Management of Vulval Lichen Planus

Background: Vulval lichen planus (VLP) is a debilitating, often treatment resistant condition, for which there is limited evidence-based guidance on assessment and management. Aim: To describe current management of women with VLP in the multi-disciplinary vulval dermatology clinic at the Royal Women’s Hospital (RWH), Melbourne, to compare this with reported practices in the literature and provide focus for future research needs. Methods: A retrospective case note review was undertaken of all women with VLP attending the vulval clinic between 2009 and 2012. Data was collected regarding age of onset, symptoms, examination findings and treatments utilized. Results: Eighty women with VLP were identified between 2009-2012. The mean age of onset was 59.8 years. Very potent topical steroids were the most commonly used first line therapy (71.3%). The most commonly utilized agent was betamethasone diproprionate optimized-vehicle ointment (46.3% of patients) with improvement in 16 (43.2%). This was followed by Clobetasol propionate ointment 0.05% which was used in 8 patients (10.0%), with improvement in 6 (75.0%). The most frequently used systemic monotherapy was methotrexate, used in 16 patients either first or second line with improvement seen in 7 (43.8%) with a greater proportion responding to higher doses of 10mg per week. Prednisolone was used in 7 patients, with a response noted in 3. Responders had all been commenced on a higher dose of 50mg. No consistent disease severity measures were used, clinician or patient reported. Conclusion: This case note review describes the current practice of Dermatologists working at a subspecialty vulval dermatology unit at a tertiary referral centre. Topical corticosteroids are utilized as first line therapy, with methotrexate the most commonly used systemic agent for refractory cases. Our study also highlights the need for validated disease severity and quality of life measures. The therapeutic regimes are partially in line with published data from the UK, the Netherlands and Iowa but differ from another large Australian centre. Future research should focus on developing disease severity measures and conducting pragmatic trials comparing commonly used treatment regimes such as with Clobetasol proprionate.