Fractional CO2 laser treatment as adjunctive therapy to topical steroids for managing vulvar lichen sclerosus

Abstract

Objectives: Uncontrolled vulvar lichen sclerosus (VLS) is often associated with distressful symptoms of genital itch, irritation, and pain and can lead to a pathological process including anatomical changes, scarring, and an elevated risk of cancer in the genital area. First-line topical corticosteroid as monotherapy is frequently not adequate to fully suppress disease activity and control symptoms. This study evaluated the efficacy of fractional CO2 laser treatments as adjunctive therapy where recalcitrant VLS had been improved, but not adequately controlled, with topical corticosteroid treatment. Outcomes were evaluated up to 12 months after a series of CO2 laser treatments delivered via a fractional handpiece.

Materials and methods: Women with a diagnosis of VLS supported by histologic findings on biopsy and/or clinical signs on physical examination received up to five monthly laser treatments. Subjects maintained existing topical corticosteroid and any exogenous hormone treatment during the study. Investigators assessed severity (0 = not present, 1 = mild, 2 = moderate, or 3 = severe) of clinical signs and architectural changes present before adjunctive study interventions and at follow-up visits. Subjects reported the presence of clinical symptoms and impact on quality of life on 4- or 5-point Likert scales. The validated Female Sexual Function Index (FSFI) was used to assess changes in sexual function. Four subjects were biopsied before adjunctive laser treatment and at follow-up.

Results: Twelve females, 11 postmenopausal, with a mean age of 57 ± 10 years received three to five monthly CO2 laser treatments. Significant improvement in all prominent clinical signs and architectural changes were reported at the 3- and 6-month follow-ups after the treatment series. Significant improvement was maintained at the 12-month follow-up, with 89% of subjects showing at least one-point improvement in elasticity compared to baseline; 86% in lichenification; 88% in sclerosis; and 80% in whitening and parchment-like skin. Labial fusion and the extent of disease improved in 50% of patients. Ulcerations present in three subjects at baseline resolved after treatment. Subjects reported 86% improvement in dyspareunia and 83% in skin tearing. Quality of life improved significantly after treatment (p < 0.01). The 6-month follow-up FSFI showed significant improvement in sexual function compared to baseline (p < 0.05), with a mean point improvement of 4.5. Histology findings after treatment showed some positive improvement, as a decrease in dermal hyalinized zone thickness. There were no treatment complications or adverse events related to the treatment.

Conclusions: Fractional CO2 laser treatment outcomes showed improvement in predominant clinical signs and architectural changes in VLS recalcitrant to topical corticosteroid treatment. Adjunctive laser treatment relieved symptoms and improved quality of life as well as sexual function. Fractional CO2 laser treatment may provide an advanced treatment modality for the management of recalcitrant VLS with improved patient care and sustainable outcomes. Further study in a larger population and with CO2 laser treatment to both vulvar tissue and the vaginal canal should be explored.

Keywords: fractional CO2 laser; sexual dysfunction; topical corticosteroids; vulvar dermatoses; vulvar lichen sclerosus.

Conflict of interest statement

Kristen Stewart will receive an honorarium for this article. Sunbal Javaid receives speaker honoraria. Konika P. Schallen is an employee of Candela; the work for this study was carried out at her private clinic. The remaining authors declare that there are no conflict of interests.

© 2021 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

Figures

Figure 1

Mean scores for prominent vulvar lichen sclerosus clinical signs and architectural changes at baseline (pretreatment) and at the 3‐, 6‐, and 12‐month follow‐ups, after three to five monthly CO2 laser treatments

Figure 2

Percentage improvement in prominent vulvar lichen sclerosus clinical signs and architectural changes at the 3‐, 6‐, and 12‐month follow‐ups, after three to five monthly CO2 laser treatments

Figure 3

(A) 47‐year‐old female presented with severe labial and clitoral hood fusion, moderate narrowing of the introitus, moderate whitening, parchment‐like skin, and lichenification. Perirectal fissure was observed. (B) At the 6‐month follow‐up after five CO2 laser treatments, there was a marked improvement in labial fusion and clitoral hood fusion, as well as improvement in the vaginal opening and in whitening, parchment‐like skin, and lichenification

Figure 4

(A) 47‐year‐old female presented with moderate labial fusion and posterior commissure bands along with mild whitening, sclerosis, parchment‐like skin, and lichenification. (B) At the 6‐month follow‐up after four CO2 laser treatments, there was improvement in whitening, sclerosis, parchment‐like skin, and lichenification, as well as a 1‐grade improvement in labial fusion and posterior commissure bands

Figure 5

(A) 51‐year‐old female presented with moderate labial fusion and ulceration on the right labium and mild hyperkeratosis, lichenification, whitening, parchment‐like skin, and sclerosis. The left labium minus was reabsorbed and significantly smaller than the right. (B) At the 6‐month follow‐up after four CO2 laser treatments, there was improvement in ulceration, hyperkeratosis, lichenification, whitening, and parchment‐like skin. Labial fusion did not show improvement

Figure 6

Average severity grades (with standard error of the mean bars) at each endpoint for those architectural changes (top line) and clinical signs (bottom line) that were present at baseline (baseline score >0). †For subjects not treated at study visit TX4 or TX5 (optional), values for assessments were carried over from TX3. **p < 0.01 (Wilcoxon signed‐rank test for paired data); ***p < 0.001 (Wilcoxon signed‐rank test for paired data)

Figure 7

Mean self‐assessment scores (with standard error of the mean bars) of superficial dyspareunia and skin tearing during study. †For subjects not treated at study visit TX4 or TX5 (optional), values for assessments were carried over from TX3. *p < 0.05 (Wilcoxon signed‐rank test for paired data)

Figure 8

Mean self‐assessment scores (with standard error of the mean bars) for impact of vulvar lichen sclerosus on decrease in sexual function and quality of life during the study. †For subjects who were not treated at study visit TX4 or TX5 (optional), values for assessments were carried over from TX3. *p < 0.05 (Wilcoxon signed‐rank test for paired data); **p < 0.01 (Wilcoxon signed‐rank test for paired data)

Figure 9

(A) Pretreatment histology of a 73‐year‐old woman showing hyperkeratosis, atrophy, elastic fiber loss, basement membrane thickening, and dermal hyalinized thickness of 0.4 mm. (B) At the 6‐month follow‐up, histology showed a reduced hyalinized zone with a dermal thickness of 0.25 mm. Hyperkeratosis and atrophy were still present, and basement membrane thickening remained unchanged (hematoxylin and eosin stain)