Vulvar Lichen Planus

Aka: Vulvar Lichen Planus, Lichen Planus of the Vulva, Vulvovaginal-Gingival Syndrome

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II. Definitions

  1. Vulvar Lichen Planus
    1. T-Cell Mediated Autoimmune inflammatory condition that affects keratinized areas including vulva

III. Pathophysiology

  1. T-Cell Mediated Autoimmune inflammatory condition affected keratinized skin
  2. May affect any region of skin or mucosa
  3. Frequently affects multiple areas (e.g. Oral Lesions, genital lesions)

IV. Epidemiology

  1. Typical onset between ages 40 to 60 years
  2. Prevalence <1%
  3. Much less common than Vulvar Lichen Sclerosus as a cause for Vulvar Dermatitis

V. Types

  1. Erosive Lichen Planus (most common variant)
    1. Glassy appearing white Papules and Plaques
    2. Progression to ulcers and erosions with altered Vulvar Anatomy
    3. Vagina involved in 70% of cases (vagina not involved in Lichen Sclerosus)
      1. Vaginitis characterized by friable, tissue with adhesions and serous discharge
    4. May concurrently involve Vulvovaginal-Gingival Syndrome
  2. Papulosquamous Lichen Planus
    1. Poorly demarcated pink opaque Papules
  3. Hypertrophic Lichen Planus
    1. Perineum and perianal hyperkeratotic lesions
    2. May present as Squamous Cell Carcinoma
  4. Other appearance
    1. Bright red, well-demarcated patches with hyperkeratotic border
    2. Wickham Striae (web-like Plaque)

VI. Symptoms

  1. Vulvar Pruritus or burning
  2. Postcoital bleeding
  3. Dyspareunia

VII. Signs

  1. Variable appearance (See types above)
  2. Speculum exam is very uncomfortable in erosive Lichen Planus due to associated Vaginitis

VIII. Labs: Erosive Lichen Planus

  1. Punch Biopsy of erosion borders
  2. KOH and Wet Prep to evaluate for fungal and Bacterial causes of Vaginitis

IX. Differential Diagnosis: Erosive Lichen Planus

  1. Lichen Sclerosus
  2. Pemphigoid
  3. Pemphigous vulgaris
  4. Behcet's Syndrome
  5. Vaginitis
  6. Drug Reaction

X. Management

  1. General
    1. Expect lesions to improve with treatment, but full resolution is rare
    2. Treatment goal is to reduce symptoms and scarring
  2. Intravaginal Hydrocortisone acetate 25% suppositories for vaginal lesions
    1. Decreases vaginal introitus closure
    2. May be used in combination with dilators
  3. Topical Corticosteroid for vulvar lesions (or applied on vaginal dilator for erosive Vaginitis)
    1. Choice of strength depends on severity
      1. Level 1: Clobetasol Propionate 0.05% ointment (ultra-potent bid in severe cases)
      2. Level 2: Betamethasone Dipropionate 0.05% ointment
      3. Level 3: Betamethasone Dipropionate 0.05% cream
      4. Level 4: Triamcinolone Acetonide 0.1% ointment (medium potency qhs in mild cases)
    2. Taper steroid on resolution of active lesions
  4. Refractory Cases
    1. Topical Calcineurin Inhibitors (e.g. Tacrolimus)
    2. Systemic Corticosteroids
      1. Indicated in cases refractory to Topical Corticosteroids
      2. Prednisone 40 to 60 mg orally daily for 2-4 weeks

XI. References

  1. Goldstein (2005) Clin Obstet Gynecol 48:818-23 [PubMed]
  2. O'Connell (2008) Am Fam Physician 77: 321-30 [PubMed]
  3. Ringel (2020) Am Fam Physician 102(9):550-7 [PubMed]

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