From the Guidelines
Vaginal estrogen is not a primary treatment for lichen sclerosis, and the first-line treatment is a potent topical corticosteroid such as clobetasol propionate 0.05% ointment. The most recent and highest quality study, published in 2018 by the British Association of Dermatologists, recommends offering all female patients with anogenital lichen sclerosus clobetasol propionate 0.05% ointment on a specific regimen for 3 months, combined with a soap substitute and a barrier preparation 1. Vaginal estrogen may be used as an adjunctive therapy in postmenopausal women with lichen sclerosus who also have vaginal atrophy symptoms, but it does not treat the underlying lichen sclerosus condition itself. Estrogen can help improve the overall health of vaginal tissues by increasing blood flow, elasticity, and moisture, which may provide some symptomatic relief when used alongside proper corticosteroid treatment. However, using estrogen alone is insufficient because lichen sclerosus is primarily an inflammatory and autoimmune condition rather than a hormone-dependent disorder.
Some key points to consider when treating lichen sclerosus include:
- The use of clobetasol propionate 0.05% ointment as the first-line treatment, with a specific regimen for 3 months 1
- The importance of combining topical corticosteroid treatment with a soap substitute and a barrier preparation 1
- The potential for vaginal estrogen to be used as an adjunctive therapy in postmenopausal women with lichen sclerosus and vaginal atrophy symptoms
- The need for patients to consult with a dermatologist or gynecologist experienced in treating lichen sclerosus to develop an appropriate treatment plan that may include both corticosteroids and, if indicated, vaginal estrogen therapy.
It is also important to note that the long-term use of clobetasol propionate is safe, with no evidence of significant steroid damage or an increase in the incidence of squamous cell carcinoma, as shown in a study published in 2010 by the British Association of Dermatologists 1.
From the Research
Treatment of Lichen Sclerosus
- The gold standard in treatment is ultra-potent topical steroids (clobetasol propionate) 2
- Second-line treatments include calcineurin inhibitors, retinoids, and immunosuppressors 2
- Surgery is used only for the treatment of complications associated with lichen sclerosus 2
Efficacy of Topical Progesterone
- Topical progesterone 8% ointment is inferior to standard therapy with topical clobetasol propionate 0.05% in previously untreated premenopausal women with vulvar LS after 12 weeks treatment 3
- The mean clinical LS scores improved from 4.6 to 2.9 in the clobetasol propionate arm, and from 4.6 to 4.5 in the progesterone arm 3
Vaginal Estrogen and Lichen Sclerosus
- There is no direct evidence to suggest that vaginal estrogen helps with lichen sclerosis 2, 3, 4, 5, 6
- The treatment options for vulvar lichen sclerosus include high-potency topical steroids, but vaginal estrogen is not mentioned as a treatment option 5
Treatment Options
- High-potency topical steroids are now the standard of care and first-line treatment for vulvar lichen sclerosus 5
- Follow-up may be done every three to six months for the first two years and then at least yearly to ensure adequacy of treatment and encourage compliance 5
- Long-term follow-up in specialist clinics is recommended for women who have persistent complaints, thickened skin, or history of neoplastic lesion 5