eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Nonneoplastic Epithelial Disorders of the Vulva: Treatment & Medication

Author: Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Contributor Information and Disclosures

Updated: Jul 9, 2007

Treatment

Medical Care

• Squamous cell hyperplasia
  • Topical steroids (eg, medium-strength betamethasone 0.1% ointment) are applied twice daily until symptoms are controlled, usually in 10-14 days. Use episodically as necessary thereafter. If unsuccessful, high-potency steroids (eg, clobetasol 0.05%) can be used in a similar fashion with return to a less potent steroid once a response is obtained.
  • Topical medium-strength corticosteroids (eg, 0.1% triamcinolone) can be applied twice daily and decreased to once daily when symptoms resolve.
• Lichen sclerosus
  • Patients with lichen sclerosis typically present with thin, parchmentlike skin, which is a poor barrier to the loss of moisture. Patients should avoid excessive drying of this skin after bathing. Bland emollients should be used to improve moisture retention. For instance, a thin layer of petrolatum (eg, Vaseline) may be helpful. Aqueous creams or emulsifying ointments are safe and cheap. Many proprietary preparations of moisturizing lotions, creams, or ointments are available.
  • Careful hygiene, avoidance of irritants and allergens, use of cotton underwear, and avoidance of constricting and heat-inducing clothing are sensible adjuncts of local care. The condition is independent of whether the patient is taking hormone replacement therapy.
• As definitive therapy, clobetasol propionate 0.05% ointment is applied twice daily. Note that a "one finger-tip unit" is about 0.5 g and should provide a single application. In using a potent corticosteroid, the amount used should be monitored, with 30 g over 3 months providing a dosage level below which few local or systemic adverse effects are likely to occur. Because the effect is usually very good, use is generally tapered off after 2-3 weeks. Indefinite maintenance with small amounts is satisfactory in most instances.
• Estrogen or testosterone creams have no role in the treatment of lichen sclerosus (Bornstein et al, 1998). Testosterone has been shown to be no better than petrolatum in treating lichen sclerosus.¹ Furthermore, it does not maintain the improvement brought about by clobetasol propionate.² When testosterone was used, it was provided as 2% testosterone propionate in petrolatum. This was applied 2-3 times a day for up to 6 months. Adverse effects, including masculinization, were not uncommon and included clitoromegaly and clitoral irritation. After completion of the initial phase, application frequency was reduced and then maintained indefinitely. Testosterone use is contraindicated in children because it is systemically absorbed and may cause androgenic adverse effects.
• Topical progesterone has been used for adults who did not respond to steroids or testosterone and for children. This agent is prepared by mixing 400 mg of progesterone in oil with 4 oz of Aquaphor and is applied twice daily. As with testosterone, pruritus must first be controlled with steroid cream before use of the progesterone cream.
• For patients with lichen sclerosus and coexistent squamous hyperplasia, therapy is as for lichen sclerosus. It may occasionally be necessary to excise hyperplastic or fissured areas of lichen sclerosus unresponsive to medical therapy, but patients must realize that recurrence rates after excision are high. This applies even after skin grafting, when lichen sclerosus may recur in the grafted skin.
• Difficult cases refractory to the usual therapies require consultation with a dermatologist and, on occasion, a plastic surgeon. Multidisciplinary management is helpful in such patients. For pruritus unresponsive to topical steroids, triamcinolone (Kenalog-10) may be injected locally at 1-cm grids. Because a retinoid has been shown to reduce connective tissue degeneration in lichen sclerosis, these agents are worth considering in resistant cases. Therapy with oral etretinate and tretinoin has been shown to be helpful. In view of adverse drug effects, topical therapy is preferable, and tretinoin has been used locally with good results. Encouraging results have been reported in small numbers of patients treated with 1% topical pimecrolimus (Elidel) administered twice daily for 3 months. Pimecrolimus is a topical macrolide immunosuppressant that inhibits T-cell activity and is US Food and Drug Administration–approved for eczema.³ A preliminary report from China suggested that focused ultrasound therapy may be efficacious and recommended further studies.⁴

Surgical Care

Surgery is reserved for patients in whom biopsy has identified associated vulvar intraepithelial neoplasia or invasive SCC. When introital stenosis is causing symptoms, vaginoplasty may be indicated. Simple vulvectomy has little or no place in the treatment of this disease because symptoms are not always relieved, signs recur, and cancer returns. The operation has significant physical and psychosexual complications.

Consultations

In some patients, difficulties in diagnosis or poor response to therapy requires consultation with a dermatologist. When introital stenosis is causing symptoms sufficient to necessitate surgery (eg, meticulous unsealing of tissue around the clitoris, careful vaginoplasty), consultation with a plastic surgeon may be indicated. In the event of a premalignant or malignant change on biopsy, referral to gynecologic oncologist is in order.

Activity

Sexual activity is contraindicated when it is uncomfortable for the patient or if it worsens pruritus, at the patient's discretion. No evidence supports the hypothesis that sexual activity interferes with healing, though abstinence during the initial phase of therapy in a symptomatic patient appears to be a sensible precaution. Dyspareunia is common, as is splitting at the introitus with intercourse. Lubricants, careful sexual technique, and application of clobetasol to heal the fissures are usually effective. Vulvoplasty is sometimes required.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. Steroid creams are grouped according to anti-inflammatory activity as low- (eg, hydrocortisone 1%), medium-, or high-potency agents. Ointments are indicated for management of thick, chronic dermatitis. Inflamed skin requires lotions or creams.

Hydrocortisone (Cortaid, Dermacort, Westcort)

Adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Has mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity.

Clobetasol (Temovate)

Very high-potency topical corticosteroid used to treat lichen sclerosus. Suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.

Triamcinolone (Aristocort)

Medium-potency agent that decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. Treats squamous cell hyperplasia.

Hormone therapy

May improve inflammatory reactions.

Progesterone (Crinone, Progestasert)

Prepared by mixing 400 mg of progesterone in oil with 4 oz of Aquaphor.

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