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Home , Benzocaine, Desonide, Lichen simplex chronicus

Disclosures and Conflicts of Interest

• No financial relationships or conflict of interest to disclose • Will be discussing off-label use of therapies • There are no preparations which are FDA approved for vulvar or vaginal use Educational Objectives

• Learn how the “lichens” differ from one another • Be able to recognize lichen simplex chronicus, , and • Be able to initiate treatment for all three conditions • Receive guidelines for the safe and appropriate use of topical, vaginal, and systemic steroid medications Help Me With This Case

• 65 yo Black female • 2 years of unrelenting genital itching • Awakens from sleep scratching • History of asthma and seasonal allergies • Worse with sweating, tight clothing • No improvement with oral fluconazole, oral metronidazole, topical clindamycin, 1% cream

Lichen Simplex Chronicus

• Chronic eczematous disease, waxes and wanes • Intense and unrelenting itching, especially at night • Localized variant of atopic (75% atopic) • “-scratch-itch” cycle perpetuates the disease • Can occur in healthy tissue or as a consequence of an itching dermatitis (, lichen sclerosus, ) • Not associated with risk of Squamous Cell CA

Treatment of Lichen Simplex Chronicus Step 1: Eliminate Irritants

• Physiologic irritants: abnormal vaginal discharge, urine, sweat, semen • Hygiene habits: excessive washing, bath soaps and laundry products, douches, hair removal products, wet wipes, lubricants, pads or daily panty liners • Medications: , spermicides, based creams or gels, benzocaine • Heat : hair dryers, heating pads, constrictive clothing

Step 2: Restore the Skin’s Barrier Function

• Educate patient about proper hygiene • Clean only with water and fingers • Pat dry, avoid friction • Emollient barrier with plain white petroleum jelly or zinc oxide: “Soak and Seal” • Cold compresses, ice packs Step 3: Reduce Inflammation

• Severe Disease: • Ultrapotent ( ointment 0.05%) daily for 2-4 weeks, then taper to mid or low potency steroid • Burst and taper of • IM 1 mg/kg (max dose 80 mg) • Milder Disease: • 0.1% or furoate 0.1% ointment 2-3 times per week for 3-6 months to prevent relapse • Second line: topical tacrolimus ointment or pimecrolimus cream if steroid intolerant. May provoke irritation Step 4: Treat Concurrent Infections

For infected excoriations or fissures: • Fluconazole 150 mg PO days 1, 4, and 7 for yeast • Cefadroxil 500 mg PO BID for 7 days or appropriate skin flora Step 5: Break the “Itch-Scratch-Itch” Cycle

• Sedating or TCA’s at HS • Hydroxyzine 10-25 mg PO 2 hours before bedtime • 25-50 mg PO at HS • 25 mg PO at HS • 25-100 mg PO at HS • Non-sedating antihistamines or SSRI’s for daytime use • Fexofenadine, Cetirizine, Loratadine • Citalopram, Sertraline, Duloxetine,

LS Causes Sexual Dysfunction

• Significantly less frequent sexual activity than health controls or women with candida • Significantly lower sexual satisfaction • Erosions, fissures, scarring, labial fusion, introital stenosis • Dyspareunia, Less frequent orgasms • Higher degree of sexual dysfunction • 42.2% report apareunia • Haefner, HK, et al. The impact of vulvar lichen sclerosus on sexual dysfunction. Journal of Women’s Health 2014; 23(9):765-770.

#6: Treat Early and Consistently

• Goals: to relieve symptoms and arrest progression of disease • Ointments are preferred: better tolerated, fewer chemical irritants and allergens, good barrier • Right potency (super or mid potency), • Right amount (“pea sized amount”), • Right location (super on , mid or low on anus), • Right dosing schedule (taper when under control)

Treatment Options: Right Potency

• First Line Treatment: Superpotent Topical • ointment 0.05% • Halobetasol propionate ointment 0.05% • Augmented dipropionate ointment 0.05% • Maintenance Tx: Mid or Low Potency Topical Steroids • Mometasone furoate ointment 0.1% • Triamcinolone acetonide ointment 0.1% • Desonide ointment 0.05% • Hydrocortisone 2.5% ointment Treatment Regimens: Right Dosing Schedule

• Superpotent topical steroid QD or BID for 2-4 weeks, then taper to every other night for 4 weeks, then 2-3 times per week for maintenance. • 30 gram tube lasts 3 months if used daily, 6 months if maintenance • , pruritus, fissures, hyperkeratosis will improve in 95% of women after 3 months of tx • Topical steroids can be used in children: switch to mid or low potency when under control For Stubborn Disease or Flares

• Intralesional triamcinolone (3-10 mg/mL) • Intradermal or submucosal, less than 10 mg total, not more than 4 times per year • Calcineurin inhibitors • Tacrolimus 0.03% and 0.1% ointment, BID X 4 weeks, then QHS, then 1-3 times per week. Apply over petrolatum or steroid ointment • Black box warning, risk of cutaneous malignancy • Oral Prednisone (0.5-1 mg/kg/d) • For flares, taper over 2-4 weeks Support and Comfort Measures

• Sitz/”Soak and Seal” with topical emollients (petrolatum, A&D ointment, Aquaphor) • Ice packs, cool gel packs and compresses • Systemic antihistamines for itching • For secondary vulvodynia: • Topical : 2% gel, 4% aqueous, 5% ointment. NO PEPPERMINT OIL! • Oral medications for neuropathic pain: tricyclic antidepressants, anticonvulsants, SSRI/SNRI

#2: What Does LP Look Like?

Signs: Symptoms: • Polygonal purple pruritic • Itching, burning, irritation, /plaques on keratinized rawness, skin, Wickham’s striae, pterygium formation at bases • dysuria, dyspareunia, post- coital bleeding, • erosive red patches on mucus membranes (urethra, vulva, vagina, • mouth pain with hard foods, esophagus, penis). spicy foods, acidic foods. • White lacy reticulations and • Esophageal: dysphagia & weight plaques in mouth and vulva loss • Erosive vaginitis, vaginal adhesions

#4: How Do I Treat VULVAR LP?

• 1st line: superpotent topical steroids. Disease control in 3-4 months with most patients. Follow every 6-12 months. (Re)biopsy for persistent , persistent erosions, hyperkeratosis. • Prolonged use of superpotent topical steroids is safe and effective • Stubborn disease may require intralesional triamcinolone injections • Severe disease may require systemic treatment with PO prednisone, azathioprine, cyclosporine, methotrexate, hydroxychloroquine, dapsone, mycophenolate mofetil, or IM triamcinolone #4: How Do I Treat ORAL OR VAGINAL LP?

• Vaginal steroids • 25 mg rectal suppositories used vaginally QHS X 14 then 2- 3 X per week • Compounded 100-500 mg hydrocortisone suppositories vaginally QHS X 14 then 2- 3 times per week • Compounded 5 mg suppositories, or 2 mg tacrolimus suppositories, or 10% hydrocortisone cream vaginally 1 gram QHS X 14 then 2-3 times per week • Oral steroid gels or • Oral Solution 0.5 mg/5 ml, 1 tsp BID swish X 5 minutes & spit, don’t eat for 30 mins after • Clobetasol propionate gel 0.05% applied topically QD or BID until lesions resolve • Surgery for vaginal and vulvar adhesions • Must be under good control before surgery. • Post op dilators with vaginal steroids and estrogen to prevent re-formation of adhesions