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- Presentation
Diagnosis and Treatment of Vulvar Lichen Sclerosis and Lichen Planus
Description
The talk reviewed vulvar lichen sclerosis and lichen planus, emphasizing that both are commonly underrecognized and can be present even without symptoms, so full body skin exams should include the vulva. Early disease can be subtle and biopsy may be nondiagnostic, so clinicians should keep a high suspicion if the clinical picture fits. Lichen sclerosis may present differently by age, often overlaps with vitiligo, and is associated with autoimmune thyroid disease, scarring, architectural loss, and an increased risk of vulvar squamous cell carcinoma. Long-term treatment remains high-potency topical corticosteroids, usually with an induction phase followed by maintenance therapy, plus careful patient education on where, how much, and how often to apply medication to prevent relapse. Gentle moisturizers, sometimes topical estrogen, and selected adjuncts such as calcineurin inhibitors or newer agents may help, while procedural treatments have variable evidence. Lichen planus, especially erosive disease, tends to cause more pain, burning, and dyspareunia, often involves the vagina and oral mucosa, and can be triggered or worsened by medications such as blood pressure drugs, statins, and NSAIDs. Management may require topical therapy, dilators, pelvic floor physical therapy, and in more severe or refractory cases systemic immunosuppression such as methotrexate, mycophenolate, or JAK inhibitors. Across both conditions, early recognition, repeated education, monitoring for scarring or malignancy, and escalation of therapy when needed were key themes.
View moreConclusions
- Vulvar lichen sclerosus is frequently underrecognized, can be asymptomatic or atypical early on, and requires a total-body exam that includes the vulva to avoid missed diagnoses and scarring.
- Symptoms do not reliably reflect disease activity in lichen sclerosus, so ongoing visual assessment and follow-up are necessary even when patients report no itch or pain.
- Pediatric lichen sclerosus is usually a chronic lifelong condition rather than one that reliably resolves at puberty, so patients and caregivers should be counseled about long-term monitoring and transition to adult care.
- Early and adequate topical corticosteroid therapy is the cornerstone of lichen sclerosus management because it controls symptoms, limits scarring, and appears to reduce progression to vulvar squamous cell carcinoma.
- Patient education on exactly how much steroid to use, where to apply it, how often, and what to do during flares is essential because self-discontinuation is common and relapse is frequent.
- Adjunctive measures such as gentle moisturizers and vulvovaginal estrogen can improve tissue health, but they do not replace anti-inflammatory treatment of lichen sclerosus.
- Nonsteroidal topical agents and procedural therapies have a more limited or lower-quality evidence base than topical corticosteroids, so they are best reserved for selected cases or specialist settings.
- When lichen sclerosus is truly refractory or complicated by major scarring, systemic options such as methotrexate, acitretin, hydroxychloroquine, mycophenolate, and JAK inhibitors may be helpful for symptom control.
- Vulvar lichen planus is often more painful and erosive than lichen sclerosus, commonly involves the medial vulva and vagina, and should prompt examination of other mucosal sites such as the mouth.
- Because lichen planus can be triggered or worsened by medications and can coexist with malignancy risk, medication review and repeat biopsy of persistent lesions are important.
- Intravaginal lichen planus can cause stenosis and scarring, so early pelvic floor physical therapy, dilators, and intravaginal anti-inflammatory treatment may preserve function and quality of life.
- If local therapy fails in vulvar lichen planus, clinicians should escalate to systemic immunosuppression sooner rather than later rather than repeatedly cycling ineffective local treatments.
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