EROSIVE VULVAR LICHEN PLANUS--VULVOVAGINAL SYNDROME

By Gary M. White, MD

Erosive lichen planus


Lichen planus of the mucosa may be erosive. When both oral and vaginal lesions occur in a woman, the term vulvo-vaginal-gingival syndrome has been used. See also lichen planus.

Clinical           

Erosions may occur in the buccal, gingival and vaginal mucosa. Erythema and a reticulated white pattern are characteristic. In the vaginal area, adhesions may occur hindering intercourse.

Vulvar Squamous Cell Carcinoma

Rarely, SCC may arise in vulval lichen planus. In one study [JAAD 2014;71;698-707], 1/3 occurred in erosive LP and 2/3 in non-erosive. All SCC were located in non-hair bearing vulvar mucosa, most common between the clitoris and the urethra. These cancers are aggressive malignancies with disease-related death in over 30% within the first 1-3 years.

Treatment

A strong topical steroid ointment may be tried initially. If this fails, topical tacrolimus may be tried, as tacrolimus 0.1% ointment applied BID has been very effective in several studies. Systemic tacrolimus has been used [JAAD CR 2017;3;253].

Other options include intralesional kenalog (e.g. 10 mg/cc) for localized areas. Systemic steroids are almost always effective but cannot be continued long term because of side effects. Oral hydroxychloroquine may be very effective. An oral and a vaginal prosthesis allowing occlusion of a class II topical steroid has been used effectively. CSA topically TID (1:1 ratio oral CSA and olive oil in a gauze applied for 10-15 minutes) was effective in one patient [AD 1993;129;7945]. Systemic CSA (e.g. 1-2 mg/kg/day) was very effective in 2 patients [AD 1994;130;1379]. Adalimumab has been used [JAAD 2011; 65, Issue 2, Pages e55–e57].

Vulvovaginal hexyl 5-aminolevulinate-hydrocloride photodynamic therapy (HAL-PDT) seems to be an effective and safe treatment for erosive vulvar LP [BJD 2015;173;1156–1162]. In this study of 40 women, there was similar benefit with one session with vulvovaginal HAL-PDT compared with daily application of topical clobetasol for 6 weeks.

Rituximab

Two women with intractable vulvovaginal LP cleared within 4 weeks with rituximab [British Journal of Dermatology, 2015;172: 538–540].

Given the risk of vulvar SCC, any woman with vulvar LP needs close followup.

Additional Pictures

Erosive lichen planus Erosive lichen planus

Erosive lichen planus

References

SCC occurring in the setting of Lichen Planus. Photos in the article illustrate how the most common site is between the clitoris and urethra. JAAD 2014;71;698-707
Pictures of severe gingivitis before and after rituximab. British Journal of Dermatology, 2015;172: 538–540.
Nice picture in the article of vulvovaginal PDT for erosive LP. BJD 2015;173;1156–1162.

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