Advances in targeted therapies and regenerative medicine are opening new avenues for improving the quality of life for patients with refractory disease.

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin disease that affects the anogenital region and typically occurs in flare-ups. The condition can appear at any age, but its incidence peaks during two periods: the prepubertal period and the perimenopausal and postmenopausal phases. However, the most significant aspect is undoubtedly the extent to which it can affect patients’ quality of life because evidence supports its major impact on genital self-image, sexual function, and the quality of life of women who have the condition.

To date, many women have achieved good results with treatments such as topical corticosteroids, but patients who experience frequent relapses or whose quality of life remains impaired have posed one of the major challenges in managing this condition. However, in recent years, new therapeutic alternatives have emerged that show promise.

To explore these further, we at El Médico Interactivo, part of the Medscape Professional Network, spoke with Laura Ortiz Moragas, gynecologist and obstetrician at the University Hospital of Fuenlabrada in Madrid, Spain. She began by clarifying that, over the past decade, the clinical management of these patients has evolved toward a more specialized, interdisciplinary approach, combining care from gynecologists, dermatologists, physical therapists, and psychologists, among other professionals.

JAK Inhibitors, Laser Therapy, and Platelet-Rich Plasma (PRP)

Regarding the various innovations, the expert reviews the most notable ones. First, it is worth noting that laser therapy is one of the fastest-growing treatment modalities in this field. The expert noted that there is scientific evidence supporting the use of fractional CO₂ vaginal laser therapy in improving symptoms and achieving remission of VLS flare-ups that are resistant to topical corticosteroid therapy. In fact, patients who initially did not respond to topical corticosteroids may respond to maintenance corticosteroids following CO₂ laser treatment.

However, one of the areas with the highest expectations is undoubtedly that of JAK inhibitors. Since 2020, several clinical trials have been published that aim to test the efficacy of JAK inhibitor agents in improving the symptoms of VLS. The results have been promising, especially for the compounds baricitinib and abrocitinib.

As Moragas clarifies, these trials have been conducted in patients who are resistant to first-line treatment with topical corticosteroids and second-line treatment with calcineurin inhibitors, so these agents could be a good option for these patients.

Furthermore, regenerative medicine strategies are also being investigated, such as PRP, autologous fat grafting, and cellular derivatives from adipose tissue. “Although a certain degree of caution is warranted with these emerging therapies, an increasing number of publications are recognizing them as another treatment option. More studies are needed to gather further evidence, but leading scientific societies in vulvar pathology, such as the Spanish Society of Cervical Pathology and Colposcopy, already include PRP as another treatment option for VLS that does not respond to standard treatments,” said the gynecologist.

Furthermore, reviews of the scientific evidence published in MDPI indicate that, while high-potency topical corticosteroids have proven effective in treating lichen sclerosus, other treatment modalities, including steroid-sparing agents and/or procedural adjuvants, have been shown to play a beneficial role in treating this condition.

Changes to Clinical Guidelines

Indeed, the emergence of these new therapeutic tools has led to an update of European and British recommendations regarding this condition. That is why healthcare professionals should take note of some key messages from these updates. “Fundamentally, it must be considered in the differential diagnosis of women who present with itching, dyspareunia, or nonspecific vulvar discomfort that does not improve with empirical treatments such as antifungals,” explained the gynecologist.

She added that, for patients who have already received a diagnosis, healthcare professionals must understand the impact this condition has on women’s quality of life and encourage them to seek follow-up care if they do not improve with their prescribed treatments.

Improving the Diagnosis of VLS

The expert emphasized that treatment efficacy is critically dependent on a timely diagnosis. However, clinicians face several diagnostic challenges, which often occur simultaneously. The condition’s symptoms can overlap with those of the genitourinary syndrome of menopause, and its clinical presentation varies widely — ranging from whitish patches and fissures to erythema. These factors, compounded by patient delays in seeking medical care, can significantly impede an accurate and prompt diagnosis.

For all these reasons, Moragas insists that this underdiagnosis leads to a genuine lack of knowledge regarding the disease’s incidence. Indeed, in addition to improving treatment, the future must involve gaining a better understanding of the disease itself. Current knowledge points to multifactorial causes, with genetic and autoimmune factors playing an important role, but the influence of other factors — such as hormonal or infectious ones — continues to be studied, although there is still no clear scientific evidence in this regard. Perhaps new findings in this area will also lead to the development of even more effective treatments.

Moragas has disclosed no relevant financial relationships.

This story was translated from El Médico Interactivo.