Chronic vulvar symptoms and dermatologic disruptions: How to make the correct diagnosis

Diagnosis: After correlating the vulvar and oral findings, you make a diagnosis of lichen planus.

Treatment: You initiate halobetasol ointment twice daily, to be applied to the vulva. You also continue vaginal estradiol cream but add hydrocortisone acetate 200 mg compounded vaginal suppositories nightly, as well as clobetasol gel to be applied to oral lesions three times a day. You follow the patient closely for secondary yeast of the mouth and vagina.

Erosive multimucosal lichen planus is a disease of cell-mediated immunity that overwhelmingly affects menopausal women. The most common surfaces involved are the mouth, vagina, rectal mucosa, and vulva; usually, at least two surfaces are affected. The esophagus, extra-auditory canals, nasal mucosa, and eyes also can be involved. Dry, extragenital skin usually is not affected in the setting of erosive vulvovaginal lichen planus.

Vulvar lichen planus most often is controlled with ultra-potent topical corticosteroids (again, clobetasol, halobetasol, or betamethasone dipropionate in an augmented vehicle), but other mucosal surfaces often are more difficult to manage. Although there is no definitive cure for this condition, careful local care, estrogen replacement, and suppression of oral and vulvovaginal candidiasis usually provide relief.

Calcineurin inhibitors (tacrolimus, pimecrolimus) sometimes are useful in patients who improve only partially after treatment with a topical corticosteroid, provided burning with application is tolerable. ¹⁰ Systemic immunosuppressants such as hydroxychloroquine, methotrexate, mycophenolate mofetil, azathioprine, cyclosporine, cyclophosphamide, and tumor necrosis factor (TNF) alpha blockers (etanercept, adalimumab, infliximab), as well as oral retinoids, can be added for more recalcitrant disease. ¹¹

How to manage disease that affects the vagina
When the vagina is involved in lichen planus, treatment is important to prevent scarring, as well as rawness and pain from irritant contact dermatitis caused by purulent vaginal secretions. Occasionally, a 25-mg hydrocortisone acetate rectal suppository inserted into the vagina nightly improves vaginal lichen planus, but sometimes more potent suppositories, such as doses of 100 to 200 mg, may be compounded. Dilators should be inserted daily to prevent vaginal synechiae.

Oral involvement requires targeted treatment
The mouth is almost always involved in lichen planus. If a dermatologist is not involved in patient care, a prescription for dexamethasone/nystatin elixir (50:50) (5 mL swish, hold, and spit four times daily) can improve oral symptoms remarkably. Alternatively, clobetasol gel applied to affected areas of the mouth three or four times daily can be helpful. Secondary yeast of the vagina and mouth are common with the use of topical corticosteroids.

Careful clinical follow-up is advised
Like uncontrolled lichen sclerosus, erosive lichen planus of the vulva produces scarring and sometimes eventuates into squamous cell carcinoma. Therefore, careful clinical surveillance is warranted. And therapy must be continued to prevent recurrence of lichen planus (as it must be for lichen sclerosus), scarring, and to decrease the risk of squamous cell carcinoma. And like lichen sclerosus, lichen planus sometimes triggers vulvodynia.

CASE 5. MULTIPLE BOILS IN THE GROIN
A 31-year-old morbidly obese African American woman comes to your office with continually evolving boils in the groin. A culture shows Bacterioides spp, Escherichia coli, and Peptococcus spp. In the past, multiple courses of various antibiotics have provided only modest relief.