Vulvar Lichen Sclerosus from Pathophysiology to Therapeutic Approaches: Evidence and Prospects

Off-Label Use of Topical Ruxolitinib in Dermatology: A Systematic Literature Review and Current Perspectives

JAK inhibitors are used to treat various inflammatory skin diseases. However, systemic formulations are associated with an increased risk of major adverse events. Ruxolitinib 1.5% cream is a selective topical JAK1 and JAK2 inhibitor, which has recently been approved by EMA and MHRA for treating non-segmental vitiligo, while being FDA-approved for both vitiligo and atopic dermatitis. Recent literature has reported the off-label use of topical Ruxolitinib for several skin conditions, but data are mostly limited to single case reports and series and few prospective studies, with mixed results. We conducted a systematic review of the literature to investigate the potential efficacy of topical Ruxolitinib in various skin diseases in an off-label setting. The following keywords were used for searching the MEDLINE (Pubmed) and Scopus databases from inception to September 2024: "ruxolitinib cream and dermatology" and "topical ruxolitinib and dermatology". Reviews, articles not focusing on the main topic, books and book chapters, and articles with no English text were excluded. A total of 170 studies were screened, of which 112 fell within exclusion criteria and 58 were assessed for eligibility. Of these, 28 studies, published between 2012 and 2024, were selected. Ruxolitinib cream resulted in being used off-label mostly for treating lichenoid and granulomatous dermatoses, as well as alopecia areata. While for the former skin conditions, topical ruxolitinib proved to be effective and safe, results on efficacy in alopecia areata were controversial. Topical ruxolitinib might be a promising therapeutic option for lichenoid and granulomatous dermatoses. Noteworthily, despite the exciting results from the oral formulation, no consistent data were described for topical ruxolitinib in alopecia areata. Our review reported encouraging results for many inflammatory skin conditions that should be investigated in further studies.

Platelet-rich fibrin attenuates inflammation and fibrosis in vulvar lichen sclerosus via the TGF-β/SMAD3 pathway

Vulvar lichen sclerosus (VLS) is a chronic, inflammatory, and progressive skin disease mainly involved in the anogenital area. Platelet-rich fibrin (PRF) is a fibrin adhesive-concentrated platelet-rich plasma (PRP) used for tissue repair and angiogenesis. In this study, we explored the effects of PRF on VLS patients, further to utilize the established VLS animal model, to confirm the therapeutic effect of PRF and regulation on the TGF-β/SMAD3 pathway. Among the 46 VLS patients included in the analysis, injectable RPF (i-PRF) treatment improved the symptoms of VLS. The immunohistochemical analysis showed that i-PRF decreased the local blurring of the dermal-epidermal boundary and increased the number of basal keratinocytes. I-PRF increased positive PGD9.5, CD34, and Melan A cell numbers, and decreases positive IL-17 and INF-γ cell numbers in VLS tissues. In the VLS rat model, i-PRF reduced inflammatory factors IL-17 and INF-γ via inhibition of NF-κB and increased CD31 and VEGF expression in external genital tissue. The i-PRF decreases fibronectin and collagen-I by inhibiting TGF-β/SMAD3 in VLS, which is the main factor that triggers inflammation and fibrosis of the external genital skin.

Clinical presentations and complications of lichen sclerosus: A systematic review

Lichen sclerosus (LS) is a chronic, inflammatory dermatosis most commonly characterized by changes in skin pigmentation and pruritus, with associated dyspareunia and genital architectural changes. There are a variety of complications associated with LS, which further worsen a patient's health-related quality of life. A systematic review was conducted to summarize the literature regarding clinical features of LS, as well as LS-associated complications. In total, 900 studies were included, which represented 17,011 clinical presentations and 2,795 complications of LS in women, and 5,745 clinical presentations and 769 complications of LS in men. In both sexes, the majority of reported cases (77% in females, 99% in males) localized to the genitals. In women, presentations were spread amongst loss of normal architecture (14%), pigmentary changes (21%) and pruritus (18%), whereas in men a greater portion of cases presented with architectural alterations (34%), as well as pigmentary changes (15%) and urogenital symptoms (15%). Other classes of LS-associated presentations included textural changes, atrophy, pain/burning/discomfort, erosions/ulcerations/excoriations, bleeding/bruising/purpura, defecatory symptoms and bullae. A small portion of cases found in the literature presented with asymptomatic LS. LS-associated complications included skin neoplasms, urogenital issues and sexual dysfunction, including dyspareunia.

Vulvar Lichen Sclerosus: A Literature Review with Consideration of Integrative Therapies

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin condition characterized by vulvar pruritus, pain, dyspareunia, and architectural changes, including significant and permanent scarring and deformity of the vulva if left untreated. Untreated VLS significantly increases the risk of invasive squamous cell carcinoma, even in asymptomatic patients. However, there is an overall paucity of preclinical and clinical research on VLS. Although the disease is becoming more commonly recognized, it is often under- or misdiagnosed and its prevalence is likely underestimated. While the exact underlying etiology is still unknown, VLS is most likely an autoimmune disorder within the background of genetic predisposition and environmental triggers. The skin and gut microbiomes also appear to be involved. The first line treatment for VLS, ultrapotent topical corticosteroids, helps relieve symptoms and reduce the risk of architectural changes and vulvar cancer. The second-line medications and treatments with more limited evidence of efficacy include topical calcineurin inhibitors, topical hormones, platelet-rich plasma, and fractional CO2 laser therapy. Surgical intervention may also be required. Additionally, some VLS patients and practitioners report improvements with diet and lifestyle changes, nutritional supplements, low-dose naltrexone, botanical medicines, and other integrative treatments, although clinical research on these integrative therapies for VLS is generally lacking. This review aims to describe VLS in adult women, summarize the recently published literature, and provide a clinical overview that includes evidence-based integrative therapies.

Efficacy and safety of 5-aminolevulinic acid photodynamic therapy in refractory genital lichen sclerosus

BACKGROUND

Genital lichen sclerosus (GLS) is a chronic inflammatory skin disease affecting the genital and anal areas. Treatment of refractory remains a challenge in clinical practice.

OBJECTIVE

This study aimed to evaluate the efficacy and safety of 5-aminolevulinic acid photodynamic therapy (5-ALA PDT) for refractory GLS.

METHODS

Thirty-five patients with histopathologically confirmed GLS (including 32 females and 3 males) were treated with 5-ALA PDT. Lesion pretreatment was performed to enhance photosensitizer penetration, and fluorescence diagnosis was used for precise point-to-point treatment. Efficacy and safety were systematically evaluated by assessing treatment outcomes, symptom improvement, side effects and maintenance of efficacy over a 6-month follow-up period.

RESULTS

After treatment, most patients experienced significant relief of pruritus, improved skin elasticity and color, and reduced lesion area. After 6 treatment sessions, 11 patients (31.43 %) achieved complete resolution of pruritus, with 3 patients (8.57 %) achieving complete remission after 3 sessions. Cattaneo scores decreased significantly after treatment and during follow-up (P < 0.05). Adverse reactions were mainly mild pain, which could be relieved by ice compression or oral analgesics.

CONCLUSIONS

5-ALA PDT shows significant efficacy and good safety for refractory GLS, improving the clinical symptoms and signs of patients, and warrants wider clinical application.

Immune Dysregulation and Cellular Composition in Lichen Sclerosus Revealed by Integrative Epigenetic Analysis with Cell Type Deconvolution

Background

Lichen sclerosus (LS) is a chronic inflammatory disease affecting skin and mucosal tissues, particularly external genitalia, with a risk of cancer. Its etiology is unknown, possibly involving immune dysregulation and inflammation.

Methods

Study used DNA methylation (DNAme) and single-cell RNA sequencing (scRNA-seq) to compare LS with normal skin. A detailed DNAme profile of LS was created, analyzing differentially methylated probes (DMPs) and cell type-specific DMPs. EpiSCORE deconvolution and immune infiltration analyses identified altered cell types in LS. Immunohistochemistry confirmed cellular changes. Enrichment analysis identified significantly altered pathways, and cell communication analysis described interactions among altered cell types in LS.

Results

DNA methylation patterns generally distinguished LS from normal skin, with a few exceptions. Data analysis showed that T cells significantly increased and fibroblasts decreased in LS. Immunohistochemical staining confirmed the changes in T cells. Enrichment analysis of DMPs indicated significant impacts on fibroblast-related processes and key immune pathways. The COLLAGEN signal was the most prominent in the cell communication. The CD99-CD99 interaction was the strongest between T cells and fibroblasts.

Conclusion

Combining DNAme and scRNA-seq data revealed changes in cellular composition and immune pathways in LS, enhancing understanding of its pathogenesis and highlighting potential therapeutic targets and diagnostic markers.

Efficacy of Fractional CO2 Laser Therapy in Improving Symptoms and Quality of Life in Women with Refractory Vulvar Lichen Sclerosus: A Prospective Observational Study

Lichen sclerosus (LS) is a chronic inflammatory condition predominantly affecting the anogenital region of postmenopausal women. It is associated with considerable aesthetic and functional impairments and an increased risk of squamous cell carcinoma. While high-potency topical corticosteroids remain the cornerstone of treatment, therapeutic options for patients with refractory LS are scarce. Fractional CO2 laser therapy has emerged as a potential second-line intervention aiming to mitigate symptoms and improve quality of life. This prospective observational study investigated the short-term efficacy and safety of fractional CO2 laser therapy in 75 women with refractory LS who underwent four treatment sessions between January 2022 and February 2024. Sixty-nine patients completed the protocol, demonstrating significant reductions in key symptoms, including pruritus (VAS score from 7.53 ± 3.02 to 4.08 ± 3.07), pain (5.83 ± 3.84 to 2.42 ± 2.85), and dyspareunia (8.26 ± 2.82 to 6.34 ± 3.30). Quality of life, sexual function, and psychological well-being also improved, as evidenced by reductions in Dermatology Life Quality Index (DLQI) scores (10.72 ± 7.25 to 5.94 ± 5.16), enhancements in sexual function (FSFI scores from 10.48 ± 8.46 to 15.52 ± 9.59), and decreased depression severity (BDI scores from 16.66 ± 12.64 to 5.94 ± 5.16). Importantly, no adverse effects were reported during the study period. Although these findings highlight the potential of fractional CO2 laser therapy as a safe and effective adjunct for refractory LS, it is essential to acknowledge the study's limitations, particularly the relatively short follow-up period. Longer-term studies are warranted to confirm sustained benefits and to evaluate the broader applicability of this approach.

Lack of oral involvement in a large cohort of women with vulvar lichen sclerosus - a multicenter prospective study

BACKGROUND AND OBJECTIVES

We assessed the prevalence of oral lichen sclerosus in a cohort of women affected with vulvar lichen sclerosus (VLS).

PATIENTS AND METHODS

This prospective, observational study included adult female patients with a histologically proven VLS who attended the Vulva Clinics of three Dermatology Units from January 2020 to July 2023. During this period, all VLS patients were asked to be examined in their oral cavities in order to detect any possible sign of oral diseases, which were then biopsied.

RESULTS

Three hundred women (mean age 64.5 ± 13.0 years) were included, of whom 21 (7%) had a concurrent extragenital LS. In six (2%) patients, white, non-removable lesions were found at oral inspection and biopsied. All cases were histologically lichen planus. No other clinically relevant oral lesions were found. The six women with histologically proven oral lichen planus had more frequent periodontal and autoimmune diseases than the other included subjects.

CONCLUSIONS

Our findings confirm the absolute rarity of oral involvement in patients with VLS. They suggest that the oral mucosa, unlike the genitals, is a setting which weakly leads to development of LS, also in predisposed subjects.

Development and Validation of a Machine Learning-Based Early Warning Model for Lichenoid Vulvar Disease: Prediction Model Development Study

BACKGROUND

Given the complexity and diversity of lichenoid vulvar disease (LVD) risk factors, it is crucial to actively explore these factors and construct personalized warning models using relevant clinical variables to assess disease risk in patients. Yet, to date, there has been insufficient research, both nationwide and internationally, on risk factors and warning models for LVD. In light of these gaps, this study represents the first systematic exploration of the risk factors associated with LVD.

OBJECTIVE

The risk factors of LVD in women were explored and a medically evidence-based warning model was constructed to provide an early alert tool for the high-risk target population. The model can be applied in the clinic to identify high-risk patients and evaluate its accuracy and practicality in predicting LVD in women. Simultaneously, it can also enhance the diagnostic and treatment proficiency of medical personnel in primary community health service centers, which is of great significance in reducing overall health care spending and disease burden.

METHODS

A total of 2990 patients who attended West China Second Hospital of Sichuan University from January 2013 to December 2017 were selected as the study candidates and were divided into 1218 cases in the normal vulvovagina group (group 0) and 1772 cases in the lichenoid vulvar disease group (group 1) according to the results of the case examination. We investigated and collected routine examination data from patients for intergroup comparisons, included factors with significant differences in multifactorial analysis, and constructed logistic regression, random forests, gradient boosting machine (GBM), adaboost, eXtreme Gradient Boosting, and Categorical Boosting analysis models. The predictive efficacy of these six models was evaluated using receiver operating characteristic curve and area under the curve.

RESULTS

Univariate analysis revealed that vaginitis, urinary incontinence, humidity of the long-term residential environment, spicy dietary habits, regular intake of coffee or caffeinated beverages, daily sleep duration, diabetes mellitus, smoking history, presence of autoimmune diseases, menopausal status, and hypertension were all significant risk factors affecting female LVD. Furthermore, the area under the receiver operating characteristic curve, accuracy, sensitivity, and F1-score of the GBM warning model were notably higher than the other 5 predictive analysis models. The GBM analysis model indicated that menopausal status had the strongest impact on female LVD, showing a positive correlation, followed by the presence of autoimmune diseases, which also displayed a positive dependency.

CONCLUSIONS

In accordance with evidence-based medicine, the construction of a predictive warning model for female LVD can be used to identify high-risk populations at an early stage, aiding in the formulation of effective preventive measures, which is of paramount importance for reducing the incidence of LVD in women.

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.

EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness; it may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are usually a whitening of the genital skin, sometimes preceded by redness and oedema; fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS (part 1), highlight important aspects in the care of LS patients, generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

Assessing the inclusion of women of color in lichen sclerosus treatment studies: a scoping review

Background

Vulvar lichen sclerosus (VLS) is an underrecognized chronic inflammatory skin condition with significant clinical features and potential for malignant transformation. To date, there are no studies comparing the course of this disease in women of color to other racial groups.

Objective

The objective of this study was to provide a scoping review examining racial demographic data in VLS treatment studies and specifically assessing for the inclusion of women of color.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a primary literature search was conducted using 4 databases: Ovid Medline(R), Scopus, Cochrane, and Web of Science from all years to December 2022. We included published studies with adult women diagnosed with VLS and containing a treatment arm using topical corticosteroids. Single case reports, literature reviews, systemic reviews, meta-analyses, and reports not available in English were excluded.

Results

Overall, 1340 nonduplicate studies were assessed for eligibility criteria. In total, 65 publications were included. Only 6 included racial demographic data. Black women made up at most 3.8% of the sample population and Latinx women made up at most 5.7%.

Limitations

Our review focused on a specific intervention (ie, the use of topical corticosteroids for the treatment of VLS), which may restrict the generalizability of our findings to other interventions. No risk of bias assessment was done due to the scoping nature of the review.

Conclusion

Women of color are underrepresented in studies of topical corticosteroid use in adult women with VLS. Intentional diversity in recruitment will enable the collection of data that is both more accurate and reflective of a broader spectrum of perspectives and life experiences.

Successful Microablative Fractional Carbon Dioxide Laser Therapy for Vulvar Lichen Sclerosus: A Case Report and Mini-review

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin disorder affecting the vulvar region. VLS predominantly affects women, and most cases occur after menopause. Common symptoms include itching, skin-whitening, pain, discomfort, fissures, and scarring. Treatment options include topical steroids, emollients, lifestyle modifications, regular follow-up, and surgical interventions. Carbon dioxide (CO2) laser treatment is a therapeutic option for managing lichen sclerosus. We report a case of VLS successfully treated with a fractional microablative CO2 laser. A 72-year-old female presented with a dry vagina and vulvar itching for 6 months. She visited a local medical clinic, and oral anti-itching medication and topical anti-itching ointment were administered. However, the condition did not improve, and she felt itching. She visited our outpatient department, and a pelvic examination showed bilateral labia minor, revealing a white skin color change and a hardening sensation. The patient was diagnosed with VLS. Microablative fractional CO2 laser therapy was subsequently administered. The treatment course comprised three laser therapy sessions (treatment day, 1 month, and 2 months after the first therapy). The vulvovaginal symptoms questionnaire-21 scores were 14, 6, and 2 for the first, second, and third courses of treatment, respectively. Vulvar itching improved significantly after laser treatment - no more steroid treatment needed. After 10 months of follow-up, the condition of the vulva was maintained well. Although the treatment protocol requires further exploration, CO2 laser treatment could be considered for VLS if topical steroids are ineffective.

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.

IL-17: a novel player in the pathogenesis of vulvar lichen sclerosus

Introduction

Vulvar lichen sclerosus (VLS) is a chronic progressive, lymphocyte-mediated inflammatory disease whose pathogenesis is complex and not fully elucidated.

Aim

In the current study we have investigated for the first time the expression of interleukin-17 (IL-17) and S100A7 in lesional skin obtained from female individuals with histologically confirmed VLS.

Material and methods

In our study we used skin biopsies obtained from female patients with histologically confirmed VLS (n = 20) and skin samples from healthy age- and gender-matched individuals (plastic surgery procedures) (n = 10) serving as controls. The tissue expressions of IL-17 and S100A7 were assessed with an immunohistochemical method.

Results

The number of cells showing IL-17 expression was significantly higher in VLS lesional skin as compared to normal skin of healthy controls (p < 0.0001). In VLS lesional skin, IL-17 was expressed in the epidermis and by cells within the inflammatory infiltrate in the upper dermis. The number of cells showing S100A7 expression was significantly higher in VLS lesional skin as compared to normal skin of healthy controls (p < 0.0001). In VLS lesional skin, S100A7 was expressed by suprabasal keratinocytes in epidermis. S100A7 was also expressed by cells within the inflammatory infiltrate in the dermis.

Conclusions

The results of our study may suggest the involvement of IL-17 and S100A7 in the pathogenesis of VLS. The better understanding of this disease may lead to the development of novel, effective therapeutic strategies e.g. using well-known biologics IL-17 inhibitors class.

Advances in the pathogenesis of vulvar lichen sclerosus

Vulvar lichen sclerosus (VLS) is a chronic non-neoplastic skin lesion characterized by vulvar itching, pain, atrophy, whitening of the skin and mucous membranes, and gradual atrophy and disappearance of the labia minora, which can eventually lead to vulvar scarring, causing functional impairment and seriously affecting the patient's physical and mental health. VLS can occur at any age, however, its pathogenesis and etiology are not fully understood. Considerable progress has been made in related research on genetic susceptibility factors, autoimmune disorders, collagen metabolism abnormalities, and their triggering factors in disease formation and progression. This article reviews the etiology of vulvar lichen sclerosus.

The Need of Differential Diagnosis Between Vulvar Lichen Sclerosus and Autoimmune Dermatoses in Adolescent Girls

INTRODUCTION

Vulvar lichen sclerosus (VLS) is a chronic inflammatory condition affecting the anogenital region, which can manifest in prepubertal or adolescent patients. The prevailing theories point to autoimmune and genetic factors. The primary symptoms of VLS typically include vulvar itching, discomfort, dysuria, and constipation. Physical examination often reveals a characteristic figure 8 pattern, involving the labia minora, clitoral hood, and perianal region. However, these symptoms and the age of onset are nonspecific and require differentiation from autoimmune dermatoses such as bullous diseases, pemphigus diseases, epidermolysis bullosa acquisita, and dermatitis herpetiformis. We performed this study to distinguish VLS from autoimmune dermatoses, and in doing so, uncover the underlying causes of chronic vulvar changes. This knowledge will enable healthcare providers to offer appropriate medical care to affected patients.

METHODS

The study was conducted between July 2020 and February 2021, with a sample of 55 girls aged 2-18 years who did not have any systemic diseases. The study group was composed of 20 girls previously diagnosed with vulvar lichen sclerosus, while the control group included 35 girls without VLS. Questionnaires regarding the medical history of the children were completed by their legal guardians. Blood samples were collected and analyzed biochemically to assess human immunoglobulin A (IgA), IgG, and IgM antibodies against various substrates, including the desmosome of stratum spinosum, basement membrane zone, desmoglein 1 (DSG1), desmoglein 3 (DSG3), BP180-NC16A-4X, BP230gC, pemphigoid antigen, collagen type VII NC1, transitional epithelium, gliadin (GAF-3X), endomysium (EMA), and cellular nucleus (ANA).

RESULTS

The analysis of the study group revealed that the most commonly observed signs and symptoms included: itching, soreness, burning sensations, and excoriation, as well as erythema or/and pallor of the skin and perineal mucosa. Among the assessed antibodies, only anti-GAF3x antibodies and ANA antibodies were detected. However, the results did not reach statistical significance (p > 0.5).

The Potential Coexistence of Autoimmune Thyroid Diseases and Pediatric Vulvar Lichen sclerosus

INTRODUCTION

Vulvar lichen sclerosus (VLS), a chronic inflammatory skin disorder, often coexists with autoimmune thyroid disease (AITD). VLS presents with subtle symptoms including vulvar itching and discomfort. Clinically, a "Figure 8" pattern involving the labia minora, clitoral hood, and perianal region is often observed. It is prevalent both in pre-pubertal girls and women aged 40-60, and the link between VLS and AITD remains unclear, with proposed causes including autoimmune, hormonal or genetic factors, and environmental triggers. This study addresses the lack of research on the association in children, aiming to investigate the largest group of underage girls to date.

AIM

This study aimed to investigate the coexistence of thyroid autoimmune diseases in girls diagnosed with vulvar lichen sclerosus (VLS) and to assess the presence of antibodies for specific thyroid autoimmune diseases.

MATERIALS AND METHODS

Our study was conducted from July 2020 to February 2021, involving a sample of 55 girls aged 2-18 years old, all free from systemic diseases. The study group comprised 20 girls previously diagnosed with vulvar lichen sclerosus (VLS), while the control group included 35 girls without VLS. Legal guardians completed questionnaires detailing the medical history of their children. Blood samples were collected from all participants and subjected to biochemical analysis. The presence of human IgG antibodies against thyroid peroxidase and IgG antibodies against thyroglobulin was assessed using the immunoenzymatic method with commercially available ELISA kits.

RESULTS

In the study group, common symptoms included itching, soreness, burning sensation, excoriation, and erythema or pallor of the skin and perineal mucosa. An evaluation of anti-thyroglobulin and anti-thyroid peroxidase antibodies revealed no statistical significance between the study and control groups (anti-TG p = 0.379, anti-TPO p = 0.96). Family history of autoimmune diseases showed no significant correlation with anti-thyroid antibodies in girls. Although no significant relation between VLS occurrence and antibody levels was found, it emphasizes the need for multidisciplinary medical care. Further research with larger patient groups is necessary.

Vulvar Lichen Sclerosus: Navigating Sex Hormone Dynamics and Pioneering Personalized Treatment Paradigm

Vulvar lichen sclerosus (VLS) is a frequently overlooked inflammatory disorder affecting the skin and mucous membranes of the vulva. With a propensity for atrophy, severe scarring, functional impairment, and malignant evolution, VLS is a disease that recurs frequently; early diagnosis, rapid treatment, and ongoing patient follow-up are essential. Potent topical corticosteroids (TCSs) are now widely recognized as the most effective treatment for achieving remission in VLS, but considering the potential complications of long-term treatment with potent TCSs, understanding the evolution of VLS during puberty becomes particularly crucial in determining the necessity for aggressive or more conservative therapeutic interventions. Emerging treatments, including PRP (platelet-rich plasma), stem cell therapy, and energy-based lasers like fractional CO2 and Nd-YAG, are being investigated to identify more effective VLS treatments than ultrapotent topical corticosteroids. However, more research is needed to assess the efficacy and safety of these new medicines. Topical clobetasol 0.05% ointment daily for 4-12 weeks is the gold standard for treating VLS. This article is a narrative review of the English-language medical literature from 2017 to November 2023, following three main sections concerning VLS: studies of the evolution amid pubertal hormonal changes; studies of the outcomes of personalized conventional therapies; and studies addressing the spectrum of innovative modalities for VLS.

Laser Therapy for Vulvar Lichen Sclerosus, a Systematic Review

Lichen sclerosus (LS) is a chronic inflammatory disease that mainly affects the anogenital area, with a higher incidence in post-menopausal women. In the long term, it can lead to loss of vulvar architecture or progress to squamous cell carcinoma. The evidence-based treatment involves high-potency topical corticosteroids in long regimens. However, second-line treatments are not well-established, including laser therapy. This current study aims to assess the level of evidence supporting this therapy. We conducted a search for primary-level studies published before April 2023 through MEDLINE/PubMed, Embase, Web of Science, Scopus, and CENTRAL, with no restrictions on the publication language or date. The methodological quality and risk of bias of the included studies were evaluated using the updated Cochrane Collaboration's tool for assessing risk of bias (RoB-2). Six studies (177 patients) met our eligibility criteria. Laser therapy was compared to topical corticosteroid treatment in five out of six studies. No significant histological differences were found, except for an increase in collagen production in the laser group. A greater reduction in itching, pain, and dyspareunia at 1 and 3 months of treatment in the laser group, as well as in the Skindex-29 at 6 months, was reported. Patient satisfaction was significantly higher among those who received laser therapy. Tolerability was excellent. No significant differences were observed in any of the previous aspects in the study compared to the placebo. In conclusion, there is not enough evidence to recommend laser therapy as a standalone treatment.

Incidence of Vulvar Lichen Sclerosus and of Cancer Among Vulvar Lichen Sclerosus Patients: Does Socioeconomic Status Have a Role?

OBJECTIVE

Socioeconomic status (SES) impacts on the incidence of many inflammatory diseases and cancers, but there is no evidence on its implication in vulvar lichen sclerosus (VLS). The authors aimed to assess possible associations between SES and both occurrence of VLS and cancer occurrence among VLS patients.

MATERIALS AND METHODS

A retrospective cohort of women resident in the province of Ferrara, Italy, affected with VLS diagnosed between 2001 and 2020, was investigated for assessing any association of SES with VLS and cancer incidence. The SES was expressed through an ecological-based deprivation index identifying 5 subgroups.

RESULT

Four-hundred women were diagnosed with VLS during the study period, with double the number of cases in the second decade (2011-2020) compared with the first (2001-2010). More VLS patients belonged to the high rather than the low SES groups (p = .032). From VLS diagnosis to 2018 (1,958.4 total person*years at risk), 22 patients received their first diagnosis of cancer, mainly the skin, breast, and vulva. No significant differences in cancer incidence were found between high/medium-high and low/medium-low SES subjects.

CONCLUSIONS

The fact that more VLS patients belonged to the highest socioeconomic classes may be due to a more frequent diagnosis in those with greater health seeking behavior and resources. An involvement of SES-related factors in VLS pathophysiological background can also be taken into consideration. Both the lack of marked social and economic differences in the study area and the availability of free visits and screening may account for the lack of association between SES and cancer development.

Multimodal OCT Control for Early Histological Signs of Vulvar Lichen Sclerosus Recurrence after Systemic PDT: Pilot Study

Photodynamic therapy (PDT) is a modern treatment for severe or treatment-resistant vulvar lichen sclerosus (VLS). The chronic and recurrent nature of VLS requires control of recurrences at an early stage. In this paper, a non-invasive multimodal optical coherence tomography (OCT) method was used to control for early histological signs of VLS recurrence after systemic PDT using Photodithazine®. To interpret the OCT data, a histological examination was performed before PDT and 3 months after PDT. Two groups of patients were identified: with early histological signs of VLS recurrence (Group I, n = 5) and without histological signs of VLS recurrence (Group II, n = 6). We use structural OCT, OCT angiography, and OCT lymphangiography throughout 6 months after PDT to visually assess the skin components and to quantitatively assess the dermis by calculating the depth-resolved attenuation coefficient and the density of blood and lymphatic vessels. The OCT data assessment showed a statistically significant difference between the patient groups 3 months after PDT. In Group II, all the studied OCT parameters reached maximum values by the 3rd month after PDT, which indicated recovery of the skin structure. At the same time, in Group I, the values of OCT parameters did not approach the values those in Group II even after 6 months. The obtained results of multimodal OCT can be used for non-invasive control of early histological recurrence of VLS after systemic PDT and for adjusting treatment tactics in advance, without waiting for new clinical manifestations of the disease.

Comparison of the efficacy of focused ultrasound at different focal depths in treating vulvar lichen sclerosus

OBJECTIVE

This study aimed to compare the efficacy and safety of focused ultrasound (FU) at different focal depths in treating vulvar lichen sclerosus (VLS).

METHODS

A retrospective study was conducted on 84 patients with VLS. Among them, 43 cases were treated with FU at a focal depth of 2.5 mm and 41 cases at a focal depth of 4.0 mm. Therapeutic time, treatment energy, postoperative efficacy, complications and recurrence rates were compared.

RESULTS

No statistically substantially differences in age, disease course, history of immune system diseases, lesion size and severity of symptoms were found between the two groups. All patients successfully received FU therapy. No significant difference in curative rate was observed between the two groups at 3, 6 and 12 months after FU therapy. At 12 months after FU therapy, the recurrence rate of the experimental group (FU treatment at 2.5 mm focal depth) was lower than the control group (FU treatment at 4.0 mm focal depth) (7.0% vs 24.4%, p = 0.027). The experimental group was treated for a shorter period of time [22.69 ± 0.64 (min) vs 24.93 ± 0.72(min), p = 0.022] and at a lower dose[5,026.05 ± 148.00(J) vs 5,484.26 ± 160.60(J) p = 0.039].

CONCLUSION

Compared with that at the routine focal depth (4.0 mm), FU therapy at a low treatment depth (2.5 mm) can achieve a similar therapeutic effect but lower recurrence rate, therapeutic time and treatment energy. This work provides insight into the optimization of clinical protocols.

Lichen sclerosus: The 2023 update

Lichen sclerosus (LS) is an underdiagnosed inflammatory mucocutaneous condition affecting the anogenital areas. Postmenopausal women are predominantly affected and, to a lesser extent, men, prepubertal children, and adolescents. The etiology of LS is still unknown. Hormonal status, frequent trauma and autoimmune diseases are well-known associations for LS, yet infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype. Furthermore, there is a distinct expression of tissue remodeling associated genes as well as microRNAs. Oxidative stress with lipid and DNA peroxidation provides an enabling microenvironment to autoimmunity and carcinogenesis. Circulating IgG autoantibodies against the extracellular matrix protein 1 and hemidesmosome may contribute to the progression of LS or simply represent an epiphenomenon. The typical clinical picture includes chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. In addition to genital scarring, and sexual and urinary dysfunction, LS may also lead to squamous cell carcinoma. Disseminated extragenital LS and oral LS are also reported. The diagnosis is usually clinical; however, a skin biopsy should be performed in case of an unclear clinical picture, treatment failure or suspicion of a neoplasm. The gold-standard therapy is the long-term application of ultrapotent or potent topical corticosteroids and, alternatively, topical calcineurin inhibitors such as pimecrolimus or tacrolimus. Collectively, LS is a common dermatological disease with a so far incompletely understood pathogenesis and only limited treatment options. To foster translational research in LS, we provide here an update on its clinical features, pathogenesis, diagnosis and (emerging) treatment options.

In vivo evaluation of vulvar lichen sclerosus with reflectance confocal microscopy and therapeutic monitoring in children

BACKGROUND

Vulvar lichen sclerosus (VLS) in girls presents with itching, dysuria, and constipation and may result in the loss of vulvar architecture. In patients with an ambiguous clinical presentation, reflectance confocal microscopy (RCM) could be a helpful noninvasive diagnostic tool. The aim of this study was to describe the RCM characteristics of VLS and explore the clinical application value of RCM in therapeutic monitoring.

METHODS

Sixteen patients with VLS were included in the study. All patients were periodically evaluated clinically with RCM, and different treatment regimens were given based on the patient's clinical appearances and RCM features.

RESULTS

Some major key diagnostic features of VLS can be observed by RCM, including round to oval cyst-like structures with medium-to-low-refractive keratinoid substances (75%), thinning of the epidermal thickness (100%), destruction of the ring-like structures around dermal papillae (100%), disorderly distributed coarse medium-refractive fibrous material (100%),polygonal, plump, high-refractive cellular structures and linear low-refractive canalicular structures (100%). All of these characteristics had a high correspondence with histopathological features. The clinical manifestations improved after individualized treatment regimens based on the clinical appearances and RCM features.

CONCLUSION

RCM allows the visualization of major key diagnostic features of VLS and represents a valid option for objective therapeutic monitoring.

The Importance of Immunological Disorders in the Pathogenesis of Lichen Sclerosus in Pediatric Patients: A Systematic Review

Lichen sclerosus (LS) is defined as a chronic mucocutaneous inflammatory disease with a localization predominantly to the anus and genitals (vulvar sclerosus (VLS)). Pediatric lichen sclerosus (LS) is a chronic inflammatory skin condition with predilection for the anogenital area that if untreated can lead to scarring. Vulvar LS is characterized by two peaks in incidence: it occurs in prepubertal girls and in postmenopausal women. To date, several mechanisms and risk factors have been proposed in the pathogenesis of pediatric vulvar LS; however, the etiology of this condition is still not fully understood and constitutes a challenge for scientists and clinicians. The presented research aimed to systematically review the existing literature on the pathogenesis of pediatric LS and to identify possible underlying autoimmune mechanisms and molecular networks. The clinical presentation of pediatric lichen sclerosus and available treatment modalities are also presented to acquaint a broader audience with this underdiagnosed and undertreated condition. As a result of our review, we discuss several potential mechanisms, molecules, and pathways that have been recognized in this disease. The purpose of our review was also to summarize what we can induce in further studies, which will ultimately help to identify the mechanism responsible for the disease and aid in the development of new, more effective treatment strategies for diagnosis and treatment by clinicians and researchers.

The efficacy and safety of secondary focused ultrasound therapy for recurrence of non-neoplastic epithelial disorders of the vulva

OBJECTIVE

To investigate the efficacy, safety, and influencing factors of secondary focused ultrasound (FU) therapy for recurrence of non-neoplastic epithelial disorders of the vulva (NNEDV).

METHODS

Patients with NNEDV who have relapsed after initial FU treatment were included in this study. They were treated with secondary FU therapy between July 2015 and July 2021. Outcome measures included the degree of symptom severity and operative complications. We further analyzed the relationships between age, course, time between relapse and initial treatment, menopause status, lesion size, pathological types, severity of symptoms, and curative rate.

RESULTS

There were 98 patients enrolled in this study, with a mean age of 47.4 ± 11.4 years. All patients successfully underwent secondary FU therapy. Blisters developed among 16 (16.3%) patients, of whom 6 (6.1%) developed superficial skin ulcers. A curative response was observed among 46 (46.9%) patients, while an effective response was observed among 44 (44.9%) patients. Only 8 (8.2%) patients showed no improvement. The total response rate was 91.8%. A total of 12 (12.2%) cases recurred among all effective cases. Patients with a recurrence of NNEDV after more than 1.5 years following their first FU therapy demonstrated a higher response rate than those with a recurrence after less than 1.5 years.

CONCLUSIONS

A second FU therapy remains effective for patients with recurrent NNEDV with no obvious side effects. The response rate, however, is higher for patients who experience recurrence of NNDEDV after more than 1.5 years.

The Aesthetic Genital Consultation: Inquiry to Scheduling

Consultation for female esthetic genital concerns is unique in that the topic is shrouded in secrecy. Few opportunities exist for the improvement of female sexual health and well-being when compared with male counterparts. Women concerned with the appearance of their genitalia seek help with improving their confidence and reducing mental and physical discomfort attributed to large labia minora. Validated questionnaires given to patients beforehand, a detailed sexual history, and a comprehensive vulvar examination help define the esthetic and functional issues. Providing informed consent and setting realistic expectations are the key final steps to a successful esthetic genital consultation.

Transcriptome Profiling and Network Analysis Provide Insights Into the Pathogenesis of Vulvar Lichen Sclerosus

Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis that affects female anogenital skin. Although VLS is considered a T cell-mediated autoimmune disease, the diagnosis criteria, molecular mechanism, and universally accepted therapies for this disease remain largely unresolved. To explore disease pathogenesis and potential biomarkers, we performed an RNA-Seq-based transcriptome analysis to profile the gene expression of VLS lesions. Differentially expressed gene (DEG) analysis revealed profound changes in expressions of coding genes, microRNAs, and long non-coding RNAs. Pathway and network analysis suggested that T cell activation-associated genes, including CD3G, CD3D, CD8B, LAT, LCK, ZAP70, CCR5, CXCR3, CXCL9, CXCL10, and CXCL11, were highly expressed in VLS, while NR4A family genes (NR4A1, NR4A2, NR4A3), whose coding products inhibit T cell activity, were significantly downregulated, suggesting heightened T cell response in VLS. Neutrophil chemoattractant genes CXCL1, CXCL2, CXCL3, CXCL8, and their cognate receptor CXCR2 were downregulated, suggesting dampened neutrophil activity. We also found the downregulation of genes involved in cell cycle progression, including cyclins (CCNB1, CCNB2, CCNL1, CCNE1, and CCNK) and centrosome factors (CENPA, CENPE, CENPF, and CENPN), while microRNA-203a and let-7, microRNAs known to inhibit cell growth, were found to be upregulated. These data collectively indicate that cell proliferation in VLS is compromised. In sum, these findings comprehensively deciphered key regulatory genes and networks in VLS, which could further our understanding of disease mechanisms and point toward therapeutic strategies.

Genital Wound Repair and Scarring

Skin wound repair has been the central focus of clinicians and scientists for almost a century. Insights into acute and chronic wound healing as well as scarring have influenced and ameliorated wound treatment. Our knowledge of normal skin notwithstanding, little is known of acute and chronic wound repair of genital skin. In contrast to extra-genital skin, hypertrophic scarring is uncommon in genital tissue. Chronic wound healing disorders of the genitals are mostly confined to mucosal tissue diseases. This article will provide insights into the differences between extra-genital and genital skin with regard to anatomy, physiology and aberrant wound repair. In light of fundamental differences between genital and normal skin, it is recommended that reconstructive and esthetic surgery should exclusively be performed by specialists with profound expertise in genital wound repair.

Early Diagnostics of Vulvar Intraepithelial Neoplasia

Simple Summary

The spectrum of vulvar disorders is wide and varies from infections, dermatoses, manifestations of hormonal and systemic conditions to vulvar intraepithelial neoplasia (VIN) and invasive cancer. It is not always possible to distinguish vulvar lesions on the basis of macroscopical aspects and the distribution of changes. For definite diagnosis of a vulvar lesion, a biopsy is needed. However, in practice, the decision to perform a biopsy is often delayed due to a lack of specificity of symptoms at the early stages of the neoplastic disease. The aim of this article is to provide clinicians, both gynecologists and dermatologists, with the main features of vulvar precancerous lesions, in order to recognize and treat them on time, thus preventing vulvar cancer. Clinical appearance of VIN is variable with significant variations present in color, surface, and topography. Evaluation of all VIN lesions should be conducted very carefully, because an underlying early invasive squamous cancer appears to be present in a significant percentage of patients.

Abstract

The spectrum of vulvar lesions ranges from infective and benign dermatologic conditions to vulvar precancer and invasive cancer. Distinction based on the characteristics of vulvar lesions is often not indicative of histology. Vulvoscopy is a useful tool in the examination of vulvar pathology. It is more complex than just colposcopic examination and presumes naked eye examination accompanied by magnification, when needed. Magnification can be achieved using a magnifying glass or a colposcope and may aid the evaluation when a premalignant or malignant lesion is suspected. It is a useful tool to establish the best location for biopsies, to plan excision, and to evaluate the entire lower genital system. Combining features of vulvar lesions can help prediction of its histological nature. Clinically, there are two distinct premalignant types of vulvar intraepithelial neoplasia: HPV-related VIN, more common in young women, multifocal and multicentric; VIN associated with vulvar dermatoses, more common in older women and usually unicentric. For definite diagnosis, a biopsy is required. In practice, the decision to perform a biopsy is often delayed due to a lack of symptoms at the early stages of the neoplastic disease. Clinical evaluation of all VIN lesions should be conducted very carefully, because an underlying early invasive squamous cancer may be present.

Photodynamic Therapy in the Treatment of Vulvar Lichen Sclerosus: A Systematic Review of the Literature

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disease involving the genital skin and mucous membrane. Patients exhibit focal atrophy and destructive scarring, with an increased risk of malignant transformation. Due to objective symptoms as well as subjective complaints, patients with VLS experience emotional distress, lowered mood, and sexual dysfunction, which is reflected in impaired health-related quality of life. Thus, the necessity of implementing appropriate therapy at the earliest possible stage of the disease in order to avoid serious complications is highlighted. We presented the systematic review of available literature, performed with MEDLINE, Cinahl, Central, Scopus, and Web of Science databases. We identified a total of twenty relevant studies which indicate that photodynamic therapy (PDT) is a valuable therapeutic modality in the treatment of VLS.