PRELIMINARY DIAGNOSIS:

• Biopsy-proven lichen sclerosus, not yet in good control
• Vaginal atrophy contributing to burning pain
• Possible irritation from base used for topical medications

Plan:

        Testing sent or ordered: Yeast culture. Result: negative

        Education: The patient was given handouts on general vulvar care, lichen sclerosus, and vaginal atrophy and her conditions were discussed. Advised to avoid irritants and irritants were specified.

        Restoration of the epithelial barrier: soak (5-10 minutes, tepid water) and seal with Vaseline twice daily for seven days.

        Treatment:

For the atrophy: Estrace cream, 1 gram inserted vaginally at bedtime for 14 days and then twice a week. Apply a small amount of the cream nightly to the vestibule, as well, on the same schedule.

For the lichen sclerosus: After 1 week of Estrace, start halobetasol 0.05%, a high potency topical steriod, applied in a thin film to all the whitened, fissured tissue nightly for 2 weeks and then every other day until your next visit.

To call the office if the burning gets worse.

Return visit findings:

One month later:
Soon after the first visit, she had called to report that halobetasol caused burning and she was switched to clobetasol 0.05% compounded with a petrolatum base that was comfortable for her. She was tolerating the Estrace cream, but thought that the discharge that dripped out the day after using it was causing some perianal irritation. Her pain level was down from a 9/10 to a 3/10.
She still had whitening on exam and some pain with q-tip touch, but she was more hopeful about recovery.
Assessment:
Improved pain with treatment of atrophy; ongoing inadequately treated lichen sclerosus
Plan:
Continue with compounded clobetasol three times a week; switch from vaginal Estrace cream to Vagifem 10 mcg inserted vaginally twice a week. Continue topical Estrace cream ¼ inch from the tube applied twice a week. Return visit in three months. Yeast culture sent and negative.

Two months later:
The patient reported ongoing burning sensations at a 2-3/10 level. She was happy with her results. She was using the compounded clobetasol Monday, Wednesday, and Friday and the Vagifem and topical Estrace Tuesday and Thursday. All the whitening had cleared up. She had increased erythema in the perineal area. pH and wet prep reflected adequate estrogen levels in the vagina.
Q-tip touch showed improvement in pain.
Assessment:
Improvement in burning pain and atrophy; lichen sclerosus in good control; ongoing burning possibly related to secondary vulvodynia
Plan:
Try nightly compounded clobetasol again for two weeks to see if burning will resolve. Then reduce the steroid ointment to three times a week again. Vulvodynia and possible treatment with a tricyclic antidepressant or anti-seizure medication discussed. Patient declined centrally acting oral medication. Yeast culture sent and negative. Follow up in four months.

Five months later:
Patient reports ongoing improvement. She is comfortable day to day, without burning or itching. She finds if she misses a Vagifem dose, she feels more uncomfortable.
Exam shows new whitened area on edge of the prepuce of clitoris. pH 4.7 and wet prep shows good estrogenization.
Assessment:
Atrophy and lichen sclerosus stable on regimen; small area of active LS
Plan:
Continue thrice weekly compounded clobetasol 0.05%, with special attention to prepuce; continue Vagifem, but increase dose to three times weekly; Continue topical Estrace cream twice a week. Yeast culture sent and negative. Follow up every six months.

Three years later:
The patient had been doing well on her own and had her own gynecologist check her LS and atrophy. However, she had had flaring symptoms of itching and irritation recently.
On exam, the labia majora were seen to be reddened uniformly, as if “sunburned.” The lichen sclerosus was in good control, with no further loss of tissue and no whitening. The pH and wet prep showed good estrogenization. No sign of yeast. Q-tip touch test showed mild irritative symptoms on the labia majora.
Assessment:
Atrophy and lichen sclerosus in good control; mild steroid rosacea or irritant skin reaction
Plan:
The patient was shown with a mirror where to apply her cream and ointment. She was advised not to apply the steroid to the outer labia majora. She was also advised to start “soak and seal” at least once a day, patting dry gently, then applying plain Vaseline to the skin of the outer vulva and vestibule. She was advised to cut back on the clobetasol, Vagifem, and Estrace to twice a week for all meds. Yeast culture was done and negative.
She returned two months later, completely comfortable, with no burning, no itching, no further anatomical or skin changes, and improved color and texture to the skin of the labia majora.
She has been asked to return every six months for routine surveillance.

TEACHING POINTS:

• Because of the 3-5% risk of women with lichen sclerosus developing squamous cell carcinoma, they need to be evaluated every six months on a routine basis, to check for ulceration or for thickened white plaques, as well as for control of the LS itself.
• We always try to use the least amount of medication necessary to control the condition.
• This patient had developed steroid rosacea from using the medication in the wrong place and using too much. It is important to show the patient with a mirror where to place the ointment, touch her skin in those areas for sense memory, and also give her a drawing showing correct placement. Show her, using plain lubricant, exactly how much to use.
• We initially tried a different brand of steroid, same strength. When she, again, had burning, we tried a compounded steroid in a neutral base (petrolatum) known not to cause skin reactions.
• This woman is not sexually active, but using a topical estrogen makes her more comfortable.