Surgical management of a persistent lichen sclerosus case and reconstruction of vulva with free rotation and V-Y advancement flaps

Abstract

Abstract. Lichen sclerosus (LS) is a lymphocyte-mediated, chronic, inflammatory dermatitis which most commonly involves the anogenital area. Treatment options include topical corticosteroids, tacrolimus, carbon dioxide laser ablation and, as a last resort vulvectomy. The objective of this study is to report a refractory anogenital LS case and describe the use of a V-Y advancement flap for reconstruction of the perineal defect after vulvectomy.

A case of persistent LS, treated succesfully with surgery is presented and the literature is reviewed. The patient tolerated the surgical procedure well and a satisfactory cosmetic result was obtained.

A multidisciplinary team is ideal in the management of patients with persistent LS. Surgical management of LS should be reserved as a last resort for patients who are refractory to other medical treatment options and, in the case of a surgical attempt, techniques for reconstruction of the vulva should be well known.

Key words: Lichen sclerosus, vulvectomy, vulvar reconstruction

Keywords

• Lichen sclerosus, vulvectomy, vulvar reconstruction

References

1. Val I, Almeida G. An overview of lichen sclerosus. Clin Obstet Gynecol 2005; 48: 808-817.
2. Meyrick Thomas RH, Ridley CM, McGibbon DH, Black MM. Lichen sclerosus et atrophicus and autoimmunity--a study of 350 women. Br J Dermatol 1988; 118: 41-46.
3. Ridley CM. Vulvar diseases. Dermatol Clin 1992; 10: 309-318.
4. UpToDate [database online version 19.2] Stewart EG, Barbieri RL, Dellavalle RP, Ofori O. Vulvar lichen sclerosus; 2011. In: www.uptodate.com, updated February 7, 2011.
5. Goldstein AT, Marinoff SC, Christopher K, Srodon M. Prevalence of vulvar lichen sclerosus in a general gynecology practice. J Reprod Med 2005; 50: 4774
6. Knol AC, Hage JJ. The infragluteal skin flap: a new option for reconstruction in the perineogenital area. Plast Reconstr Surg 1997; 99(7):1954-1959.
7. Hashimoto I, Nakanishi H, Nagae H, Harada H, Sedo H. The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume. Plast Reconstr Surg 2001; 108: 1998200
8. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 1976; 58: 176-183.

9. Powell JJ, Wojnarowska F. Lichen sclerosus. Lancet 1999; 353: 1777-1783. van Seters M, van Beurden M, de Craen AJ. Is the assumed natural history of vulvar intraepithelial neoplasia III based on enough evidence? A systematic review of 3322 published patients. Gynecol Oncol 2005; 97: 645-651.
10. Neill SM, Lewis FM, Tatnall FM, Cox NH; British Association of Dermatologists. British Association of Dermatologists' guidelines for the management of lichen sclerosus 2010. Br J Dermatol 2010; 163: 672-6
11. Jones RW, Scurry J, Neill S, MacLean AB. Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics. Am J Obstet Gynecol 2008; 198: 1-3.
12. Bracco GL, Carli P, Sonni L,et al. Clinical and histologic effects of topical treatments of vulval lichen sclerosus. A critical evaluation. J Reprod Med 1993; 38: 37-40.
13. Neill SM, Tatnall FM, Cox NH; British Association of Dermatologists. Guidelines for the management of lichen sclerosus. Br J Dermatol 2002; 147: 6406
14. ACOG Practice Bulletin No. 93: diagnosis and management of vulvar skin disorders. Obstet Gynecol 2008; 111: 1243-1253.
15. Dalziel KL, Millard PR, Wojnarowska F. The treatment of vulval lichen sclerosus with a very potent topical steroid(clobetasol propionate 0.05%) cream. Br J Dermatol 1991; 124: 461-464.
16. Dalziel KL, Wojnarowska F. Long-term control of vulval lichen sclerosus after treatment with a potent topical steroid cream. J Reprod Med 1993; 38: 25
17. Cattaneo A, Carli P, De Marco A,et al. Testosterone maintenance therapy. Effects on vulvar lichen sclerosus treated with clobetasol propionate. J Reprod Med 1996; 41: 99-102.
18. Bousema MT, Romppanen U, Geiger JM,et al. Acitretin in the treatment of severe lichen sclerosus et atrophicus of the vulva: a double-blind, placebocontrolled study. J Am Acad Dermatol 1994; 30: 225-2
19. Hengge UR, Krause W, Hofmann H, et al. Multicentre, phase II trial on the safety and efficacy of topical tacrolimus ointment for the treatment of lichen sclerosus. Br J Dermatol 2006; 155: 102110
20. Ridley CM. Lichen sclerosus et atrophicus. Br Med J (Clin Res Ed) 1987; 295: 1295-1296.
21. Abramov Y, Elchalal U, Abramov D, Goldfarb A, Schenker JG. Surgical treatment of vulvar lichen sclerosus: a review. Obstet Gynecol Surv 1996; 51: 193-1
22. Miller NF, Riley GM, Stanley M. Leukoplakia of the vulva. Am J Obstet Gynecol 1964; 64: 768-777.
23. Gurumurthy M, Morah N, Gioffre G, Cruickshank ME. The surgical management of complications of vulval lichen sclerosus. Eur J Obstet Gynecol Reprod Biol 2012; 162: 79-82.
24. Rouzier R, Haddad B, Deyrolle C, et al. Perineoplasty for the treatment of introital stenosis related to vulvar lichen sclerosus. Am J Obstet Gynecol 2002; 186: 49-52.
25. Pérez-López FR, Ceasu I, Depypere H, et al. EMAS clinical guide: Vulvar lichen sclerosus in peri and postmenopausal women. Maturitas 2013 Jan 3. doi:pii: S0378-5122(12)00406-00409.