Methotrexate for Severe Vulvar Lichen Sclerosus (GRAVES-MTX)

January 21, 2026 updated by: SAMIR ARBACHE, Clinica Dermatologica Arbache ltda

A Prospective Phase II Open-Label Pilot Study Evaluating the Efficacy and Safety of Methotrexate in the Treatment of Severe Vulvar Lichen Sclerosus

Vulvar lichen sclerosus is a chronic inflammatory skin disease affecting the vulva and genital region, which may cause intense pruritus, pain, burning sensations, and progressive scarring. In severe cases, the disease may lead to significant anatomical changes, sexual dysfunction, and a reduction in quality of life.

First-line treatment for vulvar lichen sclerosus consists of high-potency topical corticosteroids. Although many patients experience symptom relief, a considerable number of women continue to have persistent symptoms or progressive anatomical damage. For these patients, therapeutic options are limited.

MTX is an immunomodulatory medication that has been used for several decades in the treatment of inflammatory and autoimmune diseases. Previous clinical observations suggest that MTX may be beneficial for patients with severe or treatment-resistant vulvar lichen sclerosus; however, prospective clinical studies in this population remain scarce.

This prospective, open-label, phase II pilot study aims to evaluate the efficacy and safety of subcutaneous injectable MTX, administered once weekly at a standardized initial dose of 12.5 mg, in women with severe vulvar lichen sclerosus who have not responded adequately to standard topical therapy. Participants will receive treatment for 12 months, with regular clinical and laboratory monitoring.

The primary objective of the study is to assess whether treatment with MTX leads to improvement in symptoms and stabilization of vulvar skin changes, using patient-reported outcome measures and standardized clinical assessments. Secondary objectives include evaluation of treatment tolerability, adherence, and the occurrence of adverse events.

As a pilot study, this research is designed to generate preliminary data on feasibility, safety, and potential clinical benefit, which may guide future larger controlled studies and contribute to the development of evidence-based therapeutic strategies for women with severe vulvar lichen sclerosus.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed Description

Vulvar lichen sclerosus is a chronic inflammatory dermatosis of the anogenital skin, characterized by epithelial thinning, dermal sclerosis, and progressive architectural distortion. In its severe form, the disease may present with persistent symptoms such as pruritus, pain, fissuring, and functional impairment, as well as irreversible vulvar anatomical changes.

Current standard management relies on the long-term use of high-potency topical corticosteroids. Although this approach is effective for many patients, a proportion of women with severe vulvar lichen sclerosus experience inadequate symptom control or continued progression of morphological changes.

For eligibility purposes, disease severity is defined according to the Vulvar Quality of Life Index (VQLI), a tool designed to measure the impact of vulvar disease on patients' quality of life. Clinical response over time will be assessed using the Clinical Scoring System for Vulvar Lichen Sclerosus. At present, evidence-based therapeutic guidance for severe vulvar lichen sclerosus remains limited.

Methotrexate (MTX) is an immunomodulatory agent with a long history of use in the treatment of inflammatory and autoimmune diseases. Its pharmacological properties, dosing strategies, and safety profile are well established in dermatology and rheumatology. Preliminary clinical observations suggest that MTX may offer benefit in selected patients with severe or treatment-refractory vulvar lichen sclerosus; however, prospective evaluations in this population remain scarce.

This study is designed as a prospective, open-label, phase II pilot clinical trial aimed at evaluating the feasibility, safety, and potential therapeutic effect of systemic MTX in women with severe vulvar lichen sclerosus refractory to standard topical therapy. The study adopts a single-arm design with longitudinal follow-up over a 12-month period.

Participants will receive subcutaneous injectable MTX administered once weekly, with a standardized initial dose of 12.5 mg. Dose adjustments may be performed based on clinical response and safety monitoring. Folic acid supplementation will be administered on the day following the weekly MTX injection to reduce the risk of adverse effects. Clinical and laboratory assessments will be performed every three months throughout the study period.

Treatment response will be assessed using the Clinical Scoring System for Vulvar Lichen Sclerosus. Subjective assessment will include quantification of symptom severity, specifically pruritus, burning sensation, and pain. Outcomes related to sexual discomfort will be recorded descriptively.

Objective assessment will be based on evaluation of vulvar morphological changes using structured criteria supported by standardized photographic documentation. A variable number of images will be obtained, with a minimum of two photographs per participant (baseline and month 12), and additional photographs may be obtained every three months during follow-up. All images will be reviewed by independent evaluators.

Safety outcomes will include systematic recording of adverse events, laboratory abnormalities, and treatment discontinuations throughout the study period.

The planned sample size of 12 participants was defined based on the exploratory and pilot nature of the study, with the primary objective of assessing feasibility, safety, and outcome variability rather than demonstrating definitive efficacy. Methodological guidance supports this sample size as sufficient to inform the design of future larger studies, particularly in the context of a low-prevalence condition and limited prior prospective data.

Methotrexate has been prescribed for several decades in the management of inflammatory and autoimmune diseases, with a well-characterized safety profile. Contemporary evidence suggests that certain historically perceived risks may be lower when modern dosing strategies and standardized monitoring protocols are applied. Consensus-based dermatologic guidelines support the safe use of low-dose weekly subcutaneous MTX when appropriate patient selection, folic acid supplementation, and rigorous clinical and laboratory monitoring are implemented. Known adverse effects, including hepatic, hematologic, and gastrointestinal toxicity, will be monitored according to established protocols.

As an exploratory pilot study, this trial is not designed to establish definitive efficacy. Its primary purpose is to assess protocol feasibility, characterize safety and tolerability, and generate preliminary clinical data to inform the design of future controlled studies and contribute to the development of evidence-based systemic treatment strategies for women with severe vulvar lichen sclerosus.

Study Type

Interventional

Enrollment (Estimated)

12

Phase

  • Phase 2

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • Brazil
    • São Paulo
      • São José dos Campos, São Paulo, Brazil, 12245760

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Clinical diagnosis of genital lichen sclerosus et atrophicus (vulvar, perineal, or perianal);
  • Histopathological diagnosis of genital lichen sclerosus et atrophicus;
  • Disease severity defined according with a score above 24 on the Vulvar Quality of Life Index (VQLI);
  • Failure of symptom regression or progressive genital deformity after at least 3 months of treatment with a high-potency topical corticosteroid;
  • Normal baseline laboratory evaluation, including complete blood count, liver and kidney function tests, and negative serologies for HIV and hepatitis B and C;
  • For women of childbearing potential, a negative pregnancy test at screening.

Exclusion Criteria (assessed before signing the Informed Consent Form):

  • Lack of full mental or psychiatric capacity;
  • Need for assistance from a third party (legal guardian) to participate in the study;
  • Significant difficulty in understanding or expressing oneself in Portuguese;
  • Unavailability or inability to complete Likert-scale questionnaires;
  • Inability to comply with study requirements, including adherence to the treatment schedule and attendance at follow-up visits;
  • Unrealistic expectations regarding treatment benefits or the possibility of adverse effects;
  • Intention to become pregnant during the study period;
  • Refusal to adopt at least one adequate contraceptive method (hormonal or barrier) in women of childbearing potential;
  • Poor adherence to the commitment to abstain from alcoholic beverages;
  • Uncontrolled autoimmune comorbidities;
  • Refusal to sign the Informed Consent Form after adequate explanation and clarification of doubts;
  • Any indication of inability to comply with the conditions established in the research protocol. Decisions will be made to ensure participant safety and study integrity, with appropriate communication regarding the reasons for exclusion.

Exclusion Criteria (assessed after signing the Informed Consent Form):

  • Elevation of liver enzymes above normal limits or impaired renal function during laboratory monitoring. Exclusion refers to discontinuation of the experimental intervention; however, the participant will continue to receive comprehensive medical follow-up as needed;
  • Pregnancy. The participant will be withdrawn from the study intervention and referred for obstetric care, while continuing to receive medical follow-up;
  • Lack of cooperation, failure to attend scheduled follow-up visits, or failure to undergo required laboratory monitoring;
  • Any other condition that limits the participant's ability to comply with study procedures, as determined by the responsible investigator.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: N/A
  • Interventional Model: Single Group Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Subcutaneous Methotrexate

Participants allocated to this single study arm will receive subcutaneous injectable methotrexate, administered once weekly at a standardized initial dose of 12.5 mg. Dose adjustments may be made according to clinical response and safety monitoring, based on predefined protocol criteria. Folic acid supplementation will be administered on the day following the weekly methotrexate injection.

Participants will be followed quarterly for a 12-month period. Subjective clinical efficacy outcomes will be assessed, along with objective analyses related to genital morphology, documented through standardized photographic records, as well as treatment safety outcomes, including clinical and laboratory assessments performed every three months.
Drug: Methotrexate (MTX)
Subcutaneous injectable methotrexate administered once weekly, starting at a standardized initial dose of 12.5 mg per administration. Dose adjustments may be performed according to clinical response and safety monitoring, based on predefined protocol criteria. Folic acid supplementation will be administered on the day following the weekly methotrexate injection.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in vulvar symptom severity
Time Frame: 12 months
Change in vulvar symptom severity from baseline to 12 months, assessed using the total symptom score of the Clinical Scoring System for Vulvar Lichen Sclerosus (symptom domains only), as described by Günthert et al. (J Sex Med. 2012;9:2342-2350). The total score ranges from 0 to 30 points and is calculated by summing the items within the symptom domain, yielding a single aggregated value per assessment. Higher scores indicate greater symptom severity. Symptoms related to sexual discomfort or pain during sexual activity are not included in the primary outcome score and will be recorded separately and reported descriptively.
12 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in vulvar morphology
Time Frame: 12 months
Change in vulvar morphology score from baseline to 12 months, assessed using the total morphology score of the Clinical Scoring System for Vulvar Lichen Sclerosus as described by Günthert et al. (J Sex Med. 2012;9:2342-2350). The morphology score is a single aggregated score, ranging from 0 to 12, with higher scores indicating greater morphological severity.
12 months
Change in vulvar-related quality of life
Time Frame: 12 months
Change in vulvar-related quality of life from baseline to 12 months, assessed using the Vulvar Quality of Life Index (VQLI), as described by Saunderson et al. Australasian Journal of Dermatology 61.2 (2020): 152-157. Total VQLI scores range from 0 to 45, with higher scores indicating worse quality of life.
12 months
Safety and tolerability of methotrexate
Time Frame: 12 months
Safety outcomes will include the incidence of adverse events, laboratory abnormalities, and treatment discontinuations throughout the study period.
12 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Clinica Dermatologica Arbache ltda

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

January 21, 2026

Primary Completion (Estimated)

January 1, 2027

Study Completion (Estimated)

January 1, 2027

Study Registration Dates

First Submitted

December 19, 2025

First Submitted That Met QC Criteria

January 15, 2026

First Posted (Actual)

January 20, 2026

Study Record Updates

Last Update Posted (Actual)

January 22, 2026

Last Update Submitted That Met QC Criteria

January 21, 2026

Last Verified

January 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 005

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

UNDECIDED

IPD Plan Description

A decision regarding sharing of individual participant data (IPD) has not yet been made. This study is a pilot, single-center clinical trial with a small sample size involving sensitive clinical and photographic data. Any potential data sharing will be carefully considered after study completion, taking into account participant privacy, informed consent provisions, ethical approvals, and applicable data protection regulations. If data sharing is pursued, only de-identified data would be made available upon reasonable request and subject to appropriate approvals.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

Yes

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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