Vulvar Dystrophy Research Articles

Применение неодимового лазера в лечении дистрофических заболеваний вульвы

Aim: to assess effectiveness of the Aerolase Neo neodymium laser with a 1064 nm wavelength and 650 ms pulse duration in the treatment of patients with chronic vulvar dystrophies. Patients and Methods: the study included 60 patients with lichen sclerosus and vulvar leukoplakia. Patients with the verified diagnosis of early-stage vulvar lichen sclerosus were randomly assigned to 2 groups. Group 1 consisted of 45 patients who were treated with the Aerolase Neo laser and group 2 consisted of 15 patients who applied topical clobetasol propionate 0.05% ointment over the vulvar area for 2 months: two times per day before the symptoms relieved and then — once per day, depending on the intensity of clinical manifestations, for 6 months. A comprehensive medical exam of patients was performed before and after treatment. Results: histological examination revealed that the group 1 patients had a brighter red staining of the stromal collagen fibers demonstrating a pronounced collagenization of the stroma after the treatment. In the group 2 patients the examination results did not demonstrate any significant changes. The number of complaints associated with vulvar dystrophies significantly decreased among the group 1 patients who received laser therapy, and they also reported a higher satisfaction with the quality of sexual life. Those patients who used topical glucocorticoids noted the recurred itching in the vulvar area which required the continuation of maintenance therapy for up to 6 months and suggested that glucocorticoids provided a short-term effect. Conclusion: the obtained results prove the effectiveness of neodymium laser therapy for patients with vulvar dystrophies thus providing a rationale for using this method of treatment. KEYWORDS: lichen, leukoplakia, chronic vulvar dystrophies, neodymium laser, laser therapy, sexual life. FOR CITATION: Dobrokhotova Yu.E., Azimova A.Yu., Borovkova E.I. et al. The use of neodymium laser in the treatment of vulval dystrophies. Russian Journal of Woman and Child Health. 2023;6(2):138–144 (in Russ.). DOI: 10.32364/2618-8430-2023-6-2-138-144.

Vulvar dystrophies: a modern view of the problem

This article overviews modern literature data on vulvar dystrophies. The increase in the number of patients with dystrophic diseases of the vulva, a pronounced tendency towards rejuvenation, the complexity of diagnosis, frequent recurrence of the disease and low effectiveness of therapy make this issue extremely urgent. Until now, morphologists have not developed a single classification, and among clinicians, a specific etiopathogenetic concept of development of vulvar dystrophies has not been determined. There are many theories of the disease development. The process starts asymptomatically and is not diagnosed in a timely manner, and due to the localization in the intimate area, it is characterized by low circulation and an increase in the number of neglected cases. Only a comprehensive, timely started treatment with the right choice of drugs and methods of activating reparative processes will prevent development of the disease and reduce the duration of the main symptoms and the likelihood of relapses, exacerbations, and complications.

Assessing sexual function and vulvovaginal symptoms in young patients with vulvar dystrophy

Aim: to comparatively assess sexual function and intensity of vulvovaginal symptoms in patients with vulvar lichen sclerosus and mixed vulvar dystrophy. Materials and Methods. There were examined 57 patients with vulvar lichen sclerosus and 63 patients with mixed vulvar dystrophy, with mean patient age 35.0 ± 0.6 (18–45) years. Prior to therapy, the study participants completed the Female Sexual Function Index (FSFI) and the Vulvovaginal Symptoms Questionnaire (VSQ). Results. Severe sexual dysfunction (FSFI score 2) was detected in 14 % of cases (n = 8) in group 1 (sclerotic lichen vulva) and 17 % (n = 11) in group 2 (mixed dystrophy). Remaining respondents had total score below the normal cut-off. The mean FSFI score for group 1 and 2 was 17.68 and 16.78, respectively. VSQ testing found that most common complaint in both groups was itching (91 and 95 %, respectively). The majority of patients also noted a deteriorated emotional state and disease-related limitations in everyday life. The maximum VSQ score was 20 corresponding to the peak negative disease impact found in 23 % and 37 % patients in group 1 (n = 13) and group 2 (n = 23), respectively. Many patients also noted lack of lubrication most likely associated with discomfort and pain during intercourse, as well as worsened relationship with partner. Conclusion. The vulvar dystrophy negatively affects sexual function in young women. Symptoms typical to such conditions impose marked restrictions on intimate life, relationships and quality of general life. It accounts for why it is important to include questionnaires in the set of measures to assess sexual function and vulvovaginal symptoms both before and after treatment.

Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review.

Objective. Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. With numerous controversies as regards to the nomenclature, diagnosis and its association with neoplastic conditions, we decided to conduct a scoping review on this subject. Data Source. A review protocol was developed, and the Knowledge Resource Services website was used to do a search of articles pertaining to VLS with keywords “Vulvar,” “Vulval,” “diagnosis,” “lichen sclerosus et atrophicus,” “kraurosis,” “vulvar dystrophy,” and “Lichen Sclerosus”. Study Selection. The search was limited to published data from the last ten years, i.e., from July 2009 onwards and in the English language. A total of 338 articles pertaining to VLS were obtained. Older data were accessed if particular information was sought for. Results & Conclusion. The presentation is bimodal, i.e., one in prepubertal girls (average age: 7.6 years) and the other in peri- and postmenopausal women (average age: 52.6 years). However, many cases also present during reproductive years. Studies suggest a multifactorial origin as far as etiology is concerned, including a genetic, autoimmune, hormonal, and local infectious background. It affects the genital labial, perineal, and perianal areas and manifests as a patchy, thin, glistening, ivory-white area. Diagnosis is mainly based on clinical features. Biopsy is seldom required. It has been well established as a precursor lesion of dVIN and vulvar carcinoma.

Recovery therapy after photodynamic therapy of background and precancerous diseases of the vulva

A comprehensive approach that includes the treatment of background and precancerous diseases of the vulva by photodynamic therapy and plasma therapy as rehabilitation therapy was developed. The method’s effectiveness was evaluated. The study is also aimed at evaluating the effectiveness of plasma therapy after treatment of background and precancerous diseases of the vulva by photodynamic therapy. The work is based on the study results of 60 patients aged 32 to 70 years old, mean age was (53.3+3.6) years, with a morphologically verified diagnosis of vulvar intraepithelial neoplasia, mixed vulvar dystrophy (Lichen sclerosus et atrophicus, squamous cell hyperplasia), which were divided into two groups. Patients of both groups underwent photodynamic therapy using an intravenous photosensitizer «Fotolon®» (RUE «Belmedpreparaty», Republic of Belarus), which is a complex of chlorine ебс trisodium salt with low molecular weight polyvinylpyrrolidone. The session of photodynamic therapy was performed 3^1 hours after the end of the FS infusion using a universal laser coagulator «Likar-Hirurg (Surgeon)» («Photonica Plus», Ukraine, A-660 nm). Plasma therapy was performed for patients of group 2 after photodynamic therapy. It has been established that the use of photodynamic therapy and plasma therapy increases the effect of treatment of background and precancerous diseases of the vulva, accelerates the period of damaged tissues regeneration and rehabilitation of patients twice and prolongs the recurrence-free period of the disease. Keywords: photodynamic therapy, plasma therapy, precancerous diseases of the vulva.

Displasia and Cancer of the Vulva. Finding Ways to Improve the Effectiveness and Quality of Treatment Results

Cancer of the external genitals is up to 8 % in the overall structure of the incidence of malignant neoplasms of female genital organs. Under our observation there were 92 patients with vulvar dystrophy and suspected cancer. The effectiveness of treatment of vulvar dystrophy (VIN I-II degree) by the method of photodynamic therapy (PDT) 45.8±4.7%. However, dysplasia II - III degree, sclerotic changes with the formation of pronounced horn scales prevents the full PDT and recurrence of the disease. Reconstructive plastic surgery was performed using cryoapplication and « Harmonic» apparatus to reduce blood loss and duration of lymphorrhoea in the postoperative period. The use of new reconstructive plastic surgery, including with the use of abdominal skin and fascial flap combined with vascularized lower segments of the rectus muscles), have helped to reduce complications, improve cosmetic effect (patent for invention № 2580665 from 11.11.14).

New Technologies and Reconstructive Surgery Cancer of the Vulva

With vulvar dysplasia, sclerotic deprive and suspected cancer under our observation there were 92 patients. The effectiveness of treatment of vulvar dystrophy (VIN I-II degree) by the method of photodynamic therapy (PDT) 45.8±4.7%. However, dysplasia II - III degree, sclerotic changes with the formation of pronounced horn scales prevents the full PDT and recurrence of the disease. Therefore, the treatment of choice is surgical treatment with a reconstructive plastic. The use of new reconstructive plastic surgery, including with the use of abdominal skin and fascial flap combined with vascularized lower segments of the rectus muscles (patent for invention № 2580665 from 11.11.14), have helped to reduce complications, improve cosmetic effect and reduce the duration of lymphorrhea in 2-3 days.

Photodynamic Therapy in Vulvar Dystrophy Treatment

In this article, the authors analyzed and systematized the main aspects of the treatment of vulvar dystrophic diseases (VDD). The traditional methods of treatment of this pathology are surgical intervention and non-surgical methods (high-intensity laser radiation, laser CO2 coagulation, vaporization with radiation intensity of more than 1000 W/cm2 of treatment, chemotherapy and immune-modulatory therapy). Despite the effectiveness of these methods, their main deficiency is the high incidence of local recurrence of the disease (from 17% to 48%). The authors present the PDT method as an alternative, organ-preserving and highly effective therapeutic option. Most studies are devoted to the use of 5-ALA and chlorin-based photosensitizers in the treatment of VDD. The authors studied in detail the world experience of PDT for VDD, analyzed and systematized the results of treatment, advantages and disadvantages of the method.

The effect of chronic vulvar dystrophy on urinary continence in patients at climacterium

Chronic dystrophy is the growth of abnormal skin on the vulva, its causes being lichen sclerosus, with thin vulvar skin lesions and squamous hyperplasia with thick tegument. Lichen appears as discolored, translucent irregular areas of skin on/around the labia especially in women at climacterium. It can cause from lack of clinical manifestations to intense itching and progressive vulvar pain. Squamous hyperplasia transforms vulvar skin thick with white elevations causing intense itching. We examined a number of 22 climacteric patients, aged between 52 and 73 diagnosed with vulvar dystrophy in the interval 2014–2016. Urinary incontinence was diagnosed in 90% of them: 36% presented stress urinary incontinence, 40% mixed incontinence (vulvar dystrophy being a factor in the continence impairment), while in 22% of the cases the main etiology of the disease was the severe alteration of the vulvar anatomy. The 5 cases presenting important distortion of the external genital organ anatomy included partial labial adhesion or complete labial fusion caused by chronic dystrophy and required surgical intervention. The etiology in the appearance of labial adherences is thought to be inflammation of the labia with denudation of the superficial layer which heals by fibrosis causing adhesions. Labial fusion in menopause is a rare condition which in addition to chronic dystrophy has other two risk factors: relative hyperandrogenism associated with lack of estrogens and chronic urinary tract infections (UTI). Regarding recurrent UTIs, they represent both a risk factor and a consequence of labial fusion, the urine dribbling through the labial adherence over the external urethral orifice and draining through the vagina. Labial fusion affecting urinary continence is an uncommon phenomenon in postmenopausal women. The prognosis is good with surgical treatment, while estrogen and corticosteroid topic application should be used as prophylaxis for recurrence.

The impact of chronic vulvar dystrophy on sexual function at menopause

Chronic vulvar dystrophy is defined as growth of abnormal skin on the vulva, having two types according to the thickness of the skin – thin as lichen sclerosus, or thick like squamous hyperplasia. Lichen sclerosus appears as white, shiny patches of parchment-like tegument on the labia affecting mainly menopausal women. Symptoms are variable, from no obvious manifestations to intense itching and increasing vulvar pain. The affected skin area can easily bleed sometimes just by touch, often making sexual intercourse impossible. With squamous hyperplasia the vulvar skin becomes thick with white elevations, causing intense itching. Treatment includes topical corticosteroid and testosterone application, retinoids to reduce the connective tissue destruction and in advanced cases surgery. We examined a number of 25 menopausal patients, aged between 48 and 64 diagnosed with vulvar dystrophy in the interval 2014–2016. A percentage of 92% experienced difficulties in engaging sexual intercourse due to local pain, itching, dryness sensation, bleeding or labial fusion. From these, a number of 14 patients (56%) declared that vulvar symptoms determined them to cease any sexual activity because of intense complaints (40%) or physical impossibility caused by labial fusion (16%). All patients declared that the vulvar dystrophy had a negative impact on their sexual function and couple activity, affecting their quality of life between 7 and 10 on a visual analog scale. Topical corticosteroid and testosterone application was useful in most cases, relieving the symptoms after 3 months in 72% of the cases, while in the rest of the cases where the disease caused scarring or fusion of the labia surgical treatment was necessary. In conclusion, based on our study group we can affirm that chronic vulvar dystrophy can be a debilitating disease, affecting greatly menopausal women's quality of sexual life with long-term psychological implications.

The Use of Human Adipose-Derived Stem Cells in the Treatment of Physiological and Pathological Vulvar Dystrophies.

“Vulvar dystrophy” is characterized by chronic alterations of vulvar trophism, occurring in both physiological (menopause) and pathological (lichen sclerosus, vulvar graft-versus-host disease) conditions. Associated symptoms are itching, burning, dyspareunia and vaginal dryness. Current treatments often do not imply a complete remission of symptoms. Adipose-Derived Stem Cells (ADSCs) injection represents a valid alternative therapy to enhance trophism and tone of dystrophic tissues. We evaluated efficacy of ADSCs-based therapy in the dystrophic areas. From February to April 2013 we enrolled 8 patients with vulvar dystrophy. A biopsy specimen was performed before and after treatment. Digital photographs were taken at baseline and during the follow-up. Pain was detected with Visual Analogue Scale and sexual function was evaluated with Female Sexual Function Index. All patients received 2 treatments in 3 months. Follow-up was at 1 week , 1 and 3 months, and 1 and 2 years. We obtained a significant vulvar trophism enhancement in all patients, who reported pain reduction and sexual function improvement. Objective exam with speculum was easy to perform after treatment. We believe ADSCs-based therapy finds its application in the treatment of vulvar dystrophies, since ADSCs could induce increased vascularization due to their angiogenic properties and tissue trophism improvement thanks to their eutrophic effect.

Vulvar dystrophies: A long-term Brisbane study of 155 cases

Objective: To review the long-term outcomes for 155 women with a vulvar dystrophy (VD) who attended the Royal Brisbane Hospital Vulvar Clinic between 1976 and 1988. Methods: VD data from Vulvar Diseases Clinic were reviewed and analysed using the computer software Statistical package for the Social Sciences (SPSS) 11.0. Results: Of 155 patients 94 had Lichen Sclerosus (LS), 41 Lichen Simplex Chronicus (LSC) and 20 Mixed Dystrophy (MD). Three patients developed squamous cell carcinomas of the vulva between 10 and 26 years after presentation with a VD. To date only one of these three patients remains alive following treatment. Conclusion: The need for long term follow up is stressed and any of the three types of VD may become malignant. Time from diagnosis to malignant change is not predictive. VD treatments seem to go through phases with the application of potent steroid creams having stood the test of time.

Expressions of epidermal growth factor receptor (EGFR) and Ki-67 in vulvar dystrophy

Objective To explore the expressions of EGFR and Ki-67 in vulvar dystrophy and their clinical significance Methods Tissue specimens were collected from 160 patients with vulvar dystrophy.Immunohistochemical method was used to detect the expressions of EGFR and Ki-67 in these specimens.The expression levels of EGFR and Ki-67 were compared among different pathological subtypes of vulvar dystrophy,and the relationship of these expressions with clinical pathological characteristics was assessed.Results No significant differences were observed in the expressions of EGFR or Ki-67 between vulvar dystrophy of squamous cell hyperplasia type,lichen sclerosus type and mixed type (P ＞ 0.05).The expression level of EGFR was positively correlated with that of Ki-67 in vulvar dystrophy (r =0.66,P ＜ 0.05).There was a significant difference in the expression rate of EGFR and Ki-67 between patients with different courses of vulvar dystrophy (both P ＜0.05),but not between patients with different age at onset of vulvar dystrophy (both P ＞ 0.05).Conclusion The expressions of EGFR and Ki-67 are different among patients with different courses of vulvar dystrophy.

High-intensity focused ultrasound treatment for non-neoplastic epithelial disorders of the vulva

Objective To assess the efficacy of high-intensity focused ultrasound (HIFU) treatment in patients with non-neoplastic epithelial disorders of the vulva. Method We reviewed 41 cases of lichen sclerosus, 38 cases of squamous cell hyperplasia, and 17 mixed cases treated by HIFU from April 2004 to July 2008 at the Women's Hospital of Zhejiang University School of Medicine. Biopsy specimens were assessed with light microscopy before and after treatment. Results Pruritus and signs of vulvar lesions were dramatically improved following HIFU treatment, without severe complications, and 90.23% of the patients were cured or had their symptoms improved 6 months after treatment. On light microscopy, pigmentation and epithelial structures were recovered and dermal lymphocytic infiltration was reduced. The response rates were lower and complication rates higher among lichen sclerosus than among squamous cell hyperplasia cases ( P < 0.05 for both). Conclusion Treatment with HIFU may be safe and effective in cases of vulvar dystrophy.

Testosterone Versus Clobetasol for Maintenance of Vulvar Lichen Sclerosus Associated With Variable Degrees of Squamous Cell Hyperplasia

What used to be called vulvar dystrophy now is termed nonneoplastic epithelial disorders of the vulva. Within this category, the association of lichen sclerosus with varying degrees of squamous cell hyperplasia is referred to as mixed disease. This retrospective study compared responses to treatment with testosterone and clobetasol in 83 women having biopsy-proved vulvar mixed disease. All patients were initially treated with topical fluorinated corticosteroids for 6 weeks. They were then treated with either 2% testosterone propionate in petrolatum (n = 44) or 0.05% clobetasol 17-propionate cream (n = 39), each applied once a day. After symptoms were optimally controlled, twice weekly applications were advised for 3 months and treatment then was continued on an as-needed basis. The major complaints were vulvar itching and burning or discomfort. Remission rates after 6 months were 82% in women treated with testosterone and 93% in those treated with clobetasol. Disease recurred in 8% of patients: 13% of women treated with testosterone and 5% of clobetasol-treated patients. The median time to recurrence was 9 months. Persistent disease was documented histologically in 60% of patients whose symptoms did not respond to treatment. Skinning vulvectomy ultimately was performed in 2 patients with recurrent disease and 2 with vulvar intraepithelial neoplasia I–II or atypical squamous hyperplasia. Treatment was not associated with steroid vulvar atrophy or other serious complications. Both topical treatments evaluated in this retrospective study yielded excellent remission rates. Clobetasol led to a higher remission rate and lower recurrence rate than did testosterone therapy, but the differences were not statistically significant. Patients with mixed disease who fail to respond symptomatically should have a vulvar biopsy to rule out atypical components.

Study of ultrastructural changes of the non-neoplastic epithelial disorders of vulva after focused ultrasound treatment

Objective:This study was undertaken to investigate the ultrastructural changes of non-neoplastic epithelial disorders of the vulva (known as vulvar dystrophies) after focused ultrasound treatment and to assess the effectiveness of such treatment. Materials & methods: In total, 60 patients with non-neoplastic epithelial disorders of the vulva were enrolled in this study and treated by focused ultrasound therapy. Before and after treatment, changes to ultrastructures in the treatment region were evaluated using pathological and electron microscopic studies in 30 patients and the short-term treatment effectiveness was assessed. Results: Symptoms of the patients were greatly reduced or even eliminated. There was no itching or pain during sex. Lesions prior to treatment showed various degrees of hyperplastic atrophy and degenerative changes. At the same time, an increase in epithelial keratosic and decrease in melanotic granules and desmosomes was observed. Mitochondria with swelling and capillary contraction ...

Focused Ultrasound Therapy of Vulvar Dystrophies: A Feasibility Study

To explore the feasibility and efficacy of focused ultrasound treatment of squamous hyperplasia and lichen sclerosus. A simple randomized phase 2 study was conducted in which a total of 76 patients (45 with squamous hyperplasia and 31 with lichen sclerosus) were treated with focused ultrasound therapy from 1999 to 2002. Before and after the treatment, the therapeutic responses were evaluated based on changes in clinical symptoms and signs. Pre- and posttreatment biopsy specimens were also assessed through the light and electron microscopic examinations. The positive expressions of CD34 and myelin basic protein (MBP) tests with the strepavidin-peroxidase immunohistochemistry method were used to evaluate the therapeutic response. Statistical analysis was performed using chi2 (McNemar chi2) test and t test. After the ultrasound treatment, clinical symptoms were dramatically improved with a total response rate of 94.74%. Three to 6 months later the skin of treated areas returned to normal appearance. In the 2-year follow-up, 49 of 76 cases (32 squamous hyperplasia and 17 lichen sclerosus) were cured, 23 (11 squamous hyperplasia and 12 lichen sclerosus) improved and 4 (2 squamous hyperplasia and 2 lichen sclerosus) persisted. The positive expressions of CD34 and MBP after treatment increased significantly at the treated region (P < .05). No major complications occurred. Vulvar dystrophy could be effectively treated with focused ultrasound therapy. This approach appears to be a new promising treatment method, although further studies are still needed. LEVEL OF EVIDENCE II-3.

Carcinoma de vulva en paciente con liquen escleroatrófico de larga evolución

The relationship between vulvar dystrophy and the development of carcinoma of the vulva is unknown, although it doesn’t seem to be etiological. Since the coexistence of these lesions is frequent, clinicians must rule out a possibly malignant lesion in any patient with a chronic vulvar process and the patient should be closely followed while the lesion exists.

Comparación de clobetasol frente a prednicarbato para el tratamiento del prurito vulvar con o sin distrofia

Summary We present a clinical, prospective and comparative study over one year, between two topical corticosteroids in the treatment of vulvar pruritus, with or without dystrophy. Clobetasol versus prednicarbate, with 10 cases in both groups. The results were very good, with improvement of the pruritus in all cases. Those cases of vulvar dystrophy with lichen sclerosus type lesions also improved. There were no secondary effects. In conclusion, both products are efficacious in the treatment of vulvar pruritus, and vulvar dystrophy also improves.

Abnormal expression or mutation of TP53 and HPV in vulvar cancer

HPV (human papillomavirus) plays an important role in cervical cancer and may also play a role in vulvar cancer. TP53 mutation is common in a variety of cancers but its role in vulvar cancer is not well established. The aim of this study was to assess the prevalence of HPV infection and TP53 mutation as well as their correlation in vulvar cancer. Also, HPV detection and abnormal p53 expression were assessed in relation to age, co-existing vulvar intraepithelial neoplasia and vulvar dystrophy. Forty-eight samples of vulvar cancer were studied. DNA was extracted from formalin-fixed paraffin embedded tissue for polymerase chain reaction/Southern blot study with HPV 16 and 18 and L1 primers. Paraffin sections were immunostained (IHS) for p53 protein using three antibodies, p1801, CM1 and DO7. The p53 mutation was also screened using polymerase chain reaction (PCR) single-stranded conformation polymorphism (SSCP) and confirmed by sequencing. Overall, HPV was detected in 48% (23/48), of which 96% (22/23) were HPV 16 or 18. By IHS, p53 overexpression was detected in 46% of cases whilst TP53 mutations were identified in 21%. In HPV positive and negative tumours, p53 abnormal expression was detected in 39% and 52%, respectively, and TP53 mutation was found in 22% and 20%, respectively. Mutations were mainly found at codons 273 and 204. Age was not found to be associated with HPV detection. However, the presence of HPV (71%) or absence of abnormal p53 expression (65%) were higher in tumours with VIN3, but were not correlated with dystrophy.