Vulvar Lichen Sclerosis: A Contributor and Cause of Pelvic Pain
What is this diagnosis and why is it important to write about? Well, it’s because it can be a cause of pelvic pain and affects more reproductive aged people than one may think. Because it is a skin disorder that affects the vulva and genitals, it crosses over into two specialities for diagnosis: gynecology and dermatology. So, let’s chat about it!
Crystal vulva
Vulvar Lichen Sclerosis (VLS), previously known as vulvar dystrophy, is a chronic inflammatory progressive skin disease that can occur in any person. It most commonly affects people with a vulva. Unfortunately, it affects around 14.6 per 100,000 females and can affect pre-pubertal and postmenopausal females and can also present in reproductive females aged 18-40 years old. It presents as patchy, glistening, and ivory white spots that may become pale, crinkly, thin patches and plaques. It primarily affects the skin between the labia, on the labia (majora and minora), the clitoris, and clitoral hood. VLS can affect the perineum and perianal areas. Causative factors include autoimmune pathologies, hormones, and infections.
Proper diagnosis involves biopsy, however, its visible characteristics are usually satisfactory in obtaining a diagnosis. Either a gynecologist or a dermatologist can detect VLS.
Vulva from Netter MD Anatomy Book
Symptoms of VLS include redness, itching, burning, stinging, pain, and hyperkeratosis. In more severe cases, post-inflammatory progressive scarring may cause fusion or loss of the labia minora, narrowing of the vaginal introitus, and burying of the clitoris. Sometimes intercourse can exacerbate symptoms. Small cuts and fissures can also arise as a cause of VLS.
VLS is diagnosed based on visible characteristics, though a biopsy may be necessary when it is difficult to diagnose. Earlier diagnosis can be difficult because it can present more as a dermatitis, or skin irritation. If treatment (typically with steroids) is started early, then it can prevent scarring and irreversible skin changes. Those diagnosed with VLS have a higher incidence of squamous cell carcinoma and cancer.
The exact cause of VLS is unknown, however, evidence suggests an autoimmune component. Patients with VLS tend to have one or more autoimmune-related disease or a family history of autoimmune disease.
The mainstay treatment for Vulvar Lichen Sclerosus is a high potency topical corticosteroid (most commonly Clobetasol propionate cream 0.05%). This steroid is topical, reduces symptoms, and improves skin conditions if taken consistently for 2 weeks to 3 months depending on physician recommendations. Through this recommended regiment, about 60-70% of patients can experience complete remission of their symptoms, while others may have to use the steroids as needed to control unresolved symptoms. Unfortunately, a cure does not exist for VLS. Regardless if symptoms are asymptomatic, VLS should be treated to avoid disease progression and possible evolution into cancer.
If the steroid cream does not help to resolve VLS, then it is recommended that a second line of therapy is started. Second lines of treatment and therapy may include:
Combination of topical calcineurin inhibitors and steroids
Use of calcineurin inhibitors primarily acts to block the inflammatory process that contributes to VLS symptoms. This research has been done in small studies and should be used with caution. It should be noted that use of combined calcineurin inhibitors and steroid cream has helped remission of VLS in pediatric cases
Retinoids
Retinoids have a mild anti-inflammatory effect through normalizing skin metabolism and can prevent some skin cancers.
Phototherapy
This treatment is used with UV light and has been shown to help VLS, however, is inferior to treatment and remission with use of steroid creams. Furthermore, this is more difficult to administer and requires multiple sessions.
Laser Therapy
More research is coming out regarding the effectiveness of laser therapy, however, it has helped a small clinical trial with about 40 patients by putting them into remission when steroids failed. Lasers can lead to increased vascularization and restoration of skin cells and reduction of degeneration and atrophy of skin cells.
Avocado and Soybean Unsaponifiable (ASU)
These items can also have an anti-inflammatory effect on the vulva.
Adipose-Derived Stem Cells and Platelet-Rich Plasma
This can inhibit fibrosis and can regenerate damaged tissue. This treatment also has anti-inflammatory properties and immune modulatory activity and repair cells.
In addition to western medicine, participating in a consistent anti-inflammatory diet and controlling stress hormones through stress management and lifestyle modifications can help with remission of this disease. Acupuncture is an adjunct involved in the reduction of stress, decreasing inflammation, and use of herbs for VLS.
If you are noticing a skin condition in the genitals, it moves around, and is not quite consistent with an STI, do not hesitate to contact a pelvic health specialist to properly diagnose and treat this condition.
And always, please remember I am here for you! I am here for you as a provider, as a resource, and if I am unable to help, I can refer you to someone who may be able to!
*Please note this is general information and not to be used personally. Please consult your healthcare team for determination and appropriate use of treatment for VLS.
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