Learn to Like the Lichens



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Learn to Like the Lichens

Hope K. Haefner, M.D.

Professor of Obstetrics and Gynecology

Co-Director, The University of Michigan Center for Vulvar Diseases

The University of Michigan Hospitals

Learning Objectives
At the end of this course, the participant should be able to:

1. Identify and treat lichen sclerosus, lichen simplex chronicus and lichen planus


2. Develop a plan for caring for patients with the itch-scratch cycle
3. Recognize the need for biopsy to identify the various conditions which cause pruritus

A variety of dermatologic conditions affect the vulva and the vagina. It is important to become familiar with the appearances and treatments of the numerous vulvovaginal conditions that you may see in your patients.


Nonneoplastic Epithelial Disorders

1975-1986 1987-present



Lichen sclerosus et atrophicus

Lichen sclerosus

Hyperplastic dystrophy

Squamous cell hyperplasia/lichen simplex chronicus

Mixed dystrophy

Other dermatoses


Lichen sclerosus

Lichen Sclerosus – the most common chronic vulvar condition

Histology - blunting or loss of rete ridges, hyperkeratosis and loss of melanocytes are seen with a zone of pallor and often a dense interstitial lymphocytic infiltrate.
Pathophysiology: Unknown. Various genetic, autoimmune, infectious and local factors are implicated. The cause is probably multifactorial with a genetic, environmental and possibly infectious input. Often associated with other autoimmune diseases. Familial cases have been reported.
Age of onset - middle age (about 40 years) but range is from less than one year to > 80 years
Symptoms - Pruritus is most common and can be severe and intolerable

Scratching causes secondary changes and open areas that cause dysuria, burning and dyspareunia Scarring leads to dyspareunia, apareunia


May be asymptomatic - common cause of asymptomatic vulvar scarring.

Physical exam – Scattered papules or confluent papules forming plaques of ivory white with cellophane- like sheen to the surface. Found anywhere on the vulva. from the clitoris and periclitorally to the gluteal cleft. The involvement may be patchy or generalized in various patterns. It can involve any cutaneous surface but most commonly is found on the vulva in women. Extragenital disease occurs in 10-20%. LS does not involve the vagina.


Secondary changes - excoriations, purpura, erosions, thickening (lichenification) crusting, and scarring, ranging from loss of labia or burying of the clitoris to loss of all normal vulvar structures.
Differential diagnosis - sexual abuse in children, vitiligo, lichen simplex chronicus, lichen planus, cicatricial pemphigoid.
Cancer risk - about 4% develop associated SCC

Treatment:

Biopsy to confirm diagnosis

Educate the patient

Stop irritants

Cool, ventilated clothing

Topical superpotent steroids (various regimens exist)
Clobetasol propionate or halobetasol 0.05% ointment qd

for 12 weeks, then M-W-F or 1-2 times a week and follow up at 6-12

weeks then regularly at 6-12 month intervals

versus


Clobetasol propionate 0.05% bid x 1 month, then q d x 2 months. Follow with a class 4 steroid (see steroid table at the end of the handout), then gradually decrease the steroid dose. (There is debate regarding whether or not long term steroids are required.)
Treat associated Candida or secondary bacterial infection

Stop scratching

For thick lichen sclerosus consider intralesional steroid (triamcinolone 3.3 to 10 mg/ml). The dose is dependent on the location and thickness of the skin that is being injected. Never give over 40 mg of triamcinolone acetonide per month and don’t use high steroid doses on thin skin or in small areas because the tissue can slough off.
Tacrolimus ointment and pimecrolimus cream have been used for the treatment of vulvar lichen sclerosus. Burning may occur with these medications.
Surgery is done on occasion to improve function or for scarring
In all patients with lichen sclerosus:

Arrange follow-up always – indefinitely Regular follow-up is needed because there is an increased risk of developing squamous cell carcinoma (SCC) (<5 % in women).


Note – LS involves the vulva not the vagina. Scarring is not reversible by any medical therapy.
LICHEN SIMPLEX CHRONICUS (LSC )
Synonyms: Squamous cell hyperplasia, neurodermatitis, pruritus vulvae, hyperplastic

dystrophy


“LSC” – The end stage of the itch – scratch – itch cycle. It is usually part of the atopic dermatitis (eczema) spectrum. It can be associated with underlying secondarily scratched and thickened psoriasis or contact dermatitis or the end stage of several itchy vulvar conditions (e.g. LS). Scratching “feels good” especially for patients with atopic dermatitis (patients with a background of allergies, eczema, hay fever or asthma). Stress makes all of this worse.
Causes of LSC:
Infection: Candida and dermatophytosis

Dermatoses: Atopic dermatitis Psoriasis

Lichen Sclerosus Contact Dermatitis

Lichen Planus


Metabolic: Diabetes and iron deficiency anemia
Neoplasia: Vulvar intraepithelial neoplasia
The most important causes are atopic dermatitis, contact dermatitis or both.

Less common causes – psoriasis, LS


Pathophysiology – in this condition there is an altered skin barrier with varying combination of allergens, irritants and skin pathogens that result in a changed immunoregulatory process. Stress further alters the skin barrier function, making all of this worse. This condition is defined by relentless pruritus. These patients scratch in their sleep ruining the effectiveness of their daytime treatments.
Clinical Presentation:

Relentless pruritus Pigmentation changes

Chronic – years of “chronic itch” Unilateral or bilateral

Worse with heat, stress, menstruation Hair loss from scratching

“Nothing helps” Excoriations + crusts

Marked lichenification Diagnosis – clinical biopsy may be needed


Note: Scratching makes erosions with serosanguinous crusts; repeated rubbing causes skin thickening (lichenification). In LSC, you can see both erosions and lichenification.

Treatment:

Rule out other conditions

Stop all irritants

Consider Patch testing

Stop itch/scratch/itch cycles

Topical superpotent steroids, halobetasol or clobetasol 0.05% ointment,

bid for two weeks, qhs for two weeks, then M-W-F for two weeks.

(For severe disease, a longer duration of a mid dose topical steroid may be required.)

Oral steroids may be required for a short duration (dose varies dependent on disease severity; consider prednisone 40 mg po q am x 5, then 20 mg po q am x 10, however a longer taper may be required)

IM triamcinolone 1 mg/kg (up to 80 mg total) can be used instead of prednisone for severe, itchy or extensive LSC. Repeat is seldom necessary. If repeat is necessary, it can be repeated monthly x 3 total doses.
Treat infections, bacterial and yeast

- Cefadroxil 500 mg bid for 7 days

- Fluconazole 150 mg po q week x 2

Sedate - Doxepin or hydroxyzine 10 to 75 mg qhs for nighttime itching



  • Citalopram or fluoxetine or sertraline in the morning for daytime itching

  • Amitriptyline is also used at times for sedation (25 mg po qhs; can increase to 50 mg po qhs) in patients with severe itch scratch cycle. It puts the patient in a deeper sleep cycle than the other sedation agents listed above. Do not combine amitriptyline with the other sedation agents above. Caution for use in the elderly population. Check for other drug interactions.

Sitz baths or cold soaks

White cotton gloves at night


Note: If skin is very raw the topical steroids will burn. Start with plain Vaseline,

oral antibiotics, anti-yeast medication and nighttime sedation for 2-3 days,

then start the topicals.

LSC reoccurs due to sensitive skin in the area so it will need repeated management.


LOOK FOR MORE THAN ONE CAUSE OR A COMBINATION OF CAUSES as it is not uncommon to have psoriasis, contact dermatitis and lichen simplex chronicus in the same patient.
LICHEN PLANUS (LP)

Lichen planus is a distinctive inflammatory eruption of the skin and mucous membranes.


Etiology: It is a disorder of altered cell mediated immunity with exogenous antigens

targeting the epidermis.


The diagnosis is often missed on the vulva.

It tends to occur in middle aged women (age 40-60 years).

It affects skin and mucous membrane – mouth, vulva, vagina, nails, scalp,

esophagus, nose, conjunctiva of the eye, ears and bladder.

Painful LP is usually erosive; patient can have LP plus chronic vulvar

pain.
Clinical Presentation:

1. Papulosquamous – typical papules and plaques with white lacy pattern on the

vulvar trigone and periclitoral area. It may be part of

generalized LP. This can be itchy. It tends to respond to topical steroids.


  1. Hypertrophic – least common with extensive white scarring and destruction (looks like LS)

– can be very itchy. Treatment tends to be resistant.

  1. Erosive (vulvovaginal gingival syndrome) – destructive lichen planus on the mucous membranes and vulva with a desquamative vaginitis, variable erosions plus atrophy, usually pain, burning and irritation rather than itch. Treatment tends to be resistant.


Note LP involves the vulva and vagina
Erosive LP (vulvovaginal gingival syndrome)

Symptoms:

Severe pain and burning Depression + anger

Dysuria Dyspareunia / apareunia

Signs – painful, glossy red erosions (glazed erythema) and scarring are seen around the labia minora and vestibule. The borders may be white to smudgy or smoky gray. The scarring causes flattening of the vulva and loss of the labia minora.


    • May see desquamative inflammatory vaginitis

Vaginitis with vaginal erosions, atrophy, purulent malodorous discharge, vaginal synechiae and scarring. The vagina may be obliterated.

Note: up to 70% of women with vulvar LP have vaginal involvement.


This can be a chronic, destructive, debilitating and difficult condition.
Diagnosis: Look at mouth and skin for evidence of LP

Consider biopsy for H&E and immunofluorescence

Biopsies may be nonspecific

Differential diagnosis: Lichen sclerosus, drug eruption, cicatricial pemphigoid, graft vs.

host disease

Treatment:

Stop irritants Pain control

Bland therapy for ulcers Sedation

Superpotent steroid ointment (clobetasol) topically once to twice a day.

Intralesional steroid – triamcinolone 3.3 up to 10 mg/ml q 3-4 wks x 3 (do not give high dose in small area-erosions and ulcers may occur)

Intravaginal steroid – hydrocortisone acetate foam 40-80 mg qhs

or 25 to 100 mg suppository qhs (if using high dose steroids, use for short term use, then gradually decrease the dose).

If severe – hydrocortisone acetate 10% compounded in a Replens like base –3 to 5 grams (300 mg to 500mg/dose) nightly for 14 days then 3 nights a week and continue to decrease dose as per response. (Some prefer to use every other night initially, then gradually decrease the dose)

Note: adrenal suppression and risk of candidiasis


IM Triamcinolone (Kenalog 40) 1 mg/kg every 4 weeks for 3 doses. (Dose up to 80 mg total per dose) Repeated monthly for 3 months. Max 4 doses per year

Prednisone 40-60 mg a day with taper

Methotrexate 7.5-15 mg po or subcutaneously in abdomen or thigh, once a week with folate 1 mg daily

Cyclosporine 3-4 mg / kg per day

Patient education

Dilators


Support

Surgery for scarring followed by intravaginal treatment


Other Treatments:

-Clobetasol propionate 0.05% ointment/Nystatin 100,000 units/gram/3% oxy-tetracycline in cream base

- pimecrolimus (Elidel) 1% cream bid for mild LP
-Topical tacrolimus (Protopic) 0.03 or 0.l% ointment (burns) as a steroid sparer
-Hydroxychloroquine, acitretin, mycophenolate mofetile, etanercept (see below)
Course: uncertain - often very chronic

10% resolve, 50% asymptomatic and 15% do poorly


There is an International Lichen Planus Support Group Web at www.tambcd.edu/lichen

(oral disease focus)


What are the various treatments for Lichen Planus?


Papular lichen planus tends to respond to topical corticosteroids. Triamcinolone acetonide 0.1% ointment for mild disease and clobetasol propionate 0.05% ointment for severe disease.
For erosive disease the following table contains many medications that have been tried for LP treatment.

It is important to note that many of these medications are formulated for off label use.





Agent

Discussion

Anti-inflammatory antibiotics are used long term

This treatment works best for early erosive lichen planus
Doxycycline or clindamycin used long-term. Consider adding weekly fluconazole to prevent yeast infection.

Steroids are often used for lichen planus

Vaginal LP

Anusol HC vaginal suppositories are used in the following manner:

1/2 of a Anusol HC suppository per vagina twice daily for 2 months, then daily for 2 months, then maintenance treatment at 1 to 3 times per week. However, many patients do not experience significant long-term response to intravaginal steroids. The vaginal vault tends to continue to scar. To keep the vault open and prevent adhesions it often will be necessary to use vaginal dilators. The dilator may be lubricated with a hydrocortisone cream.
At times a stronger steroid may be required for vulvar LP (see text).

Topical- Clobetasol propionate (Temovate®) 0.05% ointment Intralesional- triamcinolone acetonide 5-10 mg/ml

As above, for stronger treatment:

– hydrocortisone acetate foam 40-80 mg qhs

or 25 to 100 mg suppository qhs (if using high dose steroids, use for short term use, then gradually decrease the dose).

If severe – hydrocortisone acetate 10% compounded in a Replens like base –3 to 5 grams (300 mg to 500mg/dose) nightly for 14 days then 3 nights a week and continue to decrease dose as per response. (Some prefer to use every other night initially, then gradually decrease the dose)

Oral- Oral prednisone may be required until healing has occurred. As the skin heals, topical corticosteroids may be added as the prednisone is tapered.
IM steroids (place in anterior thigh). Used for moderate disease. Dose 1 mg/kg (not to exceed 80 mg) every 4 weeks to every 8 weeks for up to 3 or 4 months.
For Oral LP- Apply Clobetasol propionate (Temovate®) gel 0.05% to affected area up to qid

Apply on a cotton ball in mouth for 5 min.

Some providers use dental molds to hold in medications in patients with gingival LP


Tacrolimus and

Pimecrolimus

Tacrolimus and

Pimecrolimus

(continued)

Tacrolimus (Protopic) 0.1% ointment bid to qid.

Apply on a cotton ball in mouth for 5 min

Vaginal medication (made by compounding pharmacy)

tacrolimus vaginal suppositories

Insert one suppository per vagina (2 mg tacrolimus per 2 gram supp) qhs Disp 50

Or 0.1% vaginal cream (compounded in a vaginal cream / Replens like base) 2-5 gms = 2 - 5 mg/dose for 2 weeks then Mon-Wed-Fri for 2 weeks and slowly decrease Disp 100 grams

Vulvar medication Apply to skin bid Tacrolimus 0.1% ointment Available in 30 or 60 gram tubes
Calcineurin inhibitors (steroid sparing)

pimecrolimus (Elidel) 1% cream bid for mild LP

topical tacrolimus (Protopic) 0.03%, 0.1% oint
Note – can burn especially on raw areas

Long term safety unknown



Less frequently used medications




Hydroxychloroquine (Plaquenil)

Occasionally used. Dose is 200 mg po bid.

Retinoids

Accutane (isotretinoin) or Etretinate (Tegison) have been used to treat oral lichen planus; however, discontinuation of the medication results in recurrence of the oral lesions. Long-term use of retinoids may result in liver dysfunction and there is no documented successful use of retinoids for vulvovaginal lichen planus. Liver function tests, cholesterol, triglycerides and complete blood cell counts should be monitored since laboratory changes are associated with the use of oral isotretinoin. Patients should be counseled concerning teratogenicity and need for optimal contraception. Topical retinoids (Retin A) are generally too irritating for this vulvar condition.

Cyclosporine

Used topically and systemically. Topical cyclosporine provides a safe and often effective but very expensive alternative for mucous membrane disease. Pelisse et al. described the use of the oral or injectable form of the medication in 100 mg amounts directly to the affected skin four times a day initially. If several mucous membranes were affected for example, 100 mg was applied to the vulva, 100 mg inserted into the vagina, and 100 mg held in the mouth for as long as tolerated before spitting. As disease is controlled, the frequency of application can be tapered. Systemically it is dosed at 4-5 mg/kg/day for 3 months (used in severe disease). Occasionally, in patients with debilitating and painful disease not adequately treated by therapies discussed above, oral cyclosporine may be used. This medication should be used only by health care providers experienced in its use.

Cyclophosphamide

Systemic antimetabolite

Azathioprine

Systemic antimetabolite

Etanercept (Enbrel)

This is used SQ (50 mg sq 2x/week until symptoms improve, then 25 mg sq 2x/week))

Mycophenolate mofetil (CellCept)

Oral use 250mg -1.5 gms/d in divided dose


Methotrexate

Oral or subcutaneous injection weekly. 7.5 to 15 mg oral or subcutaneously weekly using a 27 or 30 gauge needle. Need to give folate with this medication- 1 mg/d

Lichen Planus and Surgery

For scarred LP of the vagina - post surgery information

  1. For dilation:

Dilation is vital to keep the vagina open in patients with vaginal lichen planus. Patients need specific instructions on size of dilator and how to use dilators.  They may need a set of dilators and can to buy the dilator set from www.vaginismus.com. Start with the largest size that will fit, determined by surgery. Leave the dilator in once or twice a day for 15-20 minutes. For lubricating the dilator use either Vaseline or mineral oil. Hydrocortisone acetate cream or Estrace 0.01% vaginal cream can be used later.

II. To stop inflammation: 

A.                  For the vagina

1.       Consider using a dose of intramuscular triamcinolone 1mg/kg up to a total of 80mg/dose to be given two days after surgery and repeat this monthly for her for up to three months. Follow and assess her to see if she is going to need other long-term systemic medication, cyclosporine, mycophenolate, methotrexate, etc. Once she is healed she may need a systemic anti-inflammatory. The medication will depend on the case. These medications can be used with intermittent doses of IM triamcinolone, also depending on the case.

2.  Two days after surgery, when the stent is removed, the patient needs to start dilating with Vaseline on the dilator twice a day. In 1 to2 weeks if healing then consider 10% hydrocortisone acetate in a vaginal cream 300mg (3g) to 500 mg (5gms) nightly for a week then gradually decrease weekly to 1-3gram Mon-Wed-Fri depending on response. (The compounded prescription is 10% hydrocortisone acetate in vaginal cream base 100 g with 2 refills).  As a steroid sparer consider tacrolimus 2 mg compounded suppository nightly, or 0.1% tacrolimus compounded vaginal cream 2 grams/dose. Note – tacrolimus can cause a burning sensation.

B.                  For the vulva - to start two days after surgery, if not very eroded, topical clobetasol 0.05% ointment in a thin film PM. If eroded use plain Vaseline for 2 weeks and then restart clobetasol . If tolerated consider using tacrolimus 0.1% ointment twice a day as a steroid sparer note - as above, it can cause a burning sensation.

III           Follow up- patient needs to be seen often for support and to adjust treatment. Avoid sexual intercourse until well healed with adequate size.

 


TOPICAL CORTICOSTEROIDS


Learn three to four ointments of different strengths, making appropriate selections as needed

    • ointments are stronger than creams

    • ointments stay on longer than creams (creams are diluted and washed

away with body fluids)

- ointments are less irritating and have fewer allergens than other bases

Patients may find one base more irritating than another. Be flexible.

Do not use steroids for dysesthetic vulvodynia - steroids work by reducing

inflammation, not pain

Note: Topical steroids are not a cure. Use the steroid potency that will do the job in the quickest period of time and then decrease to a lower potency. Either stop or maintain with the lowest potency or use intermittently as necessary.


Tips: When considering topical corticosteroids, especially the superpotent types, consider:

There are more available than you need

Use them in an educated way

Limit the amount prescribed to 15g to 30 grams for high dose topical steroids

Show the patient exactly how to use it – a tiny dab spread in a thin film just to

the involved area is all that is necessary

Vulvar mucous membrane (vulvar trigone and inner labia minora) is

remarkably steroid resistant. The outside of the labia minora and the

labiocrural fold and the thighs will thin easily and develop striae.

When the patient improves, decrease the frequency of topical steroid or

manage with a low potency product.

Use under close supervision.

At any suggestion of secondary yeast infection, add a topical or oral anti- fungal.
For example, for thick itchy dermatoses like lichen simplex chronicus – use name brand clobetasol or halobetasol 0.05% ointment bid for 1-2 weeks, once a week for 1-2 weeks and then M-W-F for 1-2 weeks and for long term maintenance either infrequent and intermittent usage each week of the same or switch to intermittent use of a mild ointment such as l% hydrocortisone in petrolatum or a 1% hydrocortisone / 1% pramoxine cream mix.
Effects of corticosteroids:

Vasoconstriction – decrease erythema and swelling

Decreasing fibroblastic proliferation thins out thickened dermal lesions

Decreasing rapidly turning over keratinocytes thins out thickened epidermal

lesions

Corticosteroid responsive vulvar dermatoses include:



Thick and scaly (lichen sclerosus, lichen simplex chronicus, psoriasis, contact dermatitis)

Blistering erosive disease

Bullous diseases

Corticosteroid potency depends on:

Cortisone molecule Concentration of steroid in vehicle

Partition co-efficient of steroid vehicle system Application frequency and length of time used


Caution: steroids can be associated with irregular menses, increased BP, worsening of diabetes control, infection and glaucoma.

Table 1. Potency Ranking of Some Commonly Used Topical Corticosteroids

Class

U.S. Brand Name

Generic name

Super-
high
Potency

Temovate® Cream or Ointment more potent than Diprolene®

Cream or Ointment and Psorcon® Ointment


Temovate® Cream, 0.05%

Temovate® Ointment, 0.05%

Temovate® E, 0.05%

Diprolene® Cream, 0.05%

Diprolene® Ointment, 0.05%

Diprolene® AF Cream, 0.05%

Psorcon® Ointment, 0.05%

Ultravate® Cream, 0.05%

Ultravate® Ointment, 0.05%


clobetasol propionate

clobetasol propionate

clobetasol propionate

betamethasone dipropionate

betamethasone dipropionate

betamethasone dipropionate

diflorasone diacetate

halobetasol propionate

halobetasol propionate


II

Cyclocort® Cream, 0.1%

Cyclocort® Ointment, 0.1%

Diprosone® Ointment, 0.05%

Florone® Ointment 0.05%

Lidex® Cream, 0.05%

Lidex® Ointment, 0.05%

Lidex-E® Cream, 0.05%

Maxiflor® Ointment, 0.05%

Maxivate® , Ointment 0.05%

Topicort® Cream, 0.25%

Topicort® Ointment, 0.25%


Amcinonide

amcinonide

betamethasone dipropionate

diflorasone diacetate

fluocinonide

fluocinonide

fluocinonide

diflorasone diacetate

betamethasone dipropionate

desoximetasone

desoximetasone


III

Aristocort A® Cream 0.5%

Cutivate® Ointment, 0.05%

Diprosone® Cream, 0.05%

Elocon® Ointment 0.1%

Florone® Cream, 0.05%

Maxiflor® Cream, 0.05%

Maxivate® Cream, 0.05%

Valisone® Ointment, 0.1%



triamcinolone acetonide

fluticasone propionate

betamethasone dipropionate

mometasone furoate

diflorasone diacetate

diflorasone diacetate

betamethasone dipropionate

betamethasone valerate



IV

Aristocort® Ointment, 0.1%

Cordran® Ointment, 0.05%

Elocon® Cream, 0.1%

Kenalog® Ointment, 0.1%

Synalar® Ointment, 0.025%

Topicort LP® Cream, 0.05%



triamcinolone acetonide

flurandrenolide

mometasone furoate

triamcinolone acetonide

fluocinolone acetonide

desoximetasone



V

Aristocort® Cream, 0.1%

Cordran® Cream, 0.05%

Cutivate® Cream, 0.05%

Dermatop® Emollient cream, 0.05%

Kenalog® Cream, 0.1%

Kenalog ointment, 0.025%

Locoid® Cream, 0.1%

Synalar® Cream, 0.025%

Valisone® Cream, 0.1%

Uticort® Cream 0.025%

Westcort® Cream, 0.2%

Westcort® Ointment, 0.2%



triamcinolone acetonide

flurandrenolide

fluticasone propionate

prednicarbate

triamcinolone acetonide

triamcinolone acetonide

hydrocortisone butyrate

fluocinolone acetonide

betamethasone valerate

betamethasone benzoate

hydrocortisone valerate

hydrocortisone valerate



VI

Aclovate® Cream, 0.05%

Aclovate® Ointment, 0.05%

Tridesilon® Cream, 0.05%


alclometasone dipropionate

alclometasone dipropionate

desonide


VII

Low Potency



Numerous preparations exist

Dexamethasone, flumethalone, hydrocortisone

Methylprednisolone, prednisolone



ALTERNATIVES TO CORTICOSTEROIDS

Alternative topicals to corticosteroids are the Calcineurin inhibitors

Calcineurin inhibitors:

Pimecrolimus 1% cream (Elidel)

Tacrolimus 0.03 and 0.l% ointment (Protopic) or compounded 0.l% vaginal cream

or a 2g suppository.

These are non-steroidal

Does not cause atrophy

May sting or burn initially when used topically

Equivalent to mild to moderate topical steroids –Pimecrolimus to a mild

topical steroid and tacrolimus equivalent to a moderate to strong

topical steroid.

These are topical immunosuppressants usually for maintenance of

steroid responsive dermatoses

Note: there is a black box warning on these medications. This is because of reports of skin cancers and lymphoma with systemic Calcineurin inhibitors used in organ transplant patients. This warning was also imposed because of one manufacturer’s failure to conduct safety studies.

Note : Skin application results in minimal systemic exposure.

Vaginal use can result in systemic absorption.

Side effects of Calcineurin inhibitors:

Burn, sting

Infection – worsening of HSV, HPV, tinea, molluscum contagiosum

Safety with regard to lichen sclerosus and squamous cell carcinoma? There are a

number of studies showing good results with this medication in

lichen sclerosus in adults and children. There are three reports of genital

squamous cell carcinoma

with patients who have used tacrolimus and one with squamous cell

carcinoma on pimecrolimus.

Treatment of choice for lichen sclerosus is still superpotent topical steroids

For lichen plans that is difficult to treat with only partial control of topical steroids consider using tacrolimus and pimecrolimus. The response reported is between 55 and 94%.

Summary of Calcineurin inhibitors:

For lichen planus start with topical steroids and consider alternating with Calcineurin inhibitors.

For lichen sclerosus with atrophy or reaction to topical steroids, consider usage, discuss the risks and follow carefully. No refills without follow-up vulvar exams.

Consider for use in the following: vulvar dermatoses, psoriasis, Crohn’s, pemphigoid, etc.


Systemic corticosteroids can be useful at times. A full discussion is beyond this lecture.

IM triamcinolone acetonide (Kenalog 40) l mg per kg for an acute dermatosis (e.g. contact dermatitis or severe lichen simplex chronicus). This can be repeated in 3-4 weeks once or twice to get a severe condition under control. See appropriate monograph for all side effects of all corticosteroids and calcineurin inhibitors.



Caution in patients with diabetes- high dose steroids can interfere with their glucose control.

References

Nonneoplastic Epithelial Conditions/Lichen sclerosus
Assmann T, Becker-Wegerich P, Grewe M et al. Tacrolimus ointment for the treatment of vulvar lichen sclerosus. Journal of the American Acadamy of Dermatology 2003;48:935-7.
Baldo M. Bailey A. Bhogal B. Groves RW. Ogg G. Wojnarowska FT cells reactive with the NC16A domain of BP180 are present in vulval lichen sclerosus and lichen planus. Journal of the European Academy of Dermatology & Venereology. 2010;24(2):186-90.
Baldo M, Bhogal B, Groves RW, Powell J, Wojnarowska F. Childhood vulval lichen sclerosus: autoimmunity to the basement membrane zone protein BP180 and its relationship to autoimmunity. Clin Exp Dermatol. 2010 Apr 26.
Berger J, Telser A, Widschwendter M, Muller-Holzner E, Daxenbichler G, Marth C, Zeimet AG. Expression of retinoic acid receptors in non-neoplastic epithelial disorders of the vulva and normal vulvar skin. International Journal of Gynecologic Pathology 2000;19:95-102.
Berger MB, Damico JH, Menees SB, Fenner DE, Haefner HK. Rates of self-reported urinary, gastrointestinal, and pain comorbidities in women with vulvar lichen sclerosus. J Low Gen Tract Dis 2012;16:285-9.
Boyd AS. New and emerging therapies for lichenoid dermatoses. Dermatologic Clinics. 2000;18:21-9.
Bracco GL, Carli P, Sonni L, Maestrini G, De Marco A, Taddei GL, et al. Clinical and histologic effects of topical treatments of vulval lichen sclerosus: A critical evaluation. Journal of Reproductive Medicine 1993;38:37-40.
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