BSV08 Management of vulval lichen sclerosus: a 10-year review of clinical guidelines

Abstract

Lichen sclerosus (LS) is a chronic inflammatory skin condition most commonly affecting the vulva. It causes itch and sexual and urological dysfunction, with significant impact on quality of life. Clinical features include whitening, fissuring, ecchymosis and scarring. Recognition of LS has increased, with six management guidelines published in the past decade. Early diagnosis and treatment are essential to prevent irreversible architectural changes and malignant transformation. This study synthesizes current guideline recommendations for the management of vulval LS and highlights areas requiring further research. Six guidelines published over the past decade were included, originating from Europe, the UK, Australia, Japan and Ireland. The consensus is that vulval LS is a clinical diagnosis, with biopsies reserved for diagnostic uncertainty or suspected malignancy. Some guidelines suggest clinical photography to monitor progression. Ultrapotent and potent topical corticosteroids (TCS) remain first-line treatment, although there is no consensus on a regimen (daily vs. tapering). The amount of TCS ranged from half to one fingertip unit to ‘generously’. Older guidelines advise ad hoc use, while newer Australian, European and Irish guidelines recommend maintenance TCS. Other treatments lack robust evidence, including topical calcineurin inhibitors, topical retinoids, phototherapy, systemic retinoids, methotrexate, biologics and lasers. Follow-up is recommended at 3 months after initiation, then 6–12 monthly for stable disease, with more frequent review in active disease. Guidelines vary on care setting. European and Irish guidelines support discharge of stable cases to general practitioners (GPs), British guidelines specify GPs with specialist training, and Australian guidelines recommend shared care. Treatment-resistant cases or those with risk of malignancy should remain under specialist care. Vulval LS is a clinical diagnosis, and TCS remain the mainstay treatment with consensus on their safety and efficacy. The lack of consensus on a treatment regimen highlights an important area for further research. Other treatment options need further robust studies to prove their efficacy.