The prevalence of self-reported medical comorbidities in patients with vulvar lichen sclerosus: A single-center retrospective study.

OBJECTIVE: To compare the demographics and self-reported medical comorbidities of patients with vulvar lichen sclerosus (VLS) with those of women with other vulvar conditions. METHODS: Intake questionnaires for patients presenting to the University of Michigan Center for Vulvar Diseases between 1996 and 2019 were entered into a de-identified database (n = 1983). Responses to questions about thyroid disease, urinary symptoms and signs, gastrointestinal conditions, and pain conditions were collected. RESULTS: A total of 1983 women, including 865 patients with VLS and 1118 patients without VLS were enrolled. Pearson's χ2 analysis showed that age, hypertension, anorectal fissures, peptic ulcer disease/gastroesophageal reflux disease, urinary incontinence, fibromyalgia, thyroid disease, kidney problems, liver problems, and cancer were significantly associated with VLS when compared between the VLS and non-VLS groups (P < 0.01). However, multiple regression analysis demonstrated that only age, thyroid disease, and anorectal fissures were strongly associated with VLS (P < 0.01). CONCLUSION: Increasing age, thyroid disease, and anorectal fissures were significantly associated with VLS. The association between anorectal fissures and VLS likely represents a sequela of the disease rather than a true comorbidity.

Identification and management of vulval problems of the postmenopausal woman - Tips and tricks.

Vulval irritation and discomfort can be a common presentation to both primary and secondary care. These symptoms can become increasingly prevalent due to physiological changes, which occur to the female genitalia following menopausal transition or due to inflammatory conditions. The correct diagnosis and management can have a huge impact on the patients' quality of life. However, due to the nature of the symptoms, there can be delayed presentation to healthcare professionals. This article gives an overview of the most common benign vulval conditions in the post-menopausal woman, their clinical features and the diagnosis and initial management.

Effect of rescue fractional microablative CO2 laser on symptoms and sexual dysfunction in women affected by vulvar lichen sclerosus resistant to long-term use of topic corticosteroid: a prospective longitudinal study.

OBJECTIVE: The objective of this study was to evaluate the efficacy of rescue fractional microablative CO2 laser treatment in women with severe symptoms and sexual dysfunction related to lichen sclerosus not responsive to long-term ultra-potent topical corticosteroid treatment. METHODS: Consecutive eligible women with lichen sclerosus referred to our unit who received fractional microablative CO2 laser treatment after failure of ultra-potent topical corticosteroid treatment were enrolled in the study. The diagnosis was confirmed by histological assessment in all cases. Patients underwent two cycles of CO2 laser every 30 to 40 days. The severity of lichen sclerosus-related symptoms, sexual function, and procedure discomfort were evaluated with a visual analog scale in the same individual at baseline, after completion of each treatment cycle. Follow-up visits were scheduled during each treatment cycle and at least 1 month after completion of the treatment. The Friedman ANOVA test was used to evaluate differences in the visual analog scale scores of each symptom during treatment. RESULTS: A total of 100 patients with vulvar lichen sclerosus were screened, 40 of whom fulfilled the eligibility criteria. We found a significant improvement in vulvar itching (χ [2] = 31,182, P < 0.001), vulvar dryness (χ [2] = 40,364, P < 0.001), superficial dyspareunia (χ [2] = 37,488, P < 0.001), and sensitivity during intercourse (χ [2] = 22,143, P < 0.001) after two CO2 laser cycles. Pain related to probe movement and laser application was low and did not change significantly consequent to treatment. No systemic or local adverse effects occurred during or after laser treatment. CONCLUSION: Fractional microablative CO2 laser treatment is safe and might represent an effective rescue procedure for patients suffering from lichen sclerosus who fail to respond to long-term ultra-potent topical corticosteroid treatment. These preliminary findings require further study with adequately powered randomized controlled trials.

Clitoral Phimosis: Effects on Female Sexual Function and Surgical Treatment Outcomes.

BACKGROUND: Surgery is the optimal treatment for a severe form of clitoral phimosis (CP) that is initiated by lichen sclerosus (LS) and causes female sexual dysfunction. AIM: We aimed to determine the etiology of clitoral phimosis, its influence on sexual function, and outcomes after surgical treatment. METHODS: In this prospective cohort study, we observed the occurrence of clitoral phimosis and related changes in a group of 3,650 sexually active heterosexual women with a mean age of 34.8 ± 14.9 years (20-45 years) from September 2014 to September 2016. Ultimately, we compared the changes in sexual function and distress and satisfaction with postoperative genital appearance in 9 patients with severe clitoral phimosis at 12 months after surgical treatment. MAIN OUTCOME MEASURES: Sexual function was evaluated using the Female Sexual Distress Scale-Revised and the Female Sexual Function Index, and the patient's genital self-image was evaluated using the Female Genital Self-Image Scale; gynecologic examinations were performed on all patients. RESULTS: Various forms of CP were found in 46 of 3,650 patients (1.3%). Severe forms of CP were found in 9 cases, but it was complicated by stenosis of vaginal introitus in only 2 cases. These 9 patients underwent circumcision, and 2 of them underwent perineoplasty. Female sexual dysfunction occurred mainly in those with LS and severe forms of phimosis. Sexual function, as indicated by the total Female Sexual Function Index score, was significantly improved at 12 months after surgery (17.9 ± 0.9 vs 26.6 ± 0.5; P < .001). The Female Genital Self-Image Scale score assessing genital perception was significantly higher after surgery than before in women who underwent clitoral circumcision (20 ± 3.0 vs 12.3 ± 3.3; P < .001). The Female Sexual Distress Scale-Revised score was significantly lower after surgery than before (21.3 ± 6.2 vs 33.8 ± 6.9; P < .001). Sexual function in 2 women with CP and stenosis of vaginal introitus improved after surgery, but the sexual distress level did not decrease significantly. CLINICAL IMPLICATIONS: The results of this study will help clinicians to centralize treatment methods and advise patients on the management of clitoral phimosis. STRENGTHS & LIMITATIONS: This is a study evaluating postoperative results of sexual function, distress, and satisfaction with genitalia in women with severe CP, using validated questionnaires. However, the small number of patients and the absence of an appropriate control group are limitations. CONCLUSION: Surgical treatment of clitoral phimosis can improve sexual function, but because LS-a common underlying cause-is chronic in nature, patients may experience recurrence. Chmel R, M Novácková, Fait T, et al. Clitoral Phimosis: Effects on Female Sexual Function and Surgical Treatment Outcomes. J Sex Med 2019;16:257-266.

Vulvar Dermatoses: A Review and Update.

The purpose of this article is to review six important inflammatory dermatoses of the vulva and to update readers on the new advancements in treatment of these mucosal conditions. Psoriasis, lichen sclerosis, lichen simplex chronicus and lichen planus are common vulvar conditions that cause pruritis and/or pain. PIasma cell vulvitis and desquamative inflammatory vaginitis are rare and challenging to be recognized, which often remain undiagnosed.

Vulvar lichen sclerosus: A new regenerative approach through fat grafting.

OBJECTIVE. The aim of this study was to evaluate the efficacy of fat grafting in the treatment of severe vulvar lichen sclerosus (LS). Our primary outcome was to assess the improvement of mucocutaneous trophism, the resolution/reduction of symptoms, and the histological features of the vulvar skin after treatment. The secondary outcome was to evaluate the improvement in life quality, and in resumption and quality of sexual life. METHODS. Between 2011 and 2014, 36 patients were offered fat grafting to treat LS. Inclusion criteria were age between 25 and 80 years, histopathologic diagnosis of LS, good health, failure of previous first line treatments. RESULTS. 34 out of 36 patients (94%) showed a better vulvar trophismof the skin and mucosae; 27 (75%) had an improvement in caliber and elasticity of the vaginal introitus; clitoris burying degree was reduced in 18 patients (50%), 30 (83%) reported an increased volume of labia major a and minor a, 34 (94%) had a complete disappearance of scratching lesions, and 28 (78%) showed a remission of white lesions. Eventually 34 patients (95%) stopped using topical corticosteroids routinely. The improvement in life quality was significant for both DLQI (p b 0001) and FSFI (p b 0001). CONCLUSIONS. Fat grafting may have a role as a support and completion treatment in selected cases of women with vulvar LS who do not respond to first line therapy or in severe cases where the anatomical impairment does not allow a regular sexual function and a good quality of life.

What differentiates symptomatic from asymptomatic women with lichen sclerosus?

AIMS: To investigate the differences between symptomatic and asymptomatic women with vulvar lichen sclerosus (LS). METHODS: Data on file concerning 228 LS patients was retrospectively reviewed. RESULTS: Most patients were symptomatic (193/228; 85%). Worsening of symptoms related to specific food intake was experienced by 26% (48/182) and pork was the most frequently cited (25/48; 52%); worsening at night was reported by 47% (87/185). Being over 50 years at the time of diagnosis or being menopausal were associated with being symptomatic (RR = 2.47, 95% CI: 1.15-5.29 and 6.55, 2.05-20.91, respectively). The same was true for urinary incontinence (UI) (5.23, 1.78-15.42), the use of absorbents (without UI) (3.59, 1.05-12.34) and dyspareunia (5.28, 1.64-17.0). All patients with a family history of LS were symptomatic. There was no association with hormonal factors or specific vulvar anatomical changes. CONCLUSIONS: Pork consumption may be involved in the worsening of symptoms. UI and the use of absorbents are more commonly present in symptomatic LS patients. Dietary changes and correction of UI might be useful in the control of LS symptoms. © 2015 S. Karger AG, Basel.

The impact of vulvar lichen sclerosus on sexual dysfunction.

BACKGROUND: Lichen sclerosus (LS) is a chronic inflammatory condition that is known to arise on the vulva. Many women with LS report vulvar pain, often affecting a patient's quality of life. In this study, the sexual function of LS patients, with and without pain, was compared to control populations. MATERIALS AND METHODS: A case-control study to examine the relationship between LS and sexual dysfunction was conducted. A total of 335 women presenting to the gynecology clinic were included in the study: 197 women with biopsy confirmed LS were compared to two control groups (95 asymptomatic women were "healthy" controls and 43 women had vulvovaginal candidiasis) on self-reported current health complaints, medical and surgical history and current symptoms such as pain and itching, type and frequency of sexual activity, and satisfaction with sexual activity. RESULTS: Women with LS reported less frequent sexual activity than healthy controls (p=0.007) and Candida controls (p=0.04). Currently sexually active women with LS were significantly less likely to report vaginal intercourse (71.6%) than healthy controls (89.0%, p=0.003) or Candida controls (100%, p=0.0003), even though similar proportions of all three groups reported that vaginal intercourse was important. Satisfaction towards the quality of current sexual activity was significantly lower among women with LS compared with both the healthy and Candida control groups. 23.7% of women with LS reported that sexual activity was rarely or never satisfactory as compared with 0% of healthy controls (p<0.0001) and 6.5% of Candida controls (p=0.03). CONCLUSION: Women with LS have less frequent sexual activity and less satisfying sexual activity when compared with controls.

Metalloproteinases 2 and 9 and their tissue inhibitors 1 and 2 are increased in vulvar lichen sclerosus.

OBJECTIVES: To evaluate the expression of different matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in vulvar lichen sclerosus (LS), a chronic dermatosis in women, histologically characterized by a zone of collagen remodeling in the superior dermis. STUDY DESIGN: Analysis of the expression of different MMPs (MMP-1, -2, -9 and -13) and TIMPs (TIMP-1 and -2) by reverse transcriptase-polymerase chain reaction (RT-PCR) in vulvar biopsies from patients with LS (n=11), classified according to Hewitt histological criteria and compared with clinically normal vulvar tissue (n=5), and the immunohistochemistry of MMP-2 and -9 and TIMP-1 and -2 distribution in the remodeling zone of LS (n=31) and in clinically normal vulvar tissue (n=28). RESULTS: Although no statistically significant difference between LS and normal skin groups at the mRNA level of MMP and TIMP transcripts was shown, an increase in the immunodistribution of MMP-2 and -9 and TIMP-1 and -2 in LS compared to normal vulvar skin was observed. CONCLUSIONS: These results suggest that these molecules could be related to the process of cutaneous collagen remodeling in LS pathology.

Health-related quality of life and patient-defined benefit of clobetasol 0.05% in women with chronic lichen sclerosus of the vulva.

BACKGROUND: This study investigates the health-related quality of life in patients with vulvar lichen sclerosus (LS) and the patient-defined therapeutic benefit of clobetasol. METHODS: A survey analysis of 96 women with LS after treatment with clobetasol was performed. Quality of life was assessed with the Skindex-29. The Patient Benefit Index (PBI) was used to determine the therapeutic benefit. RESULTS: The overall response rate was 59.2%. Quality of life was most impaired by somatic symptoms (scale 'Symptoms' score 3.2) and emotional stress (scale 'Emotions' score 3.1), while social interactions (scale 'Functioning' score 1.9) played an inferior role (p < 0.001). Primary therapeutic goals 'to have confidence in the therapy' and 'to be free of itching' were achieved in 73.2 and 69.0% of patients who indicated the goal applied to them. The global PBI score was 3.06. In 93.2% of patients it was >1, indicating a potential benefit from clobetasol. CONCLUSION: Topical clobetasol is of potential therapeutic benefit for patients with vulvar LS and might therefore improve quality of life.

The effect of vulvar lichen sclerosus on quality of life and sexual functioning.

Lichen sclerosus (LS) is a chronic skin disorder mostly seen on the female anogenital skin. The aim of this study was to evaluate the quality of life (QoL) and sexuality in female patients with LS and to compare their scores with healthy controls. In addition, we wanted to find factors associated with impaired sexual functioning in patients with LS. Members of the Dutch LS foundation and support group were asked to fill in three questionnaires: the Dermatology Quality of Life Index, Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS). 215 of 368 patients returned their questionnaire (58.4%). Their scores were compared to a control group which consisted of 61 women of similar age (p = 0.472) without a skin disorder. Of all domains of QoL, LS interfered most with sexual functioning. Patients significantly scored lower on all subscales of the FSFI (desire (p = 0.016), arousal (p < 0.001), lubrication (p < 0.001), orgasm (p < 0.001), satisfaction (p < 0.001) and pain (p < 0.001), indicating worse sexual functioning. These problems with sexual functioning brought about significant sexual distress (p < 0.001). Patients who experienced more influence on their QoL had more sexual difficulties, leading to more sexual distress independent of their age.

Vulvar lichen sclerosus in the elderly: pathophysiology and treatment update.

Lichen sclerosus is a chronic skin condition that most commonly affects the anogenital skin of postmenopausal women. The aetiology of the condition is multifactorial. The most common presenting symptom is itching. Lichen sclerosus has a characteristic appearance. Diagnosis is made with vulvar biopsy. Treatment is important and the regimen most often includes topical corticosteroid ointments. Lifetime surveillance of the skin is imperative because of the increased risk of squamous cell carcinoma in patients with lichen sclerosus.

Childhood onset vulvar lichen sclerosus does not resolve at puberty: a prospective case series.

When vulvar lichen sclerosus occurs in prepubertal children it is widely believed that it is likely to remit at puberty. However when it occurs in adult women it is accepted that remission is unlikely and that in addition untreated or inadequately treated disease may be complicated by significant disturbance of vulvar architecture and less commonly squamous cell carcinoma. Our database reveals 18 girls who developed lichen sclerosus prior to puberty who are now adolescents or young adults. Twelve have remained under surveillance and the other six patients have been lost to follow-up. We report a prospective series of these 12 patients. Three patients have achieved complete remission sustained for three or more years, all prior to menarche. Nine patients, or 75% of the cohort, who still had active lichen sclerosus at puberty continue to require maintenance therapy after menarche. Of the 12, six have had significant disturbance of vulvar architecture. The concept that prepubertal lichen sclerosus resolves at puberty would appear not to be true in the majority of patients. Even when diagnosed early and treated effectively, childhood onset lichen sclerosus may be complicated by distortion of vulvar architecture.

Lichen sclerosus in the differential diagnosis of suspected child abuse cases.

Lichen sclerosus in young females can present as traumatic injuries on the vulva which can mimic sexual abuse. The case of an unconscious 6-year-old girl presenting in a reported inflicted drug overdose and with a clinical picture of ecchymosis and abrasions of the anogenital area is presented and discussed. The following case underscores the need for clinicians evaluating children for suspected abuse, to consider alternate conditions and causes that may not be related to sexual abuse.

Open-label trial of cyclosporine for vulvar lichen sclerosus.

BACKGROUND: Lichen sclerosus (LS) is a chronic inflammatory disease of skin and mucosal surfaces which is generally difficult to treat. OBJECTIVE: We evaluated the efficacy of oral cyclosporine in refractory vulvar LS. METHODS: Five patients with refractory vulvar LS were treated with oral cyclosporine (3-4 mg/kg/d) for 3 months. They were followed up on a monthly basis. RESULTS: At the end of the treatment, the mean total symptom score regressed significantly and clinical findings such as erythema and erosion showed marked improvement. Mild adverse effects were seen in 3 patients. LIMITATIONS: The patients did not give consent to rebiopsy at the end of the treatment. CONCLUSION: Moderate dose of oral cyclosporine could be an effective alternative in the treatment of refractory vulvar LS.

[Endogenous factors in the development of leukoplakia and kraurosis vulvae]. / Nekotorye éndogennye faktory v razvitii leikoplakii i krauroza vul'vy.

Levels of tropic hormones of the pituitary, glucocorticoids and male and female sex hormones were assayed in 17 cases of kraurosis and leukoplakia of the vulva prior to treatment. Most patients revealed an abnormally high androgen/estrogen ratio, elevated level of glucocorticoids and low concentrations of thyrotropic hormone, prolactin and T3. The above disturbances are closely related and interdependent.