To our knowledge, only a few studies report significant numbers of cases of vulvovaginal lichen planus (LP).1- 4 Treatment is very difficult. Vulvovaginal LP is perceived as poorly responsive to topical corticosteroids. To our knowledge, no randomized controlled trials of treatment have been performed, and only 1 case series exists.1 Treatment efficacy data are anecdotal or based on isolated case reports.5,6 The aims of this survey were to summarize the symptoms and clinical features of vulvovaginal LP and to record the therapeutic practices of physicians with special interest in genital LP in different regions of the world, with a view toward a cooperative international treatment study.
Members of the International Society for the Study of Vulvovaginal Disease (ISSVD) with a special interest in genital LP were invited to participate. Nine physicians prospectively recorded data for all cases of vulvovaginal LP seen from May 1 through September 30, 2004. The entry criterion was a definite clinical diagnosis of vulvovaginal LP.
Data were collected by the consulting physician using a standardized questionnaire, in-person interview, clinical examination, and case note review. Age at onset was defined as the age when a patient first experienced LP-related symptoms in the anogenital area. The presence or absence of vulvar and/or vaginal pruritus, burning, soreness, dyspareunia, apareunia, and vaginal discharge was recorded. Clinical examination included vaginal speculum examination except when vaginal stenosis or pain prevented this. Clinical features of the vulva, vagina, perineum, and perianal region (red and/or purple color, lacy changes, erosions, scarring, and stenosis) were noted.
The presence or absence of LP at other cutaneous and mucosal sites was recorded. The history or presence of genital malignancy associated with LP was noted. All current and past treatments (surgical, systemic, and topical) were recorded. The type of corticosteroid (topical midpotent, topical superpotent, vaginal ointment and/or foam, vaginal tablet and/or suppository, oral prednis[ol]one, intramuscular triamcinolone, and intralesional triamcinolone) was recorded. Treatment regimens were analyzed by region.
Descriptive statistics were generated to delineate features of the disease and the study population. The relationship between treatment regimens and region was assessed using χ2 tests of independence. All statistical tests were performed at an α level of .05, and all analyses were conducted using the SAS statistical software package, version 9.0 (SAS Institute, Cary, North Carolina).
Nine physicians from 3 countries recruited a total of 161 patients over 5 months: 106 patients, 2 dermatologists, and 3 gynecologists in the United States; 48 patients and 2 dermatologists in the United Kingdom; and 7 patients and 2 gynecologists in Brazil. Thirty of the cases in the present study were previously reported in a study of vulvar LP.1 The mean age at onset of genital LP symptoms was 55 years (range, 12-87 years). The mean disease duration before study entry was 6 years. Genital biopsy results were available in 129 cases (82%).
Lichen planus was vulvar in 145 cases (90%), vaginal in 77 (48%), perineal in 30 (19%), perianal in 28 (17%), and oral in 78 (48%). Nongenital skin was involved in 23 cases (14%), the scalp in 2 (1%), fingernails and/or toenails in 2 (1%), and the esophagus in 3 (2%). The most frequently reported symptoms were 116 genital soreness (72%), 106 genital burning (66%), and 101 pruritus (63%). The most frequent vulvar signs were 107 erosions (74%), 95 red and/or purple color (66%), 91 scarring (63%), and 81 lacy changes (56%). Vaginal discharge was present in 54 cases (34%). Sexual dysfunction was almost universal (95%), with dyspareunia in 97 cases (60%) and apareunia in 56 (35%). Ten women had a history of or a current genital malignant neoplasm (6 in the United States and 4 in the United Kingdom).
The most frequent topical treatments were superpotent corticosteroids in 137 cases (85%) and tacrolimus, 0.1%, ointment in 45 (28%) (Table). Regional and specialty differences were observed in the use of treatments. Physicians from the United States prescribed more superpotent topical corticosteroids than did those in the United Kingdom (91% vs 77%) (P = .006), but those in the United Kingdom used more midpotent corticosteroids than those in the United States (38% vs 13%) (P = .004). Cyclosporine, methotrexate, and intramuscular triamcinolone were used only in the United States. Topical tacrolimus was prescribed much more frequently in the United States than elsewhere: 40 of the 45 prescriptions were used in the United States (89% vs 11%) (P < .05). Vaginal corticosteroid use (ointments or foams) was significantly lower in the United Kingdom than in the United States (2% vs 19%) (P = .01).
This survey has shown that vulvovaginal LP is a highly symptomatic disease that disrupts sexual functioning. A thorough mucocutaneous examination should be performed in all patients with LP because disease is often widespread and carries an increased risk of genital malignancy. Topical superpotent steroid is the most frequently prescribed treatment for genital LP, but therapeutic preferences vary widely by region. Vaginal cream or foam corticosteroid preparations, hydroxychloroquine, methotrexate, cyclosporine, and intramuscular triamcinolone were more frequently used in the United States than the rest of the world. Topical tacrolimus was a popular therapeutic option in United States (38%). The reasons for treatment differences and treatment efficacy were not explored, but we speculate that influences on prescribing may include local customs, availability of treatment, cost, and patient preferences. In addition, dermatologists and gynecologists may see a different spectrum of disease. These data show that physicians might consider expanding their treatment options beyond the current standard practice for their respective regions. The information from this survey will be helpful in designing future international collaborative studies to assess efficacy of treatments for vulvovaginal LP.
Correspondence: Dr Margesson, 721 Chestnut St, Manchester, NH 03104-3002 (firstname.lastname@example.org).
Author Contributions: Dr Margesson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Margesson. Acquisition of data: Cooper, Haefner, and Margesson. Analysis and interpretation of data: Cooper, Abrahams-Gessel, and Margesson. Drafting of the manuscript: Cooper, Abrahams-Gessel, and Margesson. Critical revision of the manuscript for important intellectual content: Cooper, Haefner, and Margesson. Statistical analysis: Cooper and Abrahams-Gessel. Administrative, technical, and material support: Haefner, Abrahams-Gessel, and Margesson. Study supervision: Margesson.
Financial Disclosure: None reported.
Additional Contributions: The following physicians provided patients for the study: Gutemberg Almeida, MD; Andrew Goldstein, MD; Isabel do Val, MD; Libby Edwards, MD; and Fiona Lewis, MD. Bernard L. Harlow, PhD, was instrumental in starting this project.
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