Topical corticosteroids offer multiple benefits in treatment of vulvar lichen sclerosus

By Jane Lewis
An Australian study of women with vulvar lichen sclerosus (VLS) has found that long-­term preventive topical corticosteroids (TCS) not only relieve symptoms, improve function and reduce scarring, but also eliminate the risk of vulvar cancer.

Lead author, Dr Andrew Lee, Dermatology Research Fellow at Royal North Shore Hospital, Sydney, said that although VLS is relatively uncommon, it is very important to recognise and treat, as its consequences can be serious. ‘VLS often leads to the loss of normal vulvar architecture, and carcinoma can develop in some cases,’ he told Medicine Today.

Current guidelines advocate the use of TCS as first-­line treat­ment to achieve remission. However, questions remain as to how best to maintain remission, the ideal duration of follow up, and whether long­term management can prevent complications. The study, published in JAMA Dermatology, set out to answer these questions, investigating the use of TCS in 507 women with biopsy-­proven VLS who were attending a private practice in Sydney, followed up for a minimum of two years (average 4.7 years).

Following remission induced with high potency TCS, lower­-dose TSCs were used as regular preventive treatment to achieve a target outcome of normal skin colour and texture. Compared with women who reported following instructions only some or none of the time, those who were fully compliant (357 patients) were shown to be significantly more likely to achieve symptom suppression (93.3% vs 58.0%), and less likely to experience adhesions and scarring (3.4% vs 40.0%), reversible TCS­-induced cutaneous atrophy (1.1% vs 2.0%) or squamous cell carcinoma or vulvar intraepithelial neoplasia (0 vs 4.7%). No significant adverse effects of TCS treatment were reported.

‘Our data lead us to recommend this treatment strategy based on objective disease suppression and symptom control, with regular follow up to optimize compliance, adjust treatment potency, and monitor for complications,’ the authors concluded.

Commenting on clinical implications, Dr Lee said that adopting a long-­term outlook was clearly important. ‘VLS has the capacity to “silently” damage the vulva, so our study really stresses the significance of continued daily treatment, even when symptoms appear to be in remission,’ he said.

The authors of an accompanying editorial said the study has profound implications for patients with VLS and their physicians worldwide,’ providing the first evidence in women of the association between malignant neoplasms and poor treatment compliance. ‘This information will allow us to better inform our patients and encourage those who find it difficult to comply for various reasons,’ the authors wrote.

JAMA Dermatol 2015, doi: 10.1001/jamadermatol.2015.0643.
JAMA Dermatol 2015, doi: 10.1001/jamadermatol.2015.0644.