Lichen Sclerosus Characterized by Distressing Vulvar Itching in Postmenopausal Women Volume 47- Issue 4

Shiomi Ushida, Hiroshi Takagi, Satoshi Ichigo, Kazutoshi Matsunami and Atsushi Imai*

• Department of Obstetrics and Gynecology, Matsunami General Hospital, Japan

Received: December 05, 2022;   Published: December 21, 2022

*Corresponding author: Atsushi Imai, Department of Obstetrics and Gynecology, Matsunami General Hospital, 185-1 Dendai, Kasamatsu, Japan

DOI: 10.26717/BJSTR.2022.47.007553

Abstract PDF

Vulvar lichen sclerosus (LS) causes intractable itching, pain, burning, and dyapareunia and tissue scarring. Vulvar pruritus is a common symptom that significantly affects the quality of life (QOL) of affected women. In everyday life, anogenital itching is intractable. It not only impairs the QOL but may also cause sexual dysfunction. Many medications available only relive the symptoms, so far. Therefore, early detection of vulvar LS, subsequent and sustained treatment, as well as patient support and timely intervention are required.

Generally, approximately 20% of the population suffer from chronic skin itching. In 10% of such cases, the female genitalia are affected, specifically, the vulva [1-3]. The most common cause of vulvar pruritus is vulvar and vaginal candidiases followed by chronic dermatoses, including lichen sclerosus (LS) (also known as lichen sclerosus et atrophicus) and vulvar eczema. Vulvar LS causes intractable itching, pain, soreness, and dyapareunia and tissue scarring (the source of introitus narrowing, burying of the clitoris, and atrophy of the labia minora), most often affecting postmenopausal women [4-6]. The vulvar itching may worsen at night with cracking and bleeding in the vulva-perineal area. Rarely, vulvar LS is asymptomatic and detected on routine examination [7].

A physical examination is critical to differentiate vulvar LS from other causes of vulvar pruritus (Table 1). Vulvar LS commonly impairs the vulvar and perianal areas with characteristic appearance of ivory-white plaques of patches with shiny surface. The lesions progress on the inner aspects of labia majora, labia minora and clitoris, with narrowing of the introitus and ecchymosis of bleeding due to scratching. Perianal lesions may occur 30% of cases [6]. For the experienced physicians the clinical picture is often diagnostic and histological biopsy-evidence is not required. Whitish and shiny changes in the skin in the anogenital area paired with itching point to vulvar LS. When the clinical picture is ambiguous or the physician is unfamiliar with the disease, a biopsy from a typical lesion may be recommended. Some experts postulate that a biopsy is also helpful to confirm the clinician’s diagnosis and if in doubt, an expert who is familiar with the disease should be consulted. When the clinical and histological findings differ, repeat examinations must be performed with a full-thickness punch biopsy techniques.

Table 1: Differential diagnoses of vulvar pruritus.

Vulvar LS responds to the potent to ultrapotent topical corticosteroids applied for 3 months. Dosage recommendations may vary, but the dosage most often reported is daily application to the affected area for one month, followed by 4 weeks to minimizes flare-ups. Overuse of superpotent topical corticosteroids may induce atrophy and striae as early as 2-3 weeks following daily application. If the initial 3 months treatment with topical steroids does not lead to the desired full remission, a complete circumcision should be reconsidered. This procedure is reported to lead to permanent, lifelong remission in over 90% of cases [4]. A long-term treatment lasting for years or decades may improve the symptoms, even with few complaints. Individually adapted long-term treatment with corticosteroid applications for once or twice a week results in the suppression of symptoms in over 90%. When vulvar LS is in remission after initial treatment, individually adjusted long-term treatment with a minimal amount of potent steroid ointment is instructed.

This disorder is a chronic inflammatory dermatitis ¥ that can be managed with therapy. Since scarring is irreversible, main treatment goal is to prevent further progression of disease and further scarring. Squamous cell carcinomas occur in connection with vulva, not with extravulvar LS. Patients with vulvar LSA have a slightly increased risk of developing a squamous cell carcinoma, defined as an estimated lifetime risk of approximately 3 to 5 % [4-6]. Unlike human papilloma virus (HPV)-associated squamous cell carcinoma in the vulvar area, HPV is usually undetected in vulvar LS-associated cancers. P53 oncogenes, chronic inflammation and oxidative DNA damage are thought to contribute to malignant transformation [8-10].

Vulvar pruritus is a common symptom that significantly impairs the quality of life (QOL) of affected women. In daily life, anogenital itching is intractable. It not only impairs the QOL but may also cause sexual dysfunction. Many medications available only relive the symptoms, so far. Therefore, early detection of vulvar LS, subsequent and sustained treatment, as well as patient support and timely intervention are required. Additionally, patients should be monitored closely for progression of symptom resolution or lesion appearance.

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