Lichen planus is an inflammatory, autoimmune disorder of the skin and mucous membranes. While there are multiple clinical variants that may involve the skin of the whole body, the most common form affecting the vulva and vagina is called erosive lichen planus. Lichen planus affects approximately 1% of all women, and the most common site of involvement is the mucosa of the mouth and gums. Approximately 25% of women with oral lichen planus also have vulvovaginal involvement.
Erosive lichen planus is characterized by glassy, bright red erosions and ulceration involving the vulva and vagina. Like lichen sclerosus, erosive lichen planus may cause severe scarring of the vulva. However, unlike lichen sclerosus which does not affect the vagina, erosive lichen planus can cause severe erosions and scarring in the vagina and can lead to obliteration of the vagina. Vaginal involvement has been reported in up to 70% of patients with erosive lichen planus.
Women with lichen planus of the vulvovaginal region may present with itching, burning, pain, bleeding after intercourse, copious yellow discharge, and destruction of the vulvovaginal architecture. On physical examination, the vulvar skin and vaginal mucosa easily tear and bleed.
In general, vulvar and vaginal lichen planus is not readily treated as lichen sclerosus or lichen simplex chronicus. Most vulvar specialists recommend the initial use of topical medications, reserving systemic treatments for patients who fail topical treatments or those with extensive disease affecting multiple areas of the body.
First-line treatment of vulvar lichen planus are daily topical potent or ultra-potent corticosteroid ointments such as fluocinonide 0.05% or clobetasol propionate 0.05%. A warm sitz bath before application may allow better penetration through keratinized lesions. Vaginal lichen planus is treated with intravaginal hydrocortisone suppositories. Commonly used formulations are those used to treat hemorrhoids. Other treatment options include potent corticosteroid ointment applied to a vaginal dilator and inserted into the vagina. This treatment also helps in preventing obliteration of the vagina.
Tacrolimus and pimecrolimus, topical macrolide immunosuppressant has recently been described for the treatment of a vulvovaginal lichen planus. Topical cyclosporine has also been described for the treatment of oral and vulvovaginal lichen planus. However, it is of limited utility due to its irritative properties and high cost.
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(PLEASE NOTE – there are explicit photos of the genital of women and these images are not appropriate for anyone under the age of 18.)