Clinical Question: What is the response of vulvar lichen sclerosus to treatment with ultrapotent topical steroids?

Setting: Outpatient (specialty)

Study Design: Case series

Synopsis: Lichen sclerosus is most common among girls and postmenopausal women and often involves the vulva. To date, no randomized controlled trials of therapy for this condition have been conducted, although steroids often are used on the basis of small case series and pathophysiologic reasoning.

In this study, 250 women and 72 girls with vulvar lichen sclerosus were followed prospectively for a mean of 66 months. Patient response to treatment was classified in two ways: symptoms such as pruritus and soreness were classified as good (symptom free), partial, or poor (no change or worsening); physical signs of disease were classified as total, partial, minor, or poor. Topical steroids were used in most patients (86 percent of girls and 93 percent of women), with the majority using the ultrapotent topical steroid 0.05 percent clobetasol propionate ointment (50 percent of girls and 89 percent of women).

The authors had treatment response data on symptoms in 79 percent of patients and physical signs in 78 percent. Symptomatic response was good, with 66 percent becoming free of symptoms during the initial treatment period and another 30 percent having a partial response. Resolution of physical signs was less impressive, with only 22 percent experiencing total resolution and 68 percent experiencing a partial resolution. The results of a smaller study in the same issue (Renaud-Vilmer C, et al. Vulvar lichen sclerosus: effect of long-term topical application of a potent steroid on the course of the disease. Arch Dermatol June 2004;140:709–12) showed that remission was more likely in women younger than 50 years (72 percent) than in those 50 to 70 years of age (23 percent) or those older than 70 years (zero percent).

Bottom Line: This study supports the use of an ultrapotent topical steroid (i.e., 0.05 percent clobetasol propionate ointment) in women with vulvar lichen sclerosus. Unfortunately, the weak study design, which lacked a control group, is typical of the literature on this condition. (Level of Evidence: 4)