Improvement in quality of life and sexual function in patients affected by vulvar lichen sclerosus treated with combined autologous platelet-rich plasma and fat grafting.

BACKGROUND: Vulvar lichen sclerosus (LS) severely impairs patients' quality of life. OBJECTIVES: To evaluate the impact of a combined application of autologous platelet-rich plasma (PRP) and fat grafting as treatment for vulvar LS on patient quality of life. MATERIALS & METHODS: We reviewed the clinical charts of 72 patients affected by LS, who underwent regenerative surgery. The patients' quality of life was assessed using: the Dermatology Life Quality Index (DLQI), the Skindex-29, the Female Sexual Function Index (FSFI) and the patient-administered - Clinical Scoring System (CSS). RESULTS: After reconstructive surgery, all scores improved: Skindex-29 (-31.8 [IQR: 42.1, -21.8] points; p<0.001), FSFI (7.6 [IQR: 2.7, 14.7)] points; p<0.001), Patient-administered CSS (-24 [IQR: -30, -15] points; p<0.001), DLQI (-9 [IQR: -17, -7] points; p<0.001), Physician-administered CSS (-5 [IQR: -7, -5] points; p<0.001), and IGA (median ΔIGA: -4, IQR: -4, -3; p<0.001). CONCLUSION: Combined treatment with PRP and fat grafting proved to be effective in improving the quality of life of patients with vulvar LS.

Lichen Sclerosus and Sexual Dysfunction: A Systematic Review and Meta-Analysis.

BACKGROUND: Lichen sclerosus (LS) is a common autoimmune dermatological condition that is often under-diagnosed in women and has been documented to affect quality of life and sexual function. AIM: To determine the prevalence of sexual dysfunction among women with vulvar lichen sclerosus. METHODS: The authors conducted a systematic review and meta-analysis of the existing research on LS and sexual function in database including PubMed using search terms: lichen sclerosus OR vulvar lichen sclerosus OR vulvar lichen sclerosus et atrophicus OR kraurosis vulvae) AND (sexual function OR sexual functions OR sexual disorder OR sexual disorders OR sexual activity OR sexual activities OR sexual dysfunction OR sexual dysfunctions OR dyspareunia OR vaginismus). OUTCOMES: Nearly 60% of women with lichen sclerosus suffer from sexual dysfunction. RESULTS: Two hundred and ten studies were initially identified. Twenty-six articles met inclusion criteria and 3 were excluded as they did not relate to sexual function, were regarding a surgical or medical intervention and sexual dysfunction and one was a review article. Therefore, 23 studies were included in the final analysis resulting in a cumulative 486 participants with LS with 208 patients experiencing any kind of sexual dysfunction. Meta-analysis presented prevalence of sexual dysfunction among LS patients as 59% (95% CI: 48 - 70%). Dyspareunia or generalized pain with intercourse was the most commonly reported type of dysfunction. CLINICAL IMPLICATIONS: Discussing sexual concerns with women with LS could empower them to seek treatment. STRENGTHS AND LIMITATIONS: Few articles met criteria for inclusion. CONCLUSION: A large proportion of women with LS experience sexual dysfunction. More research is needed, especially that which includes biopsy-proven LS and validated tools on sexual function. Pope R, Lee MH, Myers A, et al. Lichen Sclerosus and Sexual Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med 2022;19:1616-1624.

Fractionated Carbon Dioxide Laser for the Treatment of Vulvar Lichen Sclerosus: A Randomized Controlled Trial.

OBJECTIVE: To estimate the efficacy of fractionated carbon dioxide (CO2) laser therapy for vulvar lichen sclerosus. METHODS: We conducted a prospective, double-blind, randomized, sham-controlled, trial conducted in a clinic specializing in vulvar disorders. The study participants were 40 women with active vulvar lichen sclerosus confirmed with biopsy who were abstaining from topical and systemic treatments for at least 4 weeks before enrollment. Women were randomized in a 1:1 ratio to receive either five sham laser treatments or five fractionated CO2 treatments in a 24-week period. Study participants, treating clinicians, and the evaluating pathologist were blinded. The primary endpoint was the change in the histopathology scale score between pretreatment and posttreatment biopsies. We estimated 20 per group for 80% power to detect a 40% reduction in the histopathology scale score with up to 10% attrition. A secondary endpoint was the change in the validated CSS (Clinical Scoring System for Vulvar Lichen Sclerosus). RESULTS: From November 2018 to June 2020, 40 women were randomized to participate in the trial, and 37 women (19 fractionated CO2, 18 sham) were included in an intention-to-treat (ITT) analysis. Three women were excluded from the ITT analysis because they did not have posttreatment biopsies and, therefore, a posttreatment histopathology scale score could not be obtained. There was a 0.20 reduction (improvement) in histopathology scale score from baseline in the active treatment group (95% CI -1.1, 0.80, P=.74) and a 0.1 increase from baseline in the sham treatment group (95% CI -0.90, 1.0, P=.91). The change in histopathology scale score between the active and sham arm was not statistically significant (95% CI -1.14, 1.06, P=.76). CONCLUSION: Fractionated CO2 is not an effective monotherapy treatment for vulvar lichen sclerosus. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03665584. FUNDING SOURCE: Additional funding for this study was supplied by El.En Group, Florence, Italy, the manufacturer of the laser used in this study. In addition, El.En Group supplied the laser used in the study.

Outcome of perineoplasty and de-adhesion in patients with vulvar Lichen sclerosus and sexual disorders.

OBJECTIVE: Vulvar Lichen sclerosus (LS) is a chronic inflammatory disease in which architectural changes and symptoms like itching, soreness, pain and dyspareunia can affect quality of life and sexual activity. Perineoplasty has been shown to be effective as a supportive surgical treatment in women with refractory dyspareunia in addition to the standard topical immunosuppressive treatment. The aim of this study was to evaluate retrospectively general complaints, patient satisfaction concerning sexual activity, reduction of dyspareunia/apareunia, orgasm ability and recurrence of LS after perineoplasty. STUDY DESIGN: This study is a retrospective monocentric observational study, in which patients with vulvar LS who had undergone perineoplasty were invited to fill out a standardized questionnaire during the follow-up time. The main outcome measure is the overall patient satisfaction after surgical therapy of vulvar LS. RESULTS: Forty-one of the 70 invited patients with a median age at surgery of 58 years (18-74 years) and a median 60 years (19-76 years) at the last follow-up were evaluated. The median follow-up time was 2.3 years (1-5 years). There was a significant (p < 0.001) reduction in general complaints after surgery. Twenty-two patients were very satisfied, 15 were satisfied and 3 were not satisfied with the outcome of the surgery. Only 2 patients would not recommend the surgery. Although, there was a significant (p = 0.02) reduction in dyspareunia after surgery, 10 patients still felt pain during sexual intercourse. CONCLUSION: This is one of the largest studies reporting on long-term results of perineoplasty. It showed that perineoplasty is a safe surgical treatment option with a high satisfaction rate in patients with dyspareunia due to LS and a desire to regain sexual activity. Perineoplasty can improve sexual activity and achieve overall satisfaction in selected patients even though the recurrence rate of LS in sexually active patients remains high.

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.

Vulval lichen planus-lichen sclerosus overlap.

Vulval lichen planus-lichen sclerosus overlap is an emerging observation. Few clinical reports exist with no reviews of literature. We present a focused update of this phenomenon and discuss a clinical case. We report a 63-year-old woman with a 20-year history of ulcerative vulvo-vaginitis, initially diagnosed as benign mucous membrane (cicatricial) pemphigoid. This led to prolonged treatment with oral corticosteroids with minimal improvement in symptoms. Subsequent complications of long-term use of systemic corticosteroid ensued. A clinico-pathological diagnosis of severe erosive lichen planus was made on clinical findings and on non-specific biopsy changes of ulceration and inflammation. Treatment with topical clobetasol propionate 0.05% ointment twice daily led to dramatic improvement of ulceration, easing of discomfort and marked improvement in quality of life. Clinical examination revealed Wickham's striae on the labia majora supporting the diagnosis. Six years after commencement of topical clobetasol, white plaques were noticed on the labia majora, perineum and peri-anal region consistent with lichen sclerosus, confirmed by repeat vulval skin biopsy and on vulvectomy. This case highlights the challenge of diagnosis of extensive vulvo-vaginal ulceration and the necessity to re-examine a previous diagnosis if there is poor response to treatment.

Short- and long-term efficacy of focused ultrasound therapy for non-neoplastic epithelial disorders of the vulva.

OBJECTIVE: To investigate the short- and long-term efficacy and influential factors of focused ultrasound for the treatment of non-neoplastic epithelial disorders of the vulva (NNEDV). DESIGN: A retrospective observational study. SETTING: A gynaecologic department in a single centre in China. POPULATION: Patients with NNEDV were included in this study: 85 patients were diagnosed with lichen simplex chronicus (LSC), 44 patients with vulva lichen sclerosus (VLS), and seven patients with lichen planus (LP). METHODS: A total of 136 eligible patients with NNEDV were treated with focused ultrasound. After the treatment, based on changes in the degree of symptom severity and local skin signs (lesion size, skin colour and elasticity) before and after treatment, the treatment effectiveness for each patient was assessed. We further analysed the relations among pathologic type, age, course and curative rate. Statistical analysis was performed using the Chi-square (McNemar) test. MAIN OUTCOME MEASURES: Improvement in the symptoms and physical signs and the predictive factors. RESULTS: Symptom relief was observed in all patients. The appearance and colour of the vulva returned to normal after the ultrasound treatment. Complete remission (CR) occurred in 68 of 136 (50%) patients (41 patients with LSC and 12 patients with VLS). The response rate was 93.38% (127/136). Seven patients who had a poor response to the first session of treatment were treated again with ultrasound therapy and a good response was observed. No severe complications were observed. There was no significant difference in treatment results among the different pathological types (P > 0.05). However, the course of the disease and the age of the patients were related to the treatment results (P < 0.05). CONCLUSIONS: NNEDV can be treated with focused ultrasound effectively and safely. The course of the disease and the age of the patients may be predictive factors. TWEETABLE ABSTRACT: Patients with non-neoplastic epithelial disorders of the vulva can be safely and effectively treated with focused ultrasound. No significant difference in treatment results was observed between the different types of non-neoplastic epithelial disorders of the vulva.

Surgical treatment of disabling conditions caused by anogenital lichen sclerosus in women: An account of surgical procedures and results, including patient satisfaction, benefits, and improvements in health-related quality of life.

BACKGROUND: Anogenital lichen sclerosus (LS), a chronic dermatitis that causes scarring and introital stenosis, may prevent sexual intercourse and reduce health-related quality of life (QoL). Surgery can restore the anatomy, allowing patients to resume their sexual lives. This study investigates outcomes in women treated with local skin flaps. METHODS: Thirty-eight consecutive LS-verified patients, surgically treated for debilitating conditions between 1990 and 2013, were retrospectively evaluated. A survey measured patient satisfaction, benefits, and health-related QoL, and the patients were also evaluated by a long-term clinical follow-up. RESULTS: In total, 33 patients (87%) experienced dyspareunia, 24 of whom could not perform coitus. At mean short-term follow-up (10.0 months), only five patients (15%) reported dyspareunia; for seven patients, the outcome was unknown. The survey response rate was 87%, and the mean time from treatment to response was 7.6 years. Twenty of 24 patients reported dyspareunia. Seventy-five percent of patients with preoperative dyspareunia reported a surgical benefit, 74% were satisfied/very satisfied with the cosmetic and overall results, respectively, and 58% reported that surgery had improved their sexual lives. The mean long-term clinical follow-up was 8.4 years. The follow-up rate was 78%. The main reason for recurrent dyspareunia was minor LS relapse (50%); these patients were still able to have coitus, and dyspareunia was reported as considerably minor compared to before surgery; 38% had more severe LS relapse, resulting in apareunia. CONCLUSIONS: Surgery for LS sequelae provides acceptable short-term functional results, enabling patients to resume coitus, with high patient satisfaction reported. However, the chronic relapsing nature of LS consequently provides varying and often short-term coital improvements following surgery.

A Qualitative Study on Experiences After Vulvar Surgery in Women With Lichen Sclerosus and Sexual Pain.

INTRODUCTION: Lichen sclerosus (LS) of the vulva can profoundly affect sexual interaction because of painful fissures and narrowing of the vaginal introitus. Successful surgical treatment is usually defined as restoration of (pain-free) penetrative sexual activity. AIMS: To evaluate the impact of surgery on (dyadic) sexual functioning and pleasure and psychological well-being. METHODS: Nineteen women with anogenital LS participated in audiotaped, qualitative, individual interviews after surgery to re-enable sexual intercourse. MAIN OUTCOME MEASURES: Physical, sexual, and psychological experiences were analyzed using the constant comparative method. RESULTS: Vulvar surgery resulted in a decrease of sexual pain in 13 of 19 patients (68%). Of these 13 patients, 4 were completely free of pain and the other 9 patients expressed a shift from preoperative sexual pain to postoperative sexual discomfort. These women reported improved sexual functioning, increased sexual activity and intimacy with the partner, and reinstated feelings of being an adequate woman and sexual partner. In 1 of the 19 patients (5%), surgery did not result in decreased sexual pain, yet she continued to have intercourse. Five of the 19 patients (26%) stopped having intercourse because of pain; one woman had secondary vaginismus and another woman, in retrospect, had premorbid generalized unprovoked vulvodynia. Four of these women were unable to communicate with their partner about sexual matters and to change their sexual repertoire (satisfactorily) once they had ceased intercourse (attempts). Eighteen women (95%) reported a decrease of LS symptoms in daily life. CONCLUSION: Vulvar surgery seems an effective treatment for most women with LS who experience sexual pain owing to anatomic or epithelial changes and who wish to resume intercourse. To assess whether women might benefit from such surgery and/or whether (additional) sexual counseling is indicated, preoperative sexological couple-based consultation is needed. This consultation should exclude comorbid vaginismus and generalized unprovoked vulvodynia and index the couple's pre-existing sex life, including sexual communication skills, and the ability to incorporate non-coital pain-free sexual activities.

Motives for Vulvar Surgery of Women with Lichen Sclerosus.

INTRODUCTION: Women with lichen sclerosus (LS) may experience (superficial) dyspareunia or the inability to have vaginal intercourse due to painful fissures and narrowing of the vaginal introitus. A surgical procedure may contribute to the relief of these sexual pain problems. It is unknown what motives women have to undergo surgery in order to regain the ability to have sexual intercourse. Such knowledge can offer important insights that are indispensable when discussing the option of vulvar surgery with patients with LS and might prevent potential patient dissatisfaction. This study's purpose is to examine why women with LS decide to undergo vulvar surgery in order to restore intercourse. METHODS: Nineteen women with anogenital LS participated in audiotaped qualitative individual interviews, in which their motives for undergoing vulvar surgery to restore intercourse were explored retrospectively. Interview data were analyzed using the constant comparative method. RESULTS: Three main motives for wanting to undergo surgery in order to restore intercourse were found. These were the desire to be a "normal" woman, the desire to sexually satisfy the male partner, and the desire to regain the experience of intimacy and sexual enjoyment. Another reason for surgery was to reduce daily life LS symptoms. The sexual pain complaints prevented the women from living up to their norms about heterosexuality and gender roles. Being unable to have intercourse led women to feel inadequate as a woman and as a sexual partner. CONCLUSIONS: Women with LS may opt for surgery to restore their identity as a "normal" woman and sexual partner, to regain the experience of coital intimacy, and to be less bothered by LS symptoms in daily life. The present findings point to the importance of a thorough couple-based sexual history in which women's motives for and expectations of vulvar surgery will be explored in order to facilitate a good decision and to increase treatment satisfaction.

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.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus.

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

Recent trends in surgical and reconstructive management of vulvar cancer: review of literature.

Vulvar cancer (VC) is a rare disease. The most common histologic type is squamous-cell carcinoma. VC could be divided into two types: type one, commonly associated with HPV infection, occurs in young women and type two, associated with non-neoplastic lesions that usually occurs in older women. Previously VC was often treated with radical Vulvectomy. Today update in diagnostic and surgery technique, capable to identify early stages of disease and adaptation in surgery procedures, according to the stage of disease, age of patients and possible physical and psychological morbidity consequence, allow using less radical surgery approaches. That has led to decrease therapy-associated morbidity while preserving oncologic safety and improving psychosexual outcomes. Finally, several surgical treatments are available in case of VC and, despite radical surgery is often required, less radical surgery associated with reconstructive plastic surgery decreases some of short- and long-term associated complications.

Influence of treatments on prognosis for vulvar lichen sclerosus: facts and controversies.

Lichen sclerosus (LS) is an inflammatory dermatosis with a predilection for the anogential skin. Vulvar LS can be a debilitating disease, causing pruritus and pain, and it carries the potential for atrophy, scarring, and significant functional impairment. Recently, many advances have been made regarding the etiology and natural history of the disease process; however, much debate still exists regarding the most advantageous medical and surgical management of this disorder. In an effort to provide a comprehensive review on current vulvar LS literature, the following three controversies will be discussed: (1) optimal disease treatment, (2) theories behind LS's oncogenicity and treatments for minimizing malignancy, and (3) the value of surgical treatment for LS. Ultra-potent topical corticosteroids (TCSs) are the first-line treatment for vulvar LS, while topical calcineurin inhibitors (TCIs) remain second-line agents for patients for whom TCS treatment resulted in incomplete resolution of symptoms or adverse events. Due to the relapsing nature of the disease, long-term maintenance therapy is often required. In addition, recent advances have contributed to the understanding of the association between LS and squamous cell carcinoma (SCC). While the exact mechanism responsible for LS-associated SCC is not known, immune dysregulation and inflammation may play an important role; therefore, successful treatment of LS should be directed towards alleviation of symptoms and reversal of the underlying histopathologic changes. Patients with LS-associated malignancy, as well as patients who need correction of functionally restrictive, scarring processes, can successfully undergo surgical intervention with tissue conservation.

Surgical division of labial adhesions in vulvar lichen sclerosus and lichen planus.

OBJECTIVE: Vulvar lichen sclerosus (LS) and lichen planus (LP) may cause persistent symptomatic labial adhesions. In the scant literature on this topic, there is no agreement about which operation is suitable, or the role of suppressive medical therapy. We report on simple perineotomy in the context of careful preoperative and postoperative medical suppressions. MATERIALS AND METHODS: Thirty-five patients were identified within a referral vulvar practice, with symptomatic labial adhesions due to LS or LP. After sharp dissection of adhesions and injection of anesthesia, patients doubled the frequency of their preoperative therapy and underwent close surveillance until complete healing had occurred. Suppression of the inflammatory process was continued indefinitely with regular review. RESULTS: Mean age was 57 years. Of the patients, 27 had LS and 8 had LP. Of the 35 patients, 28 (80%) had dyspareunia or apareunia. Mean symptom duration was 9 years. Of the 35 patients, 21 had posterior fusion, 11 had anterior fusion, and 3 had both anterior and posterior fusions. Of the 35 patients, 17 had mild fusion, 11 had moderate fusion, and 7 had severe introital stenosis. At the 3-month review, 31 of the 35 patients had no refusion. Mean duration of follow-up was 2 years (range = 3 months to 7.5 years). Of the 35 patients, 29 had no late refusion during this time. Of the 18 patients with dyspareunia, 8 had no pain, and 9 had less pain. Of the 10 patients with apareunia, 1 could have sex without pain, and 6 could have sex but with pain. CONCLUSION: Simple perineotomy is adequate to treat persistent labial adhesions, provided that the inflammatory process is carefully suppressed.

Mohs micrographic surgery for verrucous carcinoma of the anogenital area: report of two cases.

BACKGROUND: Verrucous carcinoma (VC) of the anogenital area is an uncommon variant of squamous cell carcinoma (SCC). Its treatment is not standardized, but surgical excision must be performed if possible. The traditional approach does not distinguish between conventional SCC and VC, despite the extremely low metastatic potential of VC. Accordingly, most patients reported in the literature have been treated with radical surgery, including regional lymphadenectomy. METHODS: We report two cases in order to describe the oncologic, functional, and esthetic results achieved by Mohs micrographic surgery (MMS) in the treatment of this disease. RESULTS: Good functional and esthetic results were achieved in both patients. No local or nodal relapses were detected during the respective 12- and 27-month follow-ups. CONCLUSIONS: Early recognition of VC and the proper evaluation of deep biopsies will avoid misdiagnosis as SCC and may prevent the occurrence of unnecessary disfiguring interventions. The MMS technique may be considered as a surgical approach in genitoanal VC, although further research is required to confirm this.

Lichen sclerosus: a review of literature and a case of an atypic surgical treatment.

Lichen sclerosus is a chronic immuno-mediated skin disease of the genital region in men and women. The treatment may be pharmacological or surgical, the choice depending on the extension of the involved area, the histological pattern and the level of functional disease complained by the patient. If the biopsy is negative for neoplastic degeneration the treatment may be pharmacological only. In our paper, we describe the case of a patient with vulvar disease and labial fusion, burial of the clitoris and severe introital stenosis. In this case, the treatment was surgical.