What is the most appropriate treatment for a postmenopausal woman with vulvar itching, dryness, and a white plaque, diagnosed with lichen sclerosis (no evidence of malignancy)?

From the Guidelines

The most appropriate treatment for this postmenopausal woman with lichen sclerosis is clobetasol propionate 0.05% ointment applied topically, as recommended by the British Association of Dermatologists' guidelines for the management of lichen sclerosus 2018 1. This treatment directly addresses the symptoms of vulvar itching, dryness, and white plaque associated with lichen sclerosis. The guidelines recommend a regimen of clobetasol propionate 0.05% ointment applied once daily for a month, alternate days for a month, and twice weekly for a month, combined with a soap substitute and a barrier preparation. Some key points to consider when treating this patient include:

• The importance of discussing the amount of topical treatment to be used, the site of application, and the safe use of an ultrapotent topical steroid with the patient 1.
• The need to offer continued use of clobetasol propionate 0.05% for ongoing active lichen sclerosis disease, with treatment titrated to maintain symptoms and resolution of skin thickening and ecchymosis 1.
• The potential for individualized treatment regimens to maintain disease control and prevent scarring in female patients with ongoing active lichen sclerosis disease despite good compliance 1.
• The consideration of referral to a specialist vulval clinic in all female patients with lichen sclerosis not responding to topical steroid, or if surgical management is being considered 1. The use of clobetasol propionate 0.05% ointment has been shown to be safe and effective in the long-term management of lichen sclerosis, with about 60% of patients experiencing complete remission of their symptoms 1.

From the Research

Treatment Options for Lichen Sclerosis

• The current first-line therapy for vulvar lichen sclerosus (VLS) is topical corticosteroids, specifically high-potent ones like clobetasol propionate 2, 3.
• Clobetasol propionate has been shown to be effective in reducing symptoms of VLS, including pruritus, burning, and pain, as well as improving quality of life 2.
• UV-A1 phototherapy may be considered a potential second-line treatment for VLS, although it was found to be inferior to topical corticosteroids in terms of practicability, relief of itch, and improvement in quality of life 2.
• Other treatment options, such as calcineurin inhibitors like tacrolimus, may also be used to maintain remission in patients with VLS, especially in pediatric cases 4.

Comparison of Treatment Options

• A study comparing clobetasol propionate with UV-A1 phototherapy found that both treatments resulted in significant clinical improvement, but clobetasol propionate was more effective in reducing symptoms and improving quality of life 2.
• Another study found that the use of clobetasol to induce remission and tacrolimus to maintain remission can be an effective treatment regimen for pediatric females with VLS 4.
• However, it is essential to note that the potency of clobetasol propionate is accompanied by local and systemic side effects, such as skin atrophy and hypothalamic-pituitary-adrenal axis suppression 3.

Considerations for Treatment

• The choice of treatment should be based on the individual patient's needs and circumstances, taking into account factors such as the severity of symptoms, potential side effects, and patient compliance 3.
• Patients applying clobetasol propionate must be well instructed in how to use it, and physicians prescribing it should consider a diversity of factors and be able to answer questions about its use 3.