

BACKGROUND

Lichen sclerosus (LS) is a chronic inflammatory dermatosis that occurs mainly in the anogenital area and causes itching and soreness. Progressive destructive scarring may result in burying of the clitoris in females and phimosis in males. Affected people have an increased risk of genital cancers.

OBJECTIVE

We sought to assess the effects of topical interventions for genital LS.

METHODS

We undertook a systematic review and meta-analysis using the methodology of the Cochrane Collaboration.

RESULTS

We included 7 randomized controlled trials with a total of 249 participants covering 6 treatments. Clobetasol propionate 0.05% was better than placebo in treating genital LS (participant-rated improvement/remission of symptoms: risk ratio 2.85 [95% confidence interval {CI} 1.45-5.61]; investigator-rated global degree of improvement: standardized mean difference [SMD] 5.74 [95% CI 4.26-7.23]) as was mometasone furoate 0.05% (change in clinical grade of phimosis: SMD -1.04 [95% CI -1.77 to -0.31]). We found no evidence supporting the efficacy of topical androgens and progesterone. There were no differences between pimecrolimus and clobetasol propionate in relieving symptoms through change in pruritus (SMD -0.33 [95% CI -0.99 to 0.33]) and burning/pain (SMD 0.03 [95% CI -0.62 to 0.69]). However, pimecrolimus was less effective than clobetasol propionate in improving gross appearance (investigator-rated global degree of improvement: SMD -1.64 [95% CI -2.40 to -0.87]).

LIMITATIONS

Most of the included studies were small.

CONCLUSIONS

The current limited evidence supports the efficacy of clobetasol propionate, mometasone furoate, and pimecrolimus in treating genital LS. Further randomized controlled trials are needed.

Lichen sclerosus and squamous cell carcinoma

Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy. The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma. Two pathogenic pathways, differentiated vulvar and penile intraepithelial neoplasias, which have recently been described in relation to squamous cell carcinoma, are both highly associated with genital lichen sclerosus independently of human papilloma virus (HPV) infection. Furthermore, tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus. The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion, and the prognostic importance of the overlapping of these 2 diseases is still unclear. This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas, the possible oncogenic mechanisms involved, and their possible association with HPV infection.

[Vulvar inflammatory dermatoses]

Vulvar skin disease is a common reason for consultation. The vulva, like the rest of the skin, can be affected by numerous diseases of various etiologies, but its particular anatomic and physiologic characteristics create additional diagnostic and therapeutic difficulties. The study of vulvar disease is emerging as a new branch of dermatology. In this article, we examine the characteristics of the normal vulva, and perform a brief, structured review of vulvar inflammatory dermatoses, which comprise a heterogeneous group of diseases in which a broad, multidisciplinary approach is essential.

Topical interventions for genital lichen sclerosus

BACKGROUND

Lichen sclerosus is a chronic, inflammatory skin condition that most commonly occurs in adult women, although it may also be seen in men and children. It primarily affects the genital area and around the anus, where it causes persistent itching and soreness. Scarring after inflammation may lead to severe damage by fusion of the vulval lips (labia); narrowing of the vaginal opening; and burying of the clitoris in women and girls, as well as tightening of the foreskin in men and boys, if treatments are not started early. Affected people have an increased risk of genital cancers.

OBJECTIVES

To assess the effects of topical interventions for genital lichen sclerosus and adverse effects reported in included trials.

SEARCH METHODS

We searched the following databases up to 16 September 2011: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), LILACS (from 1982), CINAHL (from 1981), British Nursing Index and Archive (from 1985), Science Citation Index Expanded (from 1945), BIOSIS Previews (from 1926), Conference Papers Index (from 1982), and Conference Proceedings Citation Index - Science (from 1990). We also searched ongoing trial registries and scanned the bibliographies of included studies, published reviews, and papers that had cited the included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of topical interventions in genital lichen sclerosus.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data, and assessed the risk of bias. A third author was available for resolving differences of opinion.

MAIN RESULTS

We included 7 RCTs, with a total of 249 participants, covering 6 treatments. Six of these RCTs tested the efficacy of one active intervention against placebo or another active intervention, while the other trial tested three active interventions against placebo.When compared to placebo in one trial, clobetasol propionate 0.05% was effective in treating genital lichen sclerosus in relation to the following outcomes: 'participant-rated improvement or remission of symptoms' (risk ratio (RR) 2.85, 95% confidence interval (CI) 1.45 to 5.61) and 'investigator-rated global degree of improvement' (standardised mean difference (SMD) 5.74, 95% CI 4.26 to 7.23).When mometasone furoate 0.05% was compared to placebo in another trial, there was a significant improvement in the 'investigator-rated change in clinical grade of phimosis' (SMD -1.04, 95% CI -1.77 to -0.31).Both trials found no significant differences in reported adverse drug reactions between the corticosteroid and placebo groups. The data from four trials found no significant benefit for topical testosterone, dihydrotestosterone, and progesterone. When used as maintenance therapy after an initial treatment with topical clobetasol propionate in another trial, topical testosterone worsened the symptoms (P < 0.05), but the placebo did not.One trial found no differences between pimecrolimus and clobetasol propionate in relieving symptoms through change in pruritus (itching) (SMD -0.33, 95% CI -0.99 to 0.33) and burning/pain (SMD 0.03, 95% CI -0.62 to 0.69). However, pimecrolimus was less effective than clobetasol propionate with regard to the 'investigator-rated global degree of improvement' (SMD -1.64, 95% CI -2.40 to -0.87). This trial found no significant differences in reported adverse drug reactions between the pimecrolimus and placebo groups.

AUTHORS' CONCLUSIONS

The current limited evidence demonstrates the efficacy of clobetasol propionate, mometasone furoate, and pimecrolimus in treating genital lichen sclerosus. Further RCTs are needed to determine the optimal potency and regimen of topical corticosteroids, examine other topical interventions, assess the duration of remission or prevention of flares, evaluate the reduction in the risk of genital squamous cell carcinoma or genital intraepithelial neoplasia, and examine the efficacy in improving the quality of the sex lives of people with this condition.

[Lichen sclerosus and squamous cell carcinoma]

Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy. The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma. Two pathogenic pathways, differentiated vulvar and penile intraepithelial neoplasias, which have recently been described in relation to squamous cell carcinoma, are both highly associated with genital lichen sclerosus independently of human papilloma virus (HPV) infection. Furthermore, tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus. The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion, and the prognostic importance of the overlapping of these 2 diseases is still unclear. This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas, the possible oncogenic mechanisms involved, and their possible association with HPV infection.