Disclosures and Conflicts of Interest

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2 Disclosures and Conflicts of Interest No financial relationships or conflict of interest to disclose Will be discussing off-label use of therapies There are no steroid preparations which are FDA approved for vulvar or vaginal use

3 Educational Objectives Learn how the lichens differ from one another Be able to recognize lichen simplex chronicus, lichen sclerosus, and lichen planus Be able to initiate treatment for all three conditions Receive guidelines for the safe and appropriate use of topical, vaginal, and systemic steroid medications

4 Help Me With This Case 65 yo Black female 2 years of unrelenting genital itching Awakens from sleep scratching History of asthma and seasonal allergies Worse with sweating, tight clothing No improvement with oral fluconazole, oral metronidazole, topical clindamycin, 1% hydrocortisone cream

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9 Lichen Simplex Chronicus Chronic eczematous disease, waxes and wanes Intense and unrelenting itching, especially at night Localized variant of atopic dermatitis (75% atopic) Itch-scratch-itch cycle perpetuates the disease Can occur in healthy tissue or as a consequence of an itching dermatitis (psoriasis, lichen sclerosus, contact dermatitis) Not associated with risk of Squamous Cell CA

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15 Treatment of Lichen Simplex Chronicus Step 1: Eliminate Irritants Physiologic irritants: abnormal vaginal discharge, urine, sweat, semen Hygiene habits: excessive washing, bath soaps and laundry products, douches, hair removal products, wet wipes, lubricants, pads or daily panty liners Medications: condoms, spermicides, alcohol based creams or gels, benzocaine Heat : hair dryers, heating pads, constrictive clothing

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17 Step 2: Restore the Skin s Barrier Function Educate patient about proper hygiene Clean only with water and fingers Pat dry, avoid friction Emollient barrier with plain white petroleum jelly or zinc oxide: Soak and Seal Cold compresses, ice packs

18 Step 3: Reduce Inflammation Severe Disease: Ultrapotent topical steroid (clobetasol ointment 0.05%) daily for 2-4 weeks, then taper to mid or low potency steroid Burst and taper of prednisone IM triamcinolone 1 mg/kg (max dose 80 mg) Milder Disease: Triamcinolone acetonide 0.1% or mometasone furoate 0.1% ointment 2-3 times per week for 3-6 months to prevent relapse Second line: topical tacrolimus ointment or pimecrolimus cream if steroid intolerant. May provoke irritation

19 Step 4: Treat Concurrent Infections For infected excoriations or fissures: Fluconazole 150 mg PO days 1, 4, and 7 for yeast Cefadroxil 500 mg PO BID for 7 days or appropriate skin flora antibiotic

20 Step 5: Break the Itch-Scratch-Itch Cycle Sedating antihistamines or TCA s at HS Hydroxyzine mg PO 2 hours before bedtime Diphenhydramine mg PO at HS Doxepin 25 mg PO at HS Amitriptyline mg PO at HS Non-sedating antihistamines or SSRI s for daytime use Fexofenadine, Cetirizine, Loratadine Citalopram, Sertraline, Duloxetine, Gabapentin

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34 LS Causes Sexual Dysfunction Significantly less frequent sexual activity than health controls or women with candida Significantly lower sexual satisfaction Erosions, fissures, scarring, labial fusion, introital stenosis Dyspareunia, Less frequent orgasms Higher degree of sexual dysfunction 42.2% report apareunia Haefner, HK, et al. The impact of vulvar lichen sclerosus on sexual dysfunction. Journal of Women s Health 2014; 23(9):

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39 #6: Treat Early and Consistently Goals: to relieve symptoms and arrest progression of disease Ointments are preferred: better tolerated, fewer chemical irritants and allergens, good barrier Right potency (super or mid potency), Right amount ( pea sized amount ), Right location (super on vulva, mid or low on anus), Right dosing schedule (taper when under control)

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41 Treatment Options: Right Potency First Line Treatment: Superpotent Topical Steroids Clobetasol propionate ointment 0.05% Halobetasol propionate ointment 0.05% Augmented betamethasone dipropionate ointment 0.05% Maintenance Tx: Mid or Low Potency Topical Steroids Mometasone furoate ointment 0.1% Triamcinolone acetonide ointment 0.1% Desonide ointment 0.05% Hydrocortisone 2.5% ointment

42 Treatment Regimens: Right Dosing Schedule Superpotent topical steroid QD or BID for 2-4 weeks, then taper to every other night for 4 weeks, then 2-3 times per week for maintenance. 30 gram tube lasts 3 months if used daily, 6 months if maintenance Pain, pruritus, fissures, hyperkeratosis will improve in 95% of women after 3 months of tx Topical steroids can be used in children: switch to mid or low potency when under control

43 For Stubborn Disease or Flares Intralesional triamcinolone (3-10 mg/ml) Intradermal or submucosal, less than 10 mg total, not more than 4 times per year Calcineurin inhibitors Tacrolimus 0.03% and 0.1% ointment, BID X 4 weeks, then QHS, then 1-3 times per week. Apply over petrolatum or steroid ointment Black box warning, risk of cutaneous malignancy Oral Prednisone (0.5-1 mg/kg/d) For flares, taper over 2-4 weeks

44 Support and Comfort Measures Sitz/ Soak and Seal with topical emollients (petrolatum, A&D ointment, Aquaphor) Ice packs, cool gel packs and compresses Systemic antihistamines for itching For secondary vulvodynia: Topical anesthetics: lidocaine 2% gel, 4% aqueous, 5% ointment. NO PEPPERMINT OIL! Oral medications for neuropathic pain: tricyclic antidepressants, anticonvulsants, SSRI/SNRI

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51 #2: What Does LP Look Like? Signs: Polygonal purple pruritic papules/plaques on keratinized skin, Wickham s striae, pterygium formation at nail bases erosive red patches on mucus membranes (urethra, vulva, vagina, esophagus, penis). White lacy reticulations and plaques in mouth and vulva Erosive vaginitis, vaginal adhesions Symptoms: Itching, burning, irritation, rawness, dysuria, dyspareunia, postcoital bleeding, mouth pain with hard foods, spicy foods, acidic foods. Esophageal: dysphagia & weight loss

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59 #4: How Do I Treat VULVAR LP? 1 st line: superpotent topical steroids. Disease control in 3-4 months with most patients. Follow every 6-12 months. (Re)biopsy for persistent erythema, persistent erosions, hyperkeratosis. Prolonged use of superpotent topical steroids is safe and effective Stubborn disease may require intralesional triamcinolone injections Severe disease may require systemic treatment with PO prednisone, azathioprine, cyclosporine, methotrexate, hydroxychloroquine, dapsone, mycophenolate mofetil, or IM triamcinolone

60 #4: How Do I Treat ORAL OR VAGINAL LP? Vaginal steroids Hydrocortisone acetate 25 mg rectal suppositories used vaginally QHS X 14 then 2-3 X per week Compounded mg hydrocortisone suppositories vaginally QHS X 14 then 2-3 times per week Compounded 5 mg prednisolone suppositories, or 2 mg tacrolimus suppositories, or 10% hydrocortisone cream vaginally 1 gram QHS X 14 then 2-3 times per week Oral steroid gels or mouthwashes Dexamethasone Oral Solution 0.5 mg/5 ml, 1 tsp BID swish X 5 minutes & spit, don t eat for 30 mins after Clobetasol propionate gel 0.05% applied topically QD or BID until lesions resolve Surgery for vaginal and vulvar adhesions Must be under good control before surgery. Post op dilators with vaginal steroids and estrogen to prevent re-formation of adhesions

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