Topical clobetasol urged for lichen sclerosus tx

OB/GYN News, March 15, 2003 by Norra MacReady

HOUSTON -- Ultrapotent topical clobetasol should be the mainstay of treatment for genital lichen sclerosus, despite a widely held belief that it shouldn't be used on the vulva, according to Dr. Elizabeth Edwards.

Studies comparing clobetasol ointment to 2% topical testosterone propionate in petrolatum and the vehicle alone have shown the steroid to be vastly superior at relieving vulvar symptoms and reversing the disease course, Dr. Edwards said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Testosterone was no better than plain petrolatum and was associated with masculinizing side effects such as increased facial hair, clitoral hypertrophy, and deepening of the voice.

Dr. Edwards has her patients apply Temovate (clobetasol propionate) to the area twice a day until the skin is entirely cleared, which could take as long as 4 months. She warns patients that diligent application is important, because some portions of the skin may heal more quickly than others.

During this time, she follows patients at monthly visits, checking for complications such as skin atrophy. When the lesions are gone, patients apply the steroid on a thrice-a-week schedule and are followed up every 6 months.

Temovate should not be used on hair-bearing regions of the labia majora, crural crease, or perianal skin, because those areas atrophy quickly and readily develop steroid dermatitis.

She prescribes Temovate because patients who tried generic clobetasol complained that it was less effective, said Dr. Edwards of Wake Forest University, Winston-Salem, N.C. She has no financial ties to Glaxo Wellcome, the company that makes Temovate.

The choice of ointment or cream depends on the severity of the condition: Cream works well on skin that itches but has no exudative erosions, while the ointment is indicated for painful, inflamed, eroded skin.

Approximately 3%-4% of women with lichen sclerosus will develop squamous cell carcinoma at some point in their lives, compared with an annual incidence of 1/150,000 women who don't have lichen sclerosus.

Dr. Edwards said she believes the risk is highest in patients with uncontrolled lichen sclerosus.

Skin that's raw from constant rubbing or scratching is highly vulnerable to infection, so she often prescribes prophylactic antibiotics along with clobetasol. It's important to explain to patients that lichen sclerosus is seldom cured, but it can be controlled.

As long as they apply clobetasol regularly, they'll probably be able to keep symptoms at bay, but the symptoms will almost certainly return if they stop using the steroid, Dr. Edwards said at the conference.

As supportive care, patients should be instructed to avoid excessive washing; harsh, perfumed soaps; and even panty liners, all of which may dry or irritate the skin and exacerbate itching. For patients who scratch at night, sedatives may help break the itch-scratch cycle and allow them to sleep better.

Patients who don't respond to ultrapotent steroids within 1 month should have a shave biopsy to rule out squamous cell carcinoma, Dr. Edwards said. If the biopsy is negative, try intralesional steroid injections or topical retinoids. Tacrolimus ointment (Protopic) has also yielded promising results in off-label use in patients who can't tolerate topical steroids, although it may burn briefly on application.

If all of that fails, reconsider the diagnosis or the possibility that an infection or contact dermatitis may be complicating the case. Surgical excision may be the only way to get rid of the lesions completely.