Treatment of Lichen Sclerosus Scarring with Topical Corticosteroids

Topical corticosteroids can improve active lichen sclerosus (LS) symptoms and inflammation but cannot reverse established scarring. 1, 2

Effectiveness of Topical Corticosteroids on Scarring

Ultrapotent topical corticosteroids (such as clobetasol propionate 0.05%) are the first-line treatment for LS in all patients regardless of age, sex, or affected site 1, 2
While corticosteroids effectively treat active inflammation, hyperkeratosis, ecchymoses, fissuring, and erosions, they cannot reverse existing atrophy and scarring 1
Established scarring will persist even after successful treatment of active disease 1
Early intervention with topical corticosteroids can prevent further scarring by controlling active disease 2

Apply clobetasol propionate 0.05% ointment once daily at night for 4 weeks, then on alternate nights for 4 weeks, and finally twice weekly for 4 weeks 1, 2
Approximately 60% of patients experience complete remission of symptoms with this regimen 1, 2
For patients with ongoing disease, continued use of clobetasol propionate 0.05% as needed for flares is recommended 1, 2
Most patients with ongoing disease require 30-60g of clobetasol propionate annually 1

In female patients, surgical intervention is only indicated for complications of scarring, premalignant change, or invasive squamous cell carcinoma (SCC) 1
In male patients, surgery may be necessary for severe irreversible phimosis or meatal stenosis when scarring has led to structural changes 1
Surgery should not be used for uncomplicated LS in female patients 1

Initial assessment should occur at 3 months after starting treatment to evaluate response 2
A second assessment should be performed 6 months later 2
Long-term follow-up in specialized clinics is unnecessary for uncomplicated disease that is well-controlled with small amounts of topical corticosteroid (less than 60g in 12 months) 1
Secondary care follow-up should be reserved for patients with complicated LS that is unresponsive to treatment 1

If treatment appears to fail, consider:
- Noncompliance issues (especially in elderly patients with mobility or vision problems) 1
- Incorrect diagnosis or superimposed conditions (contact allergy, urinary incontinence, infections, malignancy) 1
- Secondary sensory problems (vulvodynia) 1
- Mechanical problems due to scarring requiring surgical intervention 1

Early treatment is crucial to prevent progression to scarring 2
Untreated LS can lead to scarring within months 2
Obesity in both children and adults may accelerate scarring 2
Previous surgical interventions in affected areas may also accelerate scarring 2
Long-term use of clobetasol propionate in appropriate doses appears safe with no evidence of significant steroid damage or increased incidence of SCC 1

Mometasone furoate has shown effectiveness as an alternative to clobetasol propionate 1, 2
Topical calcineurin inhibitors (tacrolimus, pimecrolimus) have shown some efficacy but are not recommended as first-line treatment due to concerns about long-term safety and potential risk of neoplasia 1, 2
Systemic treatments should be reserved for severe, non-responsive cases 2