Treatment of Vulvovaginal Erosive and Stenosing Lichen Planus by Surgical Dilatation and Methotrexate

Abstract

Mucosal lichen planus (LP) is a rare variant of LP, itself a common skin disorder. Two-thirds of those affected have an erosive form of LP that causes severe vulvovaginal and, in some cases, oral mucosal symptoms, including burning, pain, and pruritus. The disease affects the vaginal orifice and often, the labia minora. Patients present with erythematous, partly erosive, desquamative lesions that may have a pale border. Erosive LP is thought to be an autoimmune disorder. In time, vulvovaginal LP causes scarring and narrowing of the vagina. Treatment of vulvovaginal LP has proved to be challenging. The authors report 5 women with severe symptoms of vulvar scarring and resultant stenosis or obliteration of the vagina, all of whom responded, at least in part, to treatment with surgical dilatation, methotrexate, and local preparations such as tacrolimus and a potent steroid cream. Methotrexate, given in a weekly dose of 7.5 mg, also benefited oral lesions. Stenotic changes decreased during methotrexate therapy, suggesting that it be started as soon as possible after surgical dilatation of the vagina. Topical steroids proved helpful in some patients having exacerbations of the disorder. Tacrolimus, a topical immunosuppressant, is active against vulvar LP and has helped to prevent narrowing of the vulva and vagina in patients failing to respond to a potent local steroid. Local treatment with pimecrolimus and cyclosporin has reportedly been effective. In addition, patients were asked to wash the genital area with emollients, and local estrogen treatment was given to prevent vaginal atrophy. In the present patients, methotrexate appeared to exert positive effects even after it was discontinued. The only adverse side effect was hair loss in 1 patient. All the women took folic acid while receiving methotrexate. This experience endorses the use of low-dose methotrexate in patients with severe stenosing vulvovaginal LP if surgical dilatation and local treatment have failed. It should be continued until symptoms have resolved, and may be d if the disorder recurs. These patients require close follow-up because of the possibility that vulvar LP will undergo malignant transformation.