Expert Discusses ‘Awful Disease’ Lichen Sclerosus

   More than one out of 10 office visits are due to vaginal symptoms, and 16% of American women have chronic vulvar pain. Yet “there’s virtually no vulvovaginal training for clinicians,” Elizabeth G. Stewart, MD, told attendees at a session on vulvovaginal disorders at Internal Medicine 2011, the annual meeting of the American College of Physicians in San Diego.

   Assistant Professor of Obstetrics and Gynecology at Harvard Medical School, she noted that vulvovaginal diagnosis is complicated because dozens of disorders can present with similar symptoms. Clinicians also tend to rely on patients’ self-diagnosis and manage their problems by phone, or don’t do a physical exam before treating, leading to incorrect therapies.

   Her presentation focused on common conditions such as bacterial vaginosis and candidiasis, but also shed light on a condition once considered uncommon or rare -- lichen sclerosus, “an awful disease” that has a wider incidence than previously thought.

Its cause is unknown but its believed to have an autoimmune association, she said. Incidence peaks in childhood around the age of five and in menopause, affecting one in 30 elderly women, one in 50 women in a general gynecology practice, and one in 300-1000 patients referred to dermatologists.

    Symptoms of lichen sclerosus can range from intense pruritis severe enough to interfere with sleep to dull burning pain to no symptoms at all, Dr. Stewart said. Other symptoms include dyspareunia from introital narrowing, perianal fissuring, and painful defecation. Clinical signs include pallor, loss of pigmentation and “cigarette paper” wrinkling of the skin; purpura and ecchymoses; and figure eight extension around the perianal area. If lichen sclerosus is not recognized and treated, it’s possible for patients to lose all of their vaginal architecture, Dr. Stewart said.

   “The good news about lichen sclerosus is that we learned in 1988 that you can stop it in its tracks,” Dr. Stewart said. An “ultra-potent topical steroid (clobetasol 0.05%) is first-line treatment for lichen sclerosus at any age.” It should be applied once or twice daily for four to 12 weeks, then tapered to once daily to twice weekly for maintenance.

   “This is such an important message,” she said. “If you stop steroids, the disease will come back. It’s a chronic problem that isn’t going to go away.”