Extragenital Lichen Sclerosus: What to Do When Phototherapy Has Not Achieved Lesion Improvement
This protocol addresses patients with extragenital lichen sclerosus in whom a prior phototherapy-based regimen has failed to achieve adequate improvement of LS lesions.
Clinical Scenario
Extragenital lichen sclerosus affects non-genital skin sites. Ultrapotent or potent topical corticosteroids are recommended for these patients; when structured phototherapy applied as a further step still has not produced sufficient lesion improvement, escalation to systemic treatment becomes necessary.
Previous Treatment — Failure Condition
The prior regimen was UVA1 phototherapy (or alternative light-based options such as narrowband UV-B, or topical tacrolimus combined with UV light). The treatment target that was not achieved: improvement of LS lesions.
Next-Line Approach
The protocol introduces Methotrexate, a systemic agent, potentially in combination with systemic corticosteroids — directed at achieving improvement of cutaneous LS. The complete dosing strategy, monitoring requirements, and decision algorithm are detailed in the full protocol.
References
DOI: 10.1111/jdv.20083
- We suggest ultrapotent or potent topical corticosteroids in patients with extragenital lichen sclerosus.
- We suggest MTX, taking into account teratogenicity, if systemic treatment is needed in adult patients with genital and/or extragenital lichen sclerosus. (off label)
- Therefore, MTX may be tried if standard treatment fails in extragenital as well as genital LS.
- MTX between 10 and 15 mg/week (subcutaneous or oral) for 6 months possibly combined with systemic steroids is reported to improve treatment-resistant generalized LS.
- Cutaneous LS in all patients improved after usually 3 months of treatment; 100% cure was not achieved, and the effect on genital lesions was not reported.