What are the treatment options for severe lichen sclerosus (LS) causing adhesions that nearly obstruct the vaginal introitus?

From the Guidelines

Treatment for severe lichen sclerosus with vaginal adhesions should start with potent topical corticosteroids, specifically clobetasol propionate 0.05% ointment, applied once daily for a month, then on alternate days for a month, and finally twice weekly for a month, as recommended by the British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018 1. This approach is based on the most recent and highest quality evidence available, which prioritizes the use of ultrapotent topical corticosteroids as the first-line treatment for anogenital lichen sclerosus in adult females. Key points to consider in the management of severe lichen sclerosus with vaginal adhesions include:

• The use of clobetasol propionate 0.05% ointment as the initial treatment, with the goal of reducing symptoms and preventing further scarring.
• 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, as emphasized in the guidelines 1.
• The consideration of referral to a specialist vulval clinic for patients with lichen sclerosus that does not respond to topical steroid treatment or if surgical management is being considered, as recommended by the guidelines 1.
• The potential need for surgical intervention, such as perineoplasty or vulvoperineoplasty, to release adhesions and restore the vaginal opening in severe cases, with continued use of topical corticosteroids post-operatively to prevent recurrence.
• The use of alternative treatments, such as topical calcineurin inhibitors like tacrolimus 0.1% ointment, for patients who do not respond to corticosteroids.
• The recommendation for regular follow-up with a specialist to monitor for the small risk of malignant transformation associated with long-standing disease, as well as to adjust treatment as needed to maintain disease control and prevent scarring. It is essential to prioritize the most recent and highest quality evidence, such as the British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018 1, when making treatment decisions for severe lichen sclerosus with vaginal adhesions.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: Apply a thin layer of clobetasol propionate gel, cream or ointment to the affected skin areas twice daily and rub in gently and completely. PRECAUTIONS: General: Clobetasol propionate is a highly potent topical corticosteroid that has been shown to suppress the HPA axis at doses as low as 2 g per day.

The treatment options for severe lichen sclerosis causing adhesions that nearly close off the vaginal opening may include topical corticosteroids such as clobetasol propionate.

• Application: Apply a thin layer of clobetasol propionate gel, cream, or ointment to the affected skin areas twice daily and rub in gently and completely 2.
• Duration: Treatment should be limited to 2 consecutive weeks, and amounts greater than 50 g per week should not be used 2.
• Precautions: Patients applying a topical steroid to a large surface area or to areas under occlusion should be evaluated periodically for evidence of HPA axis suppression 2.
• Key considerations: Clobetasol propionate gel, cream, and ointment should not be used with occlusive dressings, and patients should report any signs of local adverse reactions to the physician 2.

From the Research

Treatment Options for Severe Lichen Sclerosis

• Topical corticosteroids, such as clobetasol propionate 0.05%, have been shown to be effective in treating genital lichen sclerosus, including reducing symptoms and improving quality of life 3.
• Mometasone furoate 0.05% has also been found to be effective in improving symptoms, particularly in reducing the clinical grade of phimosis 3.
• Pimecrolimus has been shown to be less effective than clobetasol propionate in relieving symptoms, but may still be a viable option for some patients 3.
• Antibiotic therapy, such as penicillin or cephalosporins, may be effective in treating lichen sclerosus, particularly in patients who have responded poorly to topical corticosteroids 4.
• A treatment regimen involving clobetasol to induce remission, followed by tacrolimus to maintain remission, has been shown to be effective in treating pediatric females with lichen sclerosus 5.
• Surgical division of labial adhesions may be necessary in some cases, particularly in patients with severe introital stenosis or persistent symptomatic labial adhesions 6.

Adhesions and Surgical Intervention

• Surgical division of labial adhesions can be an effective treatment option for patients with vulvar lichen sclerosus or lichen planus who have persistent symptomatic labial adhesions 6.
• Simple perineotomy, combined with careful preoperative and postoperative medical suppression, can be an adequate treatment for persistent labial adhesions 6.
• Suppressive medical therapy, such as topical corticosteroids, should be continued indefinitely to prevent refusion of the adhesions 6.

Topical Corticosteroids

• Clobetasol propionate 0.05% cream has been shown to be effective in treating vulval lichen sclerosus, with significant clinical and histological improvement after 12 weeks of treatment 7.
• High-potency topical corticosteroids, such as clobetasol propionate, are currently recommended as the first-line treatment for lichen sclerosus 3, 7.