Board Review

A 62-year-old woman is evaluated for pain with sexual intercourse and genital itching. Her symptoms began several years ago and have been progressively worsening. She has used lubricants and topical moisturizers without improvement. She notes no vaginal discharge or odor. She has no significant medical history and takes no medications.

On physical examination, vital signs are normal. The general physical examination is unremarkable. Skin findings are shown.

There is no vaginal discharge or odor.

Which of the following ointments is the most appropriate treatment?

A) Clobetasol, 0.05%

B) Hydrocortisone, 1%

C) Mupirocin

D) Nystatin

Answer: A - Clobetasol, 0.05%

Objective: Manage lichen sclerosus in a postmenopausal woman.

Key Point

The use of potent topical glucocorticoids is considered first-line treatment for lichen sclerosus.

The patient should be treated with a topical high-potency glucocorticoid (class I or II), such as clobetasol, mometasone, or betamethasone. Her clinical presentation of white atrophic patches circumferentially involving the anus and vagina with associated pruritus and dyspareunia is consistent with lichen sclerosus. Lichen sclerosus is a benign, chronic, and progressive dermatologic condition of unclear etiology that tends to affect peri- and postmenopausal women. It manifests with marked inflammation and epithelial thinning that is pruritic; because of its usual location, lichen sclerosus is usually associated with pain during intercourse. Skin findings are characteristic, and the diagnosis is confirmed on biopsy showing epidermal thinning, scarring, and evidence of inflammation. The appropriate first-line therapy for this disease is a potent topical glucocorticoid, such as clobetasol, daily for 2 to 3 months (or until resolved) and then intermittently to prevent recurrence. Not treating lichen sclerosus will result in permanent scarring (including all anatomic structures such as the clitoris and vaginal opening), and there is evidence of early scarring with resorption of the labia minora in this patient. Close monitoring also is essential to evaluate for cutaneous squamous cell carcinomas that can occur with chronic inflammation.

A low-potency glucocorticoid, such as hydrocortisone 1% ointment, is not adequate to treat lichen sclerosus. Continued inflammation with this treatment will result in permanent scarring.

Vulvar lichen sclerosus is not caused by a bacterial infection; therefore systemic (cephalexin) or topical (mupirocin) antibiotics are not indicated.

Occasional co-infection with vaginal candidiasis can occur, which would present with foul-smelling and thick white discharge. Vulvar candidiasis can also occur, which would present with bright red patches and satellite pustules. These infections should be treated with intravaginal or oral antifungal agents. Topical nystatin is an antifungal agent used to treat candidiasis but would not be effective for treatment of vulvar lichen sclerosus.

Virgili A, Borghi A, Minghetti S, Corazza M. Mometasone fuoroate 0.1% ointment in the treatment of vulvar lichen sclerosus: a study of efficacy and safety on a large cohort of patients. J Eur Acad Dermatol Venereol. 2014 Jul;28(7):943-8. Link Out