CORRESPONDENCE
Comment on ‘‘Management of Vulvovaginal Lichen Planus: A New Approach’’
To the Editor: We read with interest the article by Bradford and Fischer ‘‘Management of Vulvovaginal Lichen Planus: A New Approach’’ [1]. This retrospective review of the presentation and management of 131 patients with vulvovaginal lichen planus is a welcome contribution to the literature with the introduction of some novel therapeutic strategies. The concept of ‘‘adequate control’’ proposed by Bradford and Ficher is important, and given that it is a chronic relapsing, remitting condition, we believe that this should be the goal of therapy. ‘‘Adequate control’’, however, is difficult to define. Bradford and Ficher required both syptomatic control and clinical resolution of inflammatory changes but acknowledged that preceding studies use symptoms alone as a guide for therapy. It is ours and other UK physicians’ experience that improvement in clinical signs lag considerably behind symptomatic recovery [2]. It is therefore clear that a set of outcomes relevant and acceptable to both patients and clinicians needs to be agreed upon for future work in this area. Bradford and Ficher present a more aggressive therapeutic approach than other published studies. The concept of ‘‘early aggressive therapy’’ is important as it is currently not clear whether this prevents complications, particularly scarring and malignancy, both of which cause considerable morbidity. Unfortunately, however, there are still uncertainties and variation in practice when it comes to the management of vulvovaginal lichen planus. There is no evidence from randomized controlled trials (RCTs) on which to Ó 2013, American Society for Colposcopy and Cervical Pathology Journal of Lower Genital Tract Disease, Volume 18, Number 1, 2014, E23YE24
base clinical practice [3]. The existing literature consists of a number of retrospective case series with only 1 prospective cohort study [4]. In addition to the studies acknowledged by Bradford and Fischer, there are 3 other published case series that describe the treatment of mucosal lichen planus in cohorts of more than 50 patients. Simpson et al. [5] published a UK multicenter audit of management of 172 patients comparing clinical practice to a proposed standard of optimal care, as well as collecting additional data. Helgesen et al. [6] describe treatment response along with clinical features in 58 patients, and Anderson et al. [7] discuss the response to hydrocortisone suppositories of 60 patients with vaginal lichen planus. Unfortunately, however, retrospective reviews are prone to bias, and data used are only as good as the original source records. Informing future management of vulvovaginal lichen planus requires a good evidence base through welldesigned RCTs. Although this will be a challenge owing to the condition’s uncommon nature, it is not impossible, and through collaboration, we should work toward performing RCTs that will move practice forward. Rosalind C. Simpson, BMBS Kim S. Thomas, PhD Centre of Evidence Based Dermatology University of Nottingham Nottingham, UK Ruth Murphy, PhD, MBChB Department of Dermatology Nottingham University Hospitals Nottingham, UK
REFERENCES 1. Bradford J, Fischer G. Management of vulvovaginal lichen planus: a new approach. J Low Genit Tract Dis 2013;17:28Y32.
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
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TO THE EDITOR
2. Simpson RC, Thomas KT, Murphy R. Vulval erosive lichen planus: a qualitative investigation of UK clinician views and principles of management. Br J Dermatol 2013 Apr 9 [Epub ahead of print] doi: 10.1111/bjd.12373. 3. Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev 2012;2:CD008092. 4. Cooper SM, Wojnarowska F. Influence of treatment of erosive lichen planus of the vulva on its prognosis. Arch Dermatol 2006;142:289Y94.
5. Simpson RC, Littlewood SM, Cooper SM, et al. Real-life experience of managing vulval erosive lichen planus: a casebased review and U.K. multicentre case note audit. Br J Dermatol 2012;167:85Y91. 6. Helgesen AL, Gjersvik P, Jebsen P, Kirschner R, Tanbo T. Vaginal involvement in genital erosive lichen planus. Acta Obstet Gynecol Scand 2010;89:966Y70. 7. Anderson M, Kutzner S, Kaufman RH. Treatment of vulvovaginal lichen planus with vaginal hydrocortisone suppositories. Obstet Gynecol 2002;100:359Y62.
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
Comment on ‘‘Management of Vulvovaginal Lichen Planus: A New Approach’’
To the Editor: We read with interest the article by Bradford and Fischer ‘‘Management of Vulvovaginal Lichen Planus: A New Approach’’ [1]. This retrospective review of the presentation and management of 131 patients with vulvovaginal lichen planus is a welcome contribution to the literature with the introduction of some novel therapeutic strategies. The concept of ‘‘adequate control’’ proposed by Bradford and Ficher is important, and given that it is a chronic relapsing, remitting condition, we believe that this should be the goal of therapy. ‘‘Adequate control’’, however, is difficult to define. Bradford and Ficher required both syptomatic control and clinical resolution of inflammatory changes but acknowledged that preceding studies use symptoms alone as a guide for therapy. It is ours and other UK physicians’ experience that improvement in clinical signs lag considerably behind symptomatic recovery [2]. It is therefore clear that a set of outcomes relevant and acceptable to both patients and clinicians needs to be agreed upon for future work in this area. Bradford and Ficher present a more aggressive therapeutic approach than other published studies. The concept of ‘‘early aggressive therapy’’ is important as it is currently not clear whether this prevents complications, particularly scarring and malignancy, both of which cause considerable morbidity. Unfortunately, however, there are still uncertainties and variation in practice when it comes to the management of vulvovaginal lichen planus. There is no evidence from randomized controlled trials (RCTs) on which to Ó 2013, American Society for Colposcopy and Cervical Pathology Journal of Lower Genital Tract Disease, Volume 18, Number 1, 2014, E23YE24
base clinical practice [3]. The existing literature consists of a number of retrospective case series with only 1 prospective cohort study [4]. In addition to the studies acknowledged by Bradford and Fischer, there are 3 other published case series that describe the treatment of mucosal lichen planus in cohorts of more than 50 patients. Simpson et al. [5] published a UK multicenter audit of management of 172 patients comparing clinical practice to a proposed standard of optimal care, as well as collecting additional data. Helgesen et al. [6] describe treatment response along with clinical features in 58 patients, and Anderson et al. [7] discuss the response to hydrocortisone suppositories of 60 patients with vaginal lichen planus. Unfortunately, however, retrospective reviews are prone to bias, and data used are only as good as the original source records. Informing future management of vulvovaginal lichen planus requires a good evidence base through welldesigned RCTs. Although this will be a challenge owing to the condition’s uncommon nature, it is not impossible, and through collaboration, we should work toward performing RCTs that will move practice forward. Rosalind C. Simpson, BMBS Kim S. Thomas, PhD Centre of Evidence Based Dermatology University of Nottingham Nottingham, UK Ruth Murphy, PhD, MBChB Department of Dermatology Nottingham University Hospitals Nottingham, UK
REFERENCES 1. Bradford J, Fischer G. Management of vulvovaginal lichen planus: a new approach. J Low Genit Tract Dis 2013;17:28Y32.
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
E24
&
TO THE EDITOR
2. Simpson RC, Thomas KT, Murphy R. Vulval erosive lichen planus: a qualitative investigation of UK clinician views and principles of management. Br J Dermatol 2013 Apr 9 [Epub ahead of print] doi: 10.1111/bjd.12373. 3. Cheng S, Kirtschig G, Cooper S, Thornhill M, Leonardi-Bee J, Murphy R. Interventions for erosive lichen planus affecting mucosal sites. Cochrane Database Syst Rev 2012;2:CD008092. 4. Cooper SM, Wojnarowska F. Influence of treatment of erosive lichen planus of the vulva on its prognosis. Arch Dermatol 2006;142:289Y94.
5. Simpson RC, Littlewood SM, Cooper SM, et al. Real-life experience of managing vulval erosive lichen planus: a casebased review and U.K. multicentre case note audit. Br J Dermatol 2012;167:85Y91. 6. Helgesen AL, Gjersvik P, Jebsen P, Kirschner R, Tanbo T. Vaginal involvement in genital erosive lichen planus. Acta Obstet Gynecol Scand 2010;89:966Y70. 7. Anderson M, Kutzner S, Kaufman RH. Treatment of vulvovaginal lichen planus with vaginal hydrocortisone suppositories. Obstet Gynecol 2002;100:359Y62.
Copyright © 2013 American Society for Colposcopy and Cervical Pathology. Unauthorized reproduction of this article is prohibited.
