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 PRACTICE RECOMMENDATIONS: Practice Management Materials • Vulva • Vagina • Cervix • Anus • Anus |
VULVA: LICHEN PLANUS: Treatments
Lichen planus is a difficult condition to treat. Steroids are frequently used as a first line of therapy. Topical steroids- A mid potency topical steroid BID ointment may be used. Generally a higher potency topical steroid will be required for patients with a poor response or patients with erosive lichen planus.
Group I is the superpotent category; potency descends with each group, to group VII, which is least potent (II, III, potent steroids; IV, V, midstrength steroids; VI, VII, mild steroids). There is no significant difference between agents within groups II through VII; the compounds are simply arranged alphabetically. However, within group I, Temovate® Cream or Ointment is more potent than Diprolene Cream or Ointment and Psorcon Ointment. Intravaginal steroids have been used for lichen planus as a first line of treatment if vaginal involvement is present. Cort-Dome vaginal suppositories are used in the following manner: 1/2 of a Cort-Dome 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. Walsh et al. developed a method to occlude topical medication on the vagina following surgical release of labial adhesions. An aggressive approach to increase delivery of topical medications included a vaginal (and oral) prosthesis, use of the vaginal moisturizer (Replens) as a vehicle for corticosteroids, and iontophoresis. Rapid response was obtained, and a less-intensive dosing schedule has resulted in remission of over 1 year. Open areas of limited size can be healed with intralesional triamcinolone acetonide injections at a concentration of 3 mg/ml. At times a stronger steroid may be required. Oral prednisone at a dose of 40 mg – 60 mg each morning until healing has occurred. As the skin heals, topical corticosteroids may be added as the prednisone is tapered. ANTIBIOTICS For erosive lichen planus, anti-inflammatory antibiotics, such as doxycycline (100 mg po bid) or clindamycin (150 mg po bid) are used long term. Hydroxychloroquine (Plaquenil) 200 mg po bid Retinoids Accutane (isotretinoin) 40 mg po bid doses or Etretinate (Tegison) 25 mg 1-2x/day has been used to ameliorate 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 condition. Griseofulvin-Anecdotal reports concerning the successful use of oral griseofulvin, 250 mg orally twice a day, have been described. Significant improvements have only occasionally been reported in women with erosive genital disease. Dapsone- 50-100 mg orally every day has been given to patients after a negative G6PD screen has been obtained. Complete blood cell counts need to be followed closely. Cyclosporine- Topical cyclosporine provides a safe and often effective but extraordinarily 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. 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 physicians experienced in its use. It is important to monitor renal function. Also, it confers an increased risk of late lymphoma. The dose consists of 1 mg/kg/day (may increase by increments of 0.5 mg/kg/day every 2-4 weeks to maximum of 3-5 mg/kg/day). Complete blood cell counts, liver function tests, cholesterol, triglycerides, electrolytes, urea nitrogen, creatinine, and creatinine clearance need to be monitored. The patient should be counseled regarding risks of renal compromise and possibility of later development of neoplasia. The cost of treatment in terms of side effects must be carefully considered. Systemic antimetabolites- cyclophosphamide, azathioprine Thalidomide- recent reports have found good results in treating erosive lichen planus of the mouth (150 mg. daily with a progressive decrease to 50 mg every other day). No studies have been done for vulvar lichen planus and thalidomide. With any of the treatments described, the lichen planus tends to recur after the treatment is discontinued. MISCELLANEOUS Surgery- should only be performed after active disease is controlled, otherwise scarring rapidly reoccurs. Following surgery, patients must use vaginal dilators daily to maintain adequate opening of the introitus and vagina. Close follow up is required at all times. Prognosis- disease recalcitrant to corticosteroids is very difficult to control with other medications. There is little or no tendency for remission, and there is a small risk for the development of a squamous cell carcinoma in chronic lesions. The lesions of lichen planus are notoriously hard to manage. Follow-up- Vulvar lesions are often chronic and may undergo malignant change. Long-term follow-up of patients with lichen planus is necessary. Patient education and support are important at all times when treating people diagnosed with lichen planus.  |
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