Potent Topical Steroids Research Articles

Prominent Alopetic Lesions of Lichenoid Drug Eruption Treated with Topical Tacrolimus

Dear Editor: Lichenoid drug eruption (LDE) is an uncommon type of drug eruption that is rarely caused by antituberculosis drugs1. A 64-year old man visited our outpatient clinic in April 2012 due to pruritic skin eruption. Eight months previously, he was diagnosed with tuberculous meningitis, and had been initially treated for 2 months with isoniazid, moxifloxacin, ethambutol, and pyrazinamide, followed by alternative maintenance therapy with streptomycin, levofloxacin, and rifabutin were used for alternative maintenance therapy for the next 5 months. Ethambutol has been added to the drug regimen 4 weeks prior to the current visit. About 3 weeks prior to the present visit, pruritus and symmetrical violaceous polygonal flat papules developed on the whole body, especially on the forehead and scalp (Fig. 1A, B). Wickham's striae on their surface and oral mucosal involvement were not observed. During an early follow-up, scalp lesions rapidly developed into alopetic lesions (Fig. 1C~E). The patient had no previous history of skin diseases and pulmonary tuberculosis. The results of routine laboratory tests were within normal limits, except for 8.8% eosinophil in the blood. The histologic findings in the specimen from the back were consistent with LDE (Fig. 1G, H). Based on the clinical and histological results, a diagnosis of LDE was made. In the light of time-event relationship, ethambutol was assumed as the offending drug and so was discontinued. LDE was treated with oral antihistamines and topical 0.03% tacrolimus. Skin lesions improved markedly within 2 weeks, and gradually regressed during a 3-month follow-up period. Along with this improvement, scalp hairs began to regrow and a considerable portion of scalp became covered (Fig. 1F). There were no side effects of the topical tacrolimus during treatment periods. Fig. 1 Large violaceous flat plaque on the forehead and small parts of scalp (A), and violaceous polygonal shaped flat papules on the back (B) were observed on initial visit. Two weeks later, scalp involvement progressed to alopetic lesions on frontal scalp ... In Korea, drug eruptions have occurred in 2.7 to 3.8% of outpatients2. LDE is a rare type (<1%) of drug eruption1, and clinical features are similar to lichen planus. However, some features have been described to be more characteristic of LDE; usually symmetrical lesions on the trunk, extremities; atypical morphology; no Wickham's striae; rare mucosal involvement; healing with residual hyperpigmentation; focal parakeratosis, hypogranulosis, and a superficial and deep perivascular infiltrate3; higher number of grouped necrotic keratinocytes; and infiltration of plasma cells and eosinophils4. Alopecia in association with LDE may be severe3 and has not been reported in the Korean dermatologic literature. Only one case report described scalp involvement without alopecia (Table 1). Treatments of LDE involve the elimination of the causative drug(s) and control of symptoms with antihistamines or topical steroids1. Oral lichen planus and oral lichenoid lesions have been successfully treated with tacrolimus5. Table 1 Summury of lichenoid drug eruption with scalp involvement in Korean dermatologic literature To our knowledge, this is the first reported case that shows prominent scalp alopetic lesion of LDE, and topical tacrolimus as an useful option to help improve these lesions. Although LDE initially involved the face and small parts of the scalp, we must keep in mind that these lesions can progress rapidly and result in severe scalp alopecia. When high potency topical steroids or long-term use of topical steroids are not allowed, topical tacrolimus is a wise option for the treatment of LDE.

Topical Corticosteroid Usage in Dermatology OPD in a Medical Teaching Hospital

Topical corticosteroids constitute the most commonly prescribed drugs in the treatment of dermatological conditions. Self medication and erratic use of these agents by patients can increase the risk of developing local and systemic side effects. To find out the trend and outcome of topical corticosteroid usage in a Tertiary Care Hospital a retrospective analysis of the prescriptions in the Department of Dermatology was done for a period of six months. Data on age, sex, diagnosis, steroids and their combinations used, delivery vehicle, potency, frequency of application, duration of treatment and adverse effects were recorded on a pre-designed proforma and analyzed. Mid potency topical steroids were commonly used followed by high, low and very high potency preparations. Age range varied from 5-65 years. Mid and high potency steroids were used in combination with antimicrobials and salicylic acid. Cream based preparations were commonly used and duration of treatment was appropriate and rational. Adverse effects were seen only in four cases and no irrational prescriptions were noted.

Annular erythema and photosensitivity as manifestations of efavirenz-induced cutaneous reactions: a review of five consecutive cases

In HIV-infected persons, a rash is the most common manifestation of drug hypersensitivity reactions. Non-nucleotide reverse transcriptase inhibitors are a major cause of cutaneous reactions. While the characteristics of nevirapine-associated cutaneous adverse drug reactions (CADRs) have been well described, there are limited data on efavirenz-associated CADRs. The objective of this study was to characterize the clinical features of consecutive cases of efavirenz-associated CADRs in a single referral centre diagnosed over a 3 year period. We retrospectively reviewed the clinical records of 231 patients admitted with CADRs to a tertiary dermatology ward in Cape Town, South Africa. In 42/231(18%) cases, there had been exposure to efavirenz in the preceding 8 weeks. Of these, 5/42 (12%) patients were diagnosed with probable efavirenz-associated CADRs based on the Naranjo score. The median exposure to efavirenz before the onset of the rash was 12 days (range 2-48). All the patients were female, with a median age of 31 years and a median CD4 cell count of 300 cells/mm(3) (range 81-887). Four had a photo-distributed eruption and one had a confluent indurated erythema affecting the face, trunk and limbs. In three out of five cases, there were annular plaques with raised erythematous edges and dusky centres, which were photo-distributed. Two patients had a mild transaminitis and another a mild eosinophilia. Histological features were non-specific, with perivascular lymphocytes the only consistent feature. In all five cases, efavirenz was withdrawn and potent topical steroid was the only CADR-specific intervention. The eruptions resolved on discharge from hospital, with no sequelae except for residual post-inflammatory hyperpigmentation. Photo-distribution and annular erythema should alert clinicians to the possibility of efavirenz-associated CADRs.

Treatment paradigm after uncomplicated cataract surgery: a prospective evaluation

PURPOSE To compare 3 clinical variables, namely, visual recovery, anterior chamber inflammation, and macular edema, between 2 different regimens after uncomplicated cataract surgery. DESIGN Prospective, randomized, single-blind study at a single center, private, teaching practice in Las Vegas, NV. METHODS Patients randomized to group I (nonsteroidal anti-inflammatory drugs, n = 113) received besifloxacin ophthalmic suspension 0.6% and bromfenac 0.09%, whereas those randomized to group II (steroid, n = 109) received besifloxacin ophthalmic suspension 0.6% and prednisolone acetate 1%.Preoperative evaluation included a baseline macular optical coherence tomography. Postoperative data collected included visual acuity, direct visual anterior segment cell and flare counts, and macular optical coherence tomographies. Foveal thickness and total macular volume were used to assess the presence of cystoid macular edema. RESULTS Visual recovery was statistically insignificant with P values at 0.7, 0.10, 0.2, and 0.7 at 1 day, 1 week, 1 month, and 2 months, respectively.The degree of anterior segment inflammation was not statistically significant (P = 0.8) between the studied populations.The foveal thickness (1 week, P = 0.8; 1 month, P = 0.2; 2 months, P = 0.2) and total macular volume (1 week, P = 0.7; 1 month, P = 0.1; 2 months, P = 0.2) were not statistically significant between the groups, and the observed power were 0.902 and 0.666, respectively. CONCLUSIONS This study demonstrated that bromfenac was equally efficacious when compared with a potent topical steroid in restoring visual function, decreasing and resolving anterior chamber inflammation, and preventing the development of macular edema.

A prospective case series of secondary intention healing for surgical wounds on the dorsum of the hand

The dorsum of the hand is a common site for squamous cell carcinoma, and excision with appropriate margins often results in surgical defects that cannot be repaired by primary side-to-side closure. To assess healing time, complications and resulting scars when surgical wounds on the dorsum of the hand were allowed to heal by secondary intention. This was a prospective study of 28 surgical defects on the dorsum of the hand, which were allowed to heal by secondary intention. Patients were followed up on days 2, 7 and 14, and then every 2 weeks until the wounds healed. Wound dressings were changed 2-3 times per week. Patients' tolerance of this treatment and their degree of satisfaction with the final results was determined. The defect diameters ranged from 15 to 46 mm (median 24 mm). The time to heal was determined in 24 patients, and ranged from 22 to 63 days (median 44 days). There were no cases of postoperative bleeding. Two patients developed erythema of the wound edge; wound swabs for culture were negative in both cases. Overgranulation developed in 12 of 28 wounds, which settled with the application of a potent topical steroid and discontinuation of the hydrocolloid dressing. Patients were either 'very satisfied' (12/18) or 'satisfied' (6/18) with the resulting scar. Secondary intention healing of surgical wounds on the dorsum of the hand is a useful management option, which is well tolerated by patients, has a low rate of complications, and gives good cosmetic results.

SAT0287 Long-Term Safety Of Ustekinumab: 5 Years of Follow-Up from the Psoriasis Clinical Development Program Including Patients with Psoriatic Arthritis

BackgroundUstekinumab(UST) is approved for moderate-to-severe psoriasis(PsO), and is currently in Phase 3 development for psoriatic arthritis(PsA).ObjectivesWe report the long-term safety experience of UST in the sub-group of PsO pts with...

A case of sensitization to alitretinoin.

Alitretinoin is a unique retinoid authorised for the treatment of adults with severe chronic hand eczema (CHE) refractory to potent topical steroids. The most common adverse events (AEs) were typical class effects of oral retinoids including headache, flushing and skin disorders. To our knowledge, there are no cases of sensitization to alitretinoin reported in literature. We present a case of sensitization to alitretinoin.

Steroid Dermatitis Resembling Rosacea: A Clinical Evaluation of 75 Patients

Background. The use of topical steroids on the skin of the face should be carefully evaluated by the dermatologist; however, its misuse still occurs producing dermatological problem resembling rosacea. Objectives. To report the different clinical manifestations of steroid dermatitis resembling rosacea and to discover causes behind abusing topical steroids on the face. Methods. In this prospective observational study, 75 patients with steroid dermatitis resembling rosacea who had history of topical steroid use on their faces for at least 1–3 months were evaluated at the Department of Dermatology, Baghdad Teaching Hospital, between August 2010 and December 2012. Results. The majority of patients were young women who used a combinations of potent and very potent topical steroid for average period of 0.25–10 years. Facial redness and hotness, telangiectasia, and rebound phenomenon with papulopustular eruption were the main clinical presentations. The most common causes of using topical steroid on the face were pigmentary problems and acne through recommendations from nonmedical personnel. Conclusion. Topical steroid should not be used on the face unless it is under strict dermatological supervision.

Reactivation of Herpes Simplex Virus and Cytomegalovirus in a Case of Thymoma-associated Graft-versus-host Disease-like Erythroderma

a 64-year-old woman with a 4-year history of pruritic erythema was admitted to our hospital because of aggravation of the erythema that did not respond to 20 mg/ day oral prednisolone. The patient had had malignant thymoma and myasthenia gravis for 12 years, together with recurrent oral herpes infection for several years. In spite of thymectomy, chemotherapy, and radiation therapy, malignant thymoma was disseminated to the thoracic cavity and no more treatment options could be utilized on admission. The patient presented with erythema that was scaly, mildly keratotic, and distributed over the face, body trunk, and extremities (Fig. 1a). The patient reported severe pruritus. Biopsy specimen of the erythema revealed superficial perivascular dermatitis with parakeratosis, hypogranulosis, dyskeratosis with satellite cell necrosis, mild acanthosis, and vacuolar change in the epidermis, and moderate infiltration of lymphocytes in the upper dermis (Fig. 1b). Direct immunofluorescence was negative (data not shown). Immunohistochemistry revealed that there were more CD8+ T cells than CD4+ T cells infiltrated in the epidermis and dermis (Fig. 1c, d). Differential diagnoses included psoriasis, lichen planus, pityriasis rosea, lichenoid drug eruption, pityriasis lichenoides chronica, and thymoma-associated GVHD-like erythroderma. psoriasis was ruled out by the presence of dyskeratosis, and parakeratosis is not usually observed in lichen planus. The clinical course was too long for pityriasis rosea, and lichenoid drug eruption could be ruled out because of the absence of eosinophils in the dermis. Furthermore, pityriasis lichenoides chronica is not usually pruritic and the eruptions are more oval than those of our case. Based on the characteristic distribution and clinical features of the erythema and pathological findings, a diagnosis of thymoma-associated GVHD-like erythroderma was made. potent topical steroid (clobetasol propionate 0.05%), systemic steroid (prednisolone 2 mg/kg/day), and cyclosporine (5 mg/kg/day) were prescribed for 2 weeks, but did not control the erythema (Fig. s1; available from http://www.medicaljournals.se/acta/content/?d oi=10.2340/00015555-1577). Intriguingly, after the initiation of oral acyclovir (15 mg/kg/day) for exacerbated oral herpes infection, the erythema began to subside. acyclovir was then switched to valacyclovir hydrochloride (15 mg/kg/day). Incidentally, we detected a high level of CMV antigenemia of up to 1,564 cells/slide, although it was only 11 cells/slide 6 months previously. The patient did not report any symptoms of retinitis, pneumonia, or colitis, thus we administered ganciclovir (5 mg/kg/day) and discontinued valacyclovir. The erythema recurred when prednisolone was tapered to 0.75 mg/kg/day; therefore, prednisolone was increased up to 1 mg/kg/day, which was not successful. Next, broadband ultraviolet Reactivation of Herpes Simplex Virus and Cytomegalovirus in a Case of Thymoma-associated Graft-versus-host Disease-like Erythroderma

Palmar lichen planus mimicking tinea nigra

Lichen planus (LP) is a chronic inflammatory skin disease characterized by polygonal, violaceous papules commonly involving flexural areas of the wrists, legs, and oral and genital mucous membranes. This report describes a patient who presented with asymptomatic black colored patches on both palms simulating Tinea nigra, a superficial fungal infection. She was previously diagnosed as allergic contact dermatitis and was being treated with potent topical steroid i.e. clobetasol propionate 0.05% and white soft paraffin. Dermatoscopy of the lesion showed brownish pigmentation along ridges of the dermatoglyphics. A biopsy from the lesional skin showed findings of lichen planus. Our case highlights the potential diagnostic confusion that can occur with unusual variants of palmoplantar lichen planus and importance of histopathology in diagnosis of such unusual lesions.

Successful treatment of tattoo-induced pseudolymphoma with sequential ablative fractional resurfacing followed by Q-switched Nd: Yag 532 nm laser

Decorative tattooing has been linked with a range of complications, with pseudolymphoma being unusual and challenging to manage. We report a case of tattoo-induced pseudolymphoma, who failed treatment with potent topical and intralesional steroids. She responded well to sequential treatment with ablative fractional resurfacing (AFR) followed by Q-Switched (QS) Nd:YAG 532 nm laser. Interestingly, we managed to document the clearance of her tattoo pigments after laser treatments on histology and would like to highlight the use of special stains such as the Grocott's Methenamine Silver (GMS) stain as a useful method to assess the presence of tattoo pigment in cases where dense inflammatory infiltrates are present.

A Comparative Clinical Evaluation of Once Daily Versus Alternate Day Application of Topical Clobetasol Propionate Cream in Psoriasis

Corticosteroids are extremely useful in the treatment of inflammatory skin disorders. Topical steroid applications are the most effective treatment for all types of psoriasis. To compare the efficacy of once daily versus alternate day application of topical steroid clobetasol propionate 0.05% (Tenovate cream®) in patients who have mild to moderate plaque psoriasis. This study was conducted on 89 patients of plaque psoriasis, who attended the skin OPD in our hospital. The patients who had a mild to moderate severity of plaque psoriasis were selected. Those patients who required systemic corticosteroids, those who were already undergoing any psoriasis treatment, those who had any other debilitating illness and pregnant and lactating women were excluded from the study. Eighty nine patients were enrolled for the study after taking written informed consent from them and they were randomly allocated into two groups. Two patients dropped out, one in each group and 1 of group 2 was prescribed systemic corticosteroids.Group 1- once daily application (n= 44)Group 2- alternate day application (n= 42)An objective scoring was done on the basis of the PSI (Psoriasis Severity Index) score, which was graded from 0-4. Follow ups were done in the 2nd, 4th and 6th weeks. It was done by the Student's 't' test and ANOVA. The results showed that there was equal improvement in both the groups in the 2nd week, since the p-value was not significant (P> 0.05), but in the 4th and 6th weeks, there was less improvement in the alternate day group (P< 0.05). An intra group comparison indicated that clobetasol was effective both in the once daily and the alternate day groups, but clinical and symptomatic improvement occurred more quickly in the once daily group after 6 weeks of assessment. Thus, it can be concluded that the alternate day application of the topical steroid clobetasol propionate cream is as effective as the once daily application in the initial 2 weeks, but by 6 weeks, its efficacy decreases. Therefore, initially, we can advocate a less frequent application of potent topical steroids but for the complete remission of the disease, the application frequency should be once daily.

Preventive Effects of Multi-Lamellar Emulsion on Low Potency Topical Steroid Induced Local Adverse Effect

BackgroundTopical steroid treatment induces diverse local Wand systemic adverse effects. Several approaches have been tried to reduce the steroid-induced adverse effects. Simultaneous application of physiological lipid mixture is also suggested.ObjectiveNovel vehicles for topical glucocorticoids formulation were evaluated for the efficacy of reducing side-effects and the drug delivery properties of desonide, a low potency topical steroid.MethodsTranscutaneous permeation and skin residual amount of desonide were measured using Franz diffusion cells. The in vivo anti-inflammatory activity was evaluated using murine model.ResultsTopical steroids formulation containing desonide, in either cream or lotion form, were prepared using multi-lamellar emulsion (MLE), and conventional desonide formulations were employed for comparison. MLE formulations did not affect the anti-inflammatory activity of the desonide in phobol ester-induced skin inflammation model, compared with conventional formulations. While the penetrated amounts of desonide were similar for all the tested formulations at 24 hours after application, the increased lag time was observed for the MLE formulations. Interestingly, residual amount of desonide in epidermis was significantly higher in lotion type MLE formulation. Steroid-induced adverse effects, including permeability barrier function impairment, were partially prevented by MLE formulation.ConclusionTopical desonide formulation using MLE as a vehicle showed a better drug delivery with increased epidermal retention. MLE also partially prevented the steroid-induced side effects, such as skin barrier impairment.

Hypoglycaemia--more than skin deep

A 43-year-old Caucasian gentleman became confused and agitated while attending a soccer match. He collapsed and was resuscitated by paramedics on the scene. He recovered promptly with intravenous fluid and dextrose. The patient subsequently reported a 6-month history of recurrent spells of sweating, agitation and lethargy suggestive of hypoglycaemia, which typically occurred in the fasting state and were relieved by sugary drinks. Past medical history was relevant for severe eczema from a young age with long-term exposure to highly potent topical steroids. At the time of presentation he was applying up to 100 g of clobetasol 0.05% ointment per month with resultant skin atrophy and spontaneous bruising. He was obese with BMI 35 kg/m2. Assessment of his adrenal reserve with a short synACTHen test was markedly abnormal with a baseline 9am cortisol of 74 nmol/l and 30-min stimulated value of 179 nmol/l (normal >500 nmol/l). Although this result may have explained some of his symptoms and accounted for the episode of collapse, he concurrently underwent a prolonged fast during which he developed symptomatic hypoglycaemia after 28 h. The …

Hypertrophic and Ulcerated Discoid Lupus Erythematosus

Hypertrophic lupus is an uncommon clinical variant of chronic cutaneous lupus that remains a challenge to treat. A 45-year-old female day-care worker with long-standing lupus presented with hypertrophic cutaneous involvement on the dorsal hand, elbow, and toe of 6 years' duration. Treatments included monotherapy with either hydroxychloroquine or chloroquine and potent topical and intralesional steroid injection. Systemic chemotherapy with R-CHOP chemotherapy for stage IIA diffuse large B-cell lymphoma did not clear the skin findings. To review the clinical presentation and treatment of hypertrophic lupus. This report documents clinical improvement in refractory hypertrophic lupus with a regimen of acitretin and combination antimalarial therapy. The available published literature on the treatment of hypertrophic lupus was reviewed. There is limited published experience combining retinoids and antimalarials for the treatment of refractory lupus. Combination therapy with two antimalarials (ie, quinacrine with either hydroxychloroquine or chloroquine) provides therapeutic benefit for resistant cutaneous disease. In this case, triple therapy with two antimalarials and an oral retinoid achieved clinical clearance relatively rapidly, and this effect was maintained over a year. This article reports successful treatment of refractory hypertrophic discoid lupus with combination therapy that included chloroquine 250 mg/d, quinacrine 100 mg/d, and actitretin 25 mg/d. This report suggests that combination therapy using two antimalarials and an oral retinoid is a consideration for refractory hypertrophic lupus, but further study is warranted.

Central centrifugal cicatricial alopecia: possible familial aetiology in two African families from South Africa

Central centrifugal cicatricial alopecia: possible familial aetiology in two African families from South Africa

Topical tacrolimus with custom trays in the treatment of severe oral chronic graft-versus-host disease refractory to a potent topical steroid therapy: a case report

The authors present a case demonstrating the success of topical tacrolimus (TAC) therapy with custom trays in the treatment of oral chronic graft-versus-host disease (cGVHD). The 41-year-old male patient initially responded to topical steroid therapy (clobetasol propionate 0.05% ointment) applied both topically and with flexible carrier trays, but later became refractory to this potent topical agent. Topical TAC therapy with flexible carrier trays and systemic prednisone therapy was initiated. The patient responded favorably with the change to topical TAC therapy with custom trays (and oral prednisone). His oral cGVHD lesions resolved within a period of 4 weeks. The improvement has remained stable at 14 months of follow-up. This is the first case reported with regard to the successful resolution of steroid recalcitrant cGVHD successfully treated with topical TAC with custom trays.

Vulvar Psoriasis in Adults and Children

There are limited data on psoriasis as it affects the vulva in the medical literature. This observational study aimed to describe the symptoms, signs, and management of vulvar psoriasis in adults and children in a private vulvar disease referral practice. A review of the existing literature on vulvar psoriasis was used to generate inclusion criteria of a chronic noninfective erythematous vulvitis without vaginal involvement. Between January 2009 and October 2011, 201 patients presenting with these criteria were coded as having psoriasis in a computerized database where standardized data were collected. In 194 of these patients, adequate data were available to include in the study. Only 12.3% of the patients presented with psoriasis as a provisional diagnosis with a mean symptom duration of 4.5 years (range = 6 weeks to 35 years). The most common presentation was a pruritic, bilaterally symmetrical, erythematous, nonscaly, well-demarcated macular eruption or slightly raised plaque (82.5%). Of the remaining patients, 9.2% presented with only diffuse symptomatic erythema, whereas 8.2% were symptomatic without erythema. In 64.9% of the patients, evidence of psoriasis was found on other parts of the skin. Initial induction treatment with potent topical corticosteroid followed by a maintenance treatment with less potent topical steroids and other psoriasis-specific treatment such as tar creams and calcipotriol resulted in a suppression of disease in 93.8% of the patients during a mean follow-up duration of 8.9 months (range = 1 month to 7.25 years). Vulvar psoriasis is a difficult diagnosis that should be considered in patients presenting with a chronic erythematous vulvitis without vaginitis. It is a chronic relapsing skin condition that requires long-term management.

Adjuvant clinical effects of polydeoxyribonucleotide in lichen sclerosus

ejd.2012.1769 Auteur(s) : Luigi Laino laino@ifo.it Dermatological Insitute San Gallicano – IRCCS, Via Elio Chianesi 53 00144 Rome, Italy We report a group of 18 individuals (12 males, 6 females, aged 22 to 64 years) suffering from mild to severe genital lichen sclerosus (LS). All patients had a history of unresponsiveness or slight improvement to potent topical steroid (clobetasol 17-propionate 0.05%). The patients were evaluated in compliance with the recent guidelines of the British Association [...]

Real-life experience of managing vulval erosive lichen planus: a case-based review and U.K. multicentre case note audit

There is a lack of published evidence for treatment and outcome measures for vulval erosive lichen planus (ELPV). To conduct a multicentre case note review to examine real-life management of ELPV comparing current U.K. practice against an agreed audit standard. Criteria for standards of care for which to evaluate current service provision were set following communication with experts from the British Society for the Study of Vulval Disease. Participants from 10 U.K. centres included nine dermatologists and one gynaecologist who run specialist vulval clinics. Standards examined the documentation of disease severity/impact measures, the use of diagnostic biopsies, treatments used and assessment of treatment response. Audit data were collected from 172 patients. Documentation of symptoms/clinical findings was excellent (99%, 170/172). A schematic diagram was present in the notes of 87% (150/172). Patient-related disease impact measures including Dermatology Life Quality Index (3%, 6/172) or visual analogue scales (1%, 2/172) were less well documented. Biopsies were performed in 78% (135/172); 71% (96/135) showed histological features consistent with erosive lichen planus. Squamous cell carcinoma developed in four patients (two vulval, two oral) and vulval intraepithelial neoplasia in two further patients. Recommended first-line treatment with a very potent topical steroid was used in 75% (129/172) with improvement in 66% (85/129). Significant variation in second-line therapy was seen. Wide variation in U.K. practice demonstrates the absence of standardized guidance for treating ELPV and the need for vulval-specific outcomes. This audit should act as a framework towards improving ELPV management and to plan future research in this area.