|Treatment action||Topical/behavioral||Oral meds||IM or intralesional meds||Vaginal meds||Testing/Notes|
|Comfort measures, general care||Sitz bath, gentle cleansing, topical petrolatum, avoidance of irritants or tight clothing, application of cool gel packs. Educate: 1) this is a chronic disease that needs life-long treatment; 2) steroid treatments are safe if used as directed.||Always do pH, wet prep, and yeast culture.Biopsy if unsure of diagnosis. (LINK to biopsy)
Steroid medications can enhance development of infectious conditions such as candidiasis, herpes simplex, and condyloma.
Link to Lichen Planus in Atlas.
|Reduction of pain with intercourse||Topical xylocaine 5%, applied as needed, usually 4-6 times a day or prior to intercourse (avoiding clitoris), then wiped off; (no more than 15 grams a day) (May cause burning when first applied).||Pain with intercourse needs to be fully evaluated (see algorithm).Pain caused by LP can resolve with healing of vestibular erosions and vaginal inflammation.
Vulvodynia can arise secondarily.
|Anti-inflammatory action for vulva and/or vestibule||Clobetasol or halobetasol 0.05% ointment applied twice a day, in a thin film, for 30 days, followed by once a day application for 14-30 days,
followed by once a day application three times a week
that followed by a maintenance dose of twice a week application of ointment.For the peri-anal area or for reduced dose for remission:
Betamethasone 17-valerate 0.1% ointment applied twice a day in a thin film until improved x 1 month
Triamcinolone acetonide 0.1% ointment applied twice a day in a thin film until improved x 1 month
|Prednisone or methylprednisolone 40-60 mg every morning for 5 days, or a tapering dose up to 7-10 days (for diffuse inflammation, or for those unresponsive to topical treatment)
(Used rarely due to known side effects of oral steroids.)
|Triamcinolone acetonide (Kenalog 10), 10 mg/mL diluted 1:1 with saline and using a 30-gauge needle; injected under plaque after application of EMLA (for large, thick areas or those unresponsive to topical treatment)Triamcinolone acetonide 40 mg/ml (Kenalog 40) 1 mg per kg intramuscularly, single dose for diffuse inflammation or for those unresponsive to topical treatment||For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting.Super potent topical steroid ointments are the treatment of choice and usually subdue symptoms or changes in the skin adequately.
Only a small amount of ointment is needed.
Treatment is life-long. Occasionally, remission allows reduction to a lower dose ointment or to a reduced frequency of once a week.
In the peri-anal area, super-potent steroids are rarely used. Instead, use mid-potency steroid ointment such as Betamethasone valerate 0.1% or Triamcinolone 0.1%.
“Flares,” where symptoms recur, are not uncommon and are usually controlled by returning temporarily to more frequent use of steroid ointment.
Always look for and culture for yeast during a flare.
Steroid rosacea is the most-likely side effect, almost always due to over use of the ointment. (LINK to steroid rosacea).
|Anti-inflammatory action for vaginal erosive lichen planus manifesting as mild DIV||Hydrocortisone suppositories 25 mg (use Anusol rectal suppositories vaginally); 1 vaginally at bedtime for 14-30 days, then every other day till seen again in one month.||DIV, in some cases linked to erosive lichen planus in the vagina, is diagnosed through pH and microscopy. (LINK to Annotation P and also microscopy tables).
In post menopausal women and those who are breastfeeding, rule out atrophy before assuming DIV since they can look similar under the microscope.
Mild DIV may present with a borderline pH, hovering near normal, some parabasal cells, and >1:1 ratio of WBCs to epithelial cells
(LINK to microscopy slide with mild DIV)
|Anti-inflammatory action for strong evidence of erosive lichen planus manifesting vaginally as DIV||Hydrocortisone compounded suppositories, 100 mg; insert one vaginally nightly x 14-30 nights, then every other night for 14-30 days, then 2-3 times weekly. Re-evaluate at 1 month intervals.||Moderate to severe DIV presents with elevated pH, many parabasal cells and many WBCs.
(LINK to microscopy slide with moderate to severe DIV)
|Antibiotics for superimposed infection||Dicloxacillin 250-500 mg orally 4 x a day for 10 days
Cephalexin 250-500 mg orally 4 x a day for 10 daysAND
Treat concomitant yeast with Fluconazole 150 mg orally x1
x2, days 1 and 3 followed
|Clindamycin 2% cream; 5 g intravaginally, nightly x 14 days (used rarely but has anti-inflammatory properties)ANDBecause hydrocortisone has the potential for overgrowth of yeast, consider adding 2% Clotrimazole to the compounded suppositories (Hydrocortisone 100 mg suppositories with 2% Clotrimazole)
Treat incidental yeast with oral Fluconazole.
|If giving antibiotics, consider also treating for potential yeast infection with an anti-fungal.Be aware that Fluconzaole has many potential drug to drug interactions.|
|Alternative treatments for recalcitrant LS||Calcineurin inhibitors:
Topical tacrolimus (Protopic) 0.3% or 0.1% ointmentOR
pimecrolimus (Elidel) 1% cream applied once or twice a day can be used as an alternative topical medication or in conjunction with the topical steroid.
|These medications may burn and they are expensive. We prescribe the tiniest amount as a trial for the patient.Burning may be ameliorated by applying topical Vaseline first.
The burning will sometimes taper off after a few applications.
These meds can be used concomitantly with topical steroid ointment.