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Editorial |

Reduced Risk of Squamous Cell Carcinoma With Adequate Treatment of Vulvar Lichen Sclerosus

Susan M. Cooper, MD, FRCP1; Nina Madnani, MD, DVD2,3; Lynnette Margesson, MD, FRCPC4,5
[+] Author Affiliations
1Department of Dermatology, Oxford University Hospitals Trust, Oxford, England
2Department of Dermatology, P. D. Hinduja National Hospital and Medical Research Center, Mumbai, India
3Department of Dermatology, Sir HN Reliance Foundation Hospital, Mumbai, India
4Department of Obstetrics and Gynecology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
5Department of Surgery (Dermatology), Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
JAMA Dermatol. 2015;151(10):1059-1060. doi:10.1001/jamadermatol.2015.0644.
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In this issue, Lee and colleagues1 present the results of the largest prospective clinical cohort study to date concerning 507 women with vulvar lichen sclerosus (VLS). The authors present evidence that poor compliance with topical corticosteroid (TCS) treatment predisposes patients to the development of vulvar cancer and scarring. They propose that initial treatment regimens should be selected using a variety of corticosteroid potencies based on the severity of signs at presentation. They also propose that maintenance treatment for VLS should be the norm, increasing or decreasing the potency of treatment as necessary. The authors recommend life-long specialist follow-up.

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Response to Management of Adult Vulvar Lichen Sclerosus: Adult Male Genital Perspective
Posted on December 24, 2015
Doiron PR, Kravvas G, Bunker CB
Chelsea & Westminster Hospital
Conflict of Interest: None Declared
Our interest was engaged by the findings of Lee et al1 and the accompanying editorial by Cooper et al2, regarding the management of adult vulvar lichen sclerosus and the observed abolition of the risk of skin cancer.

Our group works with adult male genital lichen sclerosus (MGLSc) during weekly clinics across two clinical sites in central London. In terms of preventing disease progression, mitigating impact on both sexual and urinary function, and eliminating the risk of intraepithelial neoplasia and invasive carcinoma, our goals are well aligned with those presented by Lee and colleagues.

Our proactive management strategy, outlined below, differs from that presented by Lee and colleagues given the obvious anatomical and attendant structural differences in our respective patient populations. MGLSc is almost exclusively a disease of the uncircumcised male3, thought to result from chronic, intermittent exposure of a susceptible epithelium to urine.4 Typically, our patients are managed initially with a one-month course of ultrapotent topical corticosteroid, barrier emollients and soap substitutes.5 Approximately 50-60% of men respond to this treatment.3,5 If disease is refractory, circumcision is recommended and that is curative in the majority of cases.3,5

Lee and colleagues have reassuringly demonstrated that in patients who underwent vigilant management of their genital lichen sclerosus, no cases of intraepithelial neoplasia or invasive squamous cell carcinoma (SCC) were seen.1 The findings align with our results from a case series of 329 MGLSc patients, none of whom developed SCC.3 This is in sharp contrast to the rates of 2-12.5%3 published in the literature. This supports the argument that vigilant management of lichen sclerosus mitigates and perhaps even eliminates the risk of SCC, which has been the case in our experience. Anecdotally, none of the approximately 400 MGLSc patients who have been seen in our clinics over the last four years have developed penile intraepithelial neoplasia or invasive SCC. A retrospective project characterizing this cohort of patients is currently underway.

We congratulate the authors on their important work which arms practitioners with valuable, practical information to assist in clinical decision-making and patient advice.

Acknowledgements
Dr. Tang Ngee Shim (Chelsea and Westminster Hospital) for his contributions to the retrospective project currently underway.

References
1. Lee A, Bradford J, Fischer G. Long-term management of adult vulvar lichen sclerosus: a prospective cohort study of 507 women. JAMA Dermatol. 2015;151(10):1061-67.
2. Cooper SM, Madnani N, Margesson L. Reduced risk of squamous cell carcinoma with adequate treatment of vulvar lichen sclerosus. JAMA Dermatol. 2015;151(10):1059-60.
3. Edmonds EV, Hunt S, Hawkins D, Dinneen M, Francis N, Bunker CB. Clinical parameters in male genital lichen sclerosus: a case series of 329 patients. JEADV. 2012;26:730-37.
4. Bunker CB. Occlusion, urine and genital lichen sclerosus. Indian J Dermatol Venereol Leprol. 2012;78:367-8.
5. Bunker CB, Shim TN. Male genital lichen sclerosus. Indian J Dermatol. 2015;60(2):111-17.
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