From the Guidelines
The first-line treatment for vulval lichen sclerosus in a 47-year-old woman is clobetasol propionate 0.05% ointment, applied once daily for a month, alternative days for a month, and twice weekly for a month, as recommended by the British Association of Dermatologists guidelines 1. This treatment approach is based on the most recent and highest quality study available, which prioritizes morbidity, mortality, and quality of life as the outcome. The guidelines suggest offering all female patients with anogenital lichen sclerosus clobetasol propionate 0.05% ointment on the specified regimen, combined with a soap substitute and a barrier preparation.
Key points to consider when treating vulval lichen sclerosus 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 consider an individualized treatment regimen of topical steroid to maintain disease control and prevent scarring in female patients with ongoing active lichen sclerosus disease despite good compliance 1.
- The potential for referral to a specialist vulval clinic in all female patients with lichen sclerosus not responding to a topical steroid, or if surgical management is being considered 1.
In terms of application, a pea-sized amount (approximately 0.5g) is sufficient to cover the entire vulval area, and patients should be instructed to apply the medication to the affected areas only, avoiding healthy skin. After initial treatment, clinical improvement should be assessed at 3 months, and if symptoms persist, consider increasing the potency or frequency of application. Topical corticosteroids work by reducing inflammation, suppressing immune responses, and decreasing itching and irritation, with side effects being uncommon with appropriate use 1. Emollients can be used alongside corticosteroids to maintain skin hydration.
It is essential to prioritize the most recent and highest quality study available, which in this case is the British Association of Dermatologists guidelines from 2018 1, over older studies such as the guidelines from 2002 1, to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.
From the FDA Drug Label
CLINICAL PHARMACOLOGY The corticosteroids are a class of compounds comprising steroid hormones secreted by the adrenal cortex and their synthetic analogs. In pharmacologic doses, corticosteroids are used primarily for their anti-inflammatory and/or immunosuppressive effects Topical corticosteroids such as clobetasol propionate are effective in the treatment of corticosteroid-responsive dermatoses primarily because of their anti-inflammatory, antipruritic, and vasoconstrictive actions.
The appropriate topical treatment for a 47-year-old woman with vulval lichen sclerosus is clobetasol propionate 2.
- Clobetasol propionate is a topical corticosteroid that has been shown to be effective in the treatment of corticosteroid-responsive dermatoses, including lichen sclerosus.
- However, the provided drug labels do not explicitly state the dosage and administration for vulval lichen sclerosus, only for scalp psoriasis.
- Therefore, the dosage and administration for vulval lichen sclerosus should be determined by a healthcare professional.
From the Research
Topical Treatment for Vulval Lichen Sclerosus
The appropriate topical treatment for a 47-year-old woman with vulval lichen sclerosus includes:
- Ultra-potent and potent corticosteroids, administered for 12 weeks, as the first-line recommended treatment for active VLS 3
- Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, as effective and safe alternatives 3, 4, 5, 6
- Long-term maintenance strategies aimed at preventing recurrences, which mostly consist of topical corticosteroids, administered on an "as needed" basis, on a continuative regimen, or on a low-dose, intermittent regimen 3
Treatment Options
Some studies have compared the efficacy of different topical treatments for vulval lichen sclerosus, including:
- Clobetasol versus pimecrolimus: clobetasol was found to be superior in improving inflammation 5
- Clobetasol versus tacrolimus: clobetasol was found to be significantly more effective in treating vulvar lichen sclerosus than topical tacrolimus 6
- Pimecrolimus as a safe and effective treatment for vulvar lichen sclerosus, with 3 out of 4 patients reporting complete resolution of symptoms after 3 months of treatment 4
Key Considerations
When choosing a topical treatment for vulval lichen sclerosus, it is essential to consider the potential risks and benefits of each option, including: