Diagnosis and Management of Vulvovaginal Lichen Planus

Abstract

Importance Genital lichen planus is a debilitating disorder that lacks definitive recommendations regarding diagnosis and treatment. Objective The aim of this study was to present best practices from available evidence for the diagnosis and treatment of genital lichen planus. Evidence Acquisition We conducted a narrative review of the literature on genital lichen planus by searching PubMed using the following search terms: “vulvar lichen planus” OR (vulvar diseases[mesh] OR vulva[mesh]) AND lichen planus[mesh] OR vulvar[ti] AND “lichen planus”[ti]. We included all languages and years in the search. Results The search resulted in 273 citations that we reviewed for relevancy and selected 60 as the foundation for this review that focuses on genital sites. Diagnosis can be made without biopsy, and when a biopsy is taken, the pathologic findings may be nonspecific. Topical ultrapotent corticosteroids are most commonly used as first-line treatment of genital lichen planus. Conclusions and Relevance When patients present with genital lichen planus, a complete review of systems and a thorough physical examination should be performed because of the prevalence of extragenital sites. Treatment of genital disease should start with a topical, ultrapotent steroid, and follow-up visits should occur to ensure improvement and to monitor for adverse drug reactions and malignancy. Target Audience Obstetricians, gynecologists, and family physicians. Learning Objectives After reading this article, readers should be able to differentiate between lichen planus and other common vulvar dermatoses on physical examination; evaluate a patient for nongenital manifestations of lichen planus; assess if a vulvar biopsy is necessary for diagnosis; and construct a management plan for patients affected by genital lichen planus.

Vulvovaginal erosive lichen planus refractory to topical therapies: What's next? A case report

“…Genital subtypes of LP can be categorized into three main subtypes: erosive, classic, and hypertrophic. The erosive subtype is the most prevalent of these and usually exhibits a raw, erosive inflammatory pattern of lesions that are often a local manifestation of widespread disease [ 2 , 3 , 9 , 10 ]. The differential diagnosis of vulvar LP includes lichen sclerosis, autoimmune blistering disorders, herpes zoster, and non-HPV-associated vulvar intraepithelial neoplasms and squamous cell carcinoma.…”

“…Positive biopsies show classic lichenoid features (band-like lymphocytic infiltrate), basal layer damage, and absent subepithelial sclerosis. [ 1 , 9 , 14 , 16 ] Accurate and timely diagnosis of vulvovaginal LP requires a high level of clinical suspicion and collaboration between specialties, including dentists (for oral or gingival lesions), dermatologists, and gynecologists.…”

“…There is considerable experience with commercially available hydrocortisone suppositories 25 mg for vaginal involvement. [ 4 , 9 ]. Because of the rarity of vulvovaginal LP, no adequately powered randomized controlled trials exist to guide therapy when topical steroids fail.…”

“…Because of the rarity of vulvovaginal LP, no adequately powered randomized controlled trials exist to guide therapy when topical steroids fail. [ 6 , 9 ] When topical therapies fail to provide an adequate response for vulvovaginal LP, systemic steroids or immunosuppressant agents should be initiated, but there is noticeably less evidence available to guide selection. [ 6 ]…”

“…The optimal long-term systemic therapy for LP is unclear. [ 3 , 6 , 9 , 10 , 17 ] In this case, hydroxychloroquine was initially elected because of relatively low toxicity and low-moderate adverse event rate, the most common being gastrointestinal distress. Evidence for hydroxychloroquine effectiveness in LP has been found in small case series.…”