My patient was diagnosed with lichen sclerosus on vulvar biopsy. What is the recommended treatment, and how long should it be used? If the patient is asymptomatic, must therapy be implemented at all?—JAQUELINE STONE, ANPC, West Orange, N.J.
The most common symptom of vulvar lichen sclerosus is pruritus (the intensity of itching does not correlate with the extent of lesions). Other symptoms include burning sensation, dyspareunia, and dysuria. In addition, lichen sclerosus can be found in adjacent areas of more than 60% of vulvar squamous cell carcinomas. Hence some investigators recommend that “asymptomatic lichen sclerosus…be treated as [one] would symptomatic lichen sclerosus” (Dermatol Ther. 2004; 17:28-37). Even with treatment, there is still a 4%-6% chance of subsequent malignant transformation of vulvar lichen sclerosus. Superpotent (clobetasol propionate 0.05% ointment) or potent topical corticosteroids are the treatment of choice for lichen sclerosus. Several treatment regimens are effective. One regimen calls for Month 1: daily application; Month 2: three times per week; Month 3: twice weekly; Months 4-6: biweekly with clobetasol propionate, or weekly with a lower-potency corticosteroid (e.g., betamethasone valerate). Another regimen is Month 1: twice daily; Months 2 and 3: daily; Month 4 and beyond: lower-potency corticosteroid one or two times daily, followed by a lower strength and frequency of the topical corticosteroid (Clin Obstet Gynecol. 2005;48:808-817).—Philip R. Cohen, MD (134-11)