Use Clobetasol on Lichen Sclerosus, Then Biopsy

OB/GYN News, May 1, 2001 by Timothy F. Kirn

SOUTH LAKE TAHOE, NEV, -- If a patient presents with what appears to be lichen sclerosus of the vulva, it is often a good idea to treat her with clobetasol propionate before attempting to biopsy any lesions unless an obvious carcinoma is present, Dr. C. Paul Morrow recommended.

Of the inflammatory dermatoses of the vulva, lichen sclerosus is the most common and has the highest potential for malignancy. It therefore needs to be diagnosed and treated with special diligence, he said at an obstetrics and gynecology conference sponsored by the University of California, Davis.

Lichen sclerosus--symmetrical, confluent skin involvement--is usually confined to the glabrous, non-hair-bearing skin. The skin typically has a very white, parchmentlike look, said Dr. Morrow, a professor in the division of gynecologic oncology at the University of Southern California, Los Angeles.

However, since the hallmark of the disease is pruritus, when patients first present with severe cases they often have been scratching excessively, leading to heavily keratinized and ulcerated areas. In these cases, it can be difficult to decide whether what you are seeing is carcinoma or lichen sclerosus, and it can be hard to know where to biopsy to make either diagnosis, Dr. Morrow said.

Therefore, he often first treats suspected cases of lichen sclerosus empirically, with clobetasol propionate 0.05% cream, twice daily for a week. That is usually enough time for the scratching damage to begin to resolve and it is then easier to see where to biopsy In these patients, Dr. Morrow usually takes four or more biopsies.

Generally, he has patients apply the cream twice daily for 2 months. Some patients will go into remission with this initial treatment, he said.

After the initial treatment, Dr. Morrow prescribes intermediate-potency corticosteroids for flare-ups. However, he has found that patients will frequently use their remaining supply of clobetasol, and this does not appear to be a problem, he said.

Treatment failure with clobetasol is almost always due to noncompliance with. the regimen, he said. "They just don't have the time to put on the medication in their busy lives."

Other therapies for initial treatment include topical 2% testosterone and intermediate-potency corticosteroids, but Dr. Morrow said he prefers to use the high-potency clobetasol on severe cases of lichen sclerosus. Testosterone can actually make the symptoms worse, he said. Testosterone also gets absorbed systemically and can have secondary effects.

Intermediate-potency corticosteroids may alleviate some of the pruritus and may resolve some lesions, but in his experience clobetasol is more effective.

Laser treatments and split-thickness skin grafts can be used for refractory lichen sclerosus, but both measures have a high rate of failure, he said.

Because the risk of vulvar cancer is so high, Dr. Morrow said he sees lichen sclerosus patients every 6 months. The rate of vulvar cancer in women with lichen sclerosus has been reported to be as high as 20%, but most estimates put it at around 4%-6%, he said. At a rate of a woman with lichen sclerosus has a risk of vulvar cancer that is 50-250 times higher than that of a woman with out the disease.