Genital Lichen Sclerosus in Adult Women When Calcineurin Inhibitor Treatment Has Not Controlled Symptoms
Clinical Scenario
This protocol applies to women aged 18 years or older with genital lichen sclerosus who are not pregnant. It is the indicated next step after a prior course of topical calcineurin inhibitor therapy — or intralesional corticosteroid injection for hyperkeratotic lesions where malignancy had been excluded — did not produce adequate symptom control.
Why the Previous Line Was Not Sufficient
Topical calcineurin inhibitors (tacrolimus or pimecrolimus), used as a second-choice or adjunctive treatment, are expected to suppress pruritus, burning, and dyspareunia by 12 weeks. When that threshold is not reached, the clinical situation calls for escalation. This protocol defines what comes next after that failure.
Approach at This Line
Management moves beyond topical therapy. The structured regimen at this stage centres on phototherapy as a second-choice intervention, with a systemic treatment pathway available when clinically required. The specific selection, sequencing, and monitoring criteria are set out in the full protocol.
Goal: reduction of pruritus and hyperkeratosis
References
DOI: 10.1111/jdv.20083
- We suggest UVA 1 therapy in women with genital lichen sclerosus as a second choice treatment, taking into account carcinogenicity and practicality.
- Low (20 J/cm²) or medium (50 J/cm²) dose UVA1 phototherapy for a total of 40 applications per cycle.
- We suggest acitretin, taking into account teratogenicity, if systemic therapy is needed in women with genital lichen sclerosus. (off label)
- We suggest MTX, taking into account teratogenicity, if systemic treatment is needed in adult patients with genital and/or extragenital lichen sclerosus. (off label)
- 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.
- However, intensity of all symptoms and signs was lower in the acitretin group, with a statistically significant difference for pruritus, atrophy and hyperkeratosis.
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