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EMAS clinical guide: Vulvar lichen sclerosus in peri and postmenopausal women

      Abstract

      Introduction

      Vulvar lichen sclerosus (LS) is a chronic inflammatory disease which affects genital labial, perineal and perianal areas, producing significant discomfort and psychological distress. However there may be diagnostic delay because of late presentation and lack of recognition of symptoms.

      Aims

      The purpose of this clinical guide is to provide advice on early recognition and treatment.

      Material and methods

      Literature review and consensus of expert opinion.

      Results and conclusions

      The etiology of LS in peri and postmenopausal women is unknown, although autoimmune, genetic and infectious factors have been implicated. Definitive diagnosis of non-malignant disorders depends on the histology of biopsied tissue. LS associated with cellular atypia should be classified as intraepithelial neoplasia. Topical corticosteroids are the most effective treatment, although prolonged treatment may be associated with dermal atrophy. Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, may be a safe and effective alternative treatment without risk of corticosteroid-related vulvar atrophy since they do not affect collagen synthesis. LS recurrences are frequent, and can lead to significant physical discomfort and emotional distress that affect mood and sexual relationships. Anatomical changes may require surgical management.

      Keywords

      1. Introduction

      Lichen sclerosous (LS) is a chronic progressive, non-neoplastic, epithelial atrophic disease with a marked inflammation that manifests as patchy, thinner than normal white fibrous skin. It affects more women than men, and may be found in different sites, although the most common is in the external genitalia (85–95% of cases) [
      • Ridley C.M.
      • Neill S.M.
      Non-infective cutaneous conditions of the vulva.
      ,
      • Thomas R.H.
      • Ridley C.M.
      • McGibbon D.H.
      • Black M.M.
      Anogenital lichen sclerosus in women.
      ,
      • McPherson T.
      • Cooper S.
      Vulval lichen sclerosus and lichen planus.
      ]. Vulvar LS has also been called lichen albus, hypoplastic dystrophy, and vulvar kraurosis. The predominant symptoms are pruritus and pain, although many women have a long asymptomatic period. Women with LS have an increased risk of squamous cell carcinoma, and human papillomavirus infection or radiotherapy may be involved in carcinogenesis.
      Vulvar LS can occur at any age but tends to have two peaks of onset: prepubertal girls and peri- or postmenopausal women [
      • McPherson T.
      • Cooper S.
      Vulval lichen sclerosus and lichen planus.
      ]. Some scientific organizations have issued consensus guidelines about vulvar skin disorders and/or LS management [
      • Jones R.W.
      • Scurry J.
      • Neill S.
      • MacLean A.B.
      Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics.
      ,
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ,
      • Royal College of Obstetricians and Gynaecologists
      The management of vulval skin disorders. Green-top Guideline 58.
      ]. The purpose of this clinical guide is to provide advice on early recognition and treatment in peri- and postmenopausal women.

      2. Prevalence

      While LS is a common condition, its prevalence is uncertain [
      • McPherson T.
      • Cooper S.
      Vulval lichen sclerosus and lichen planus.
      ,
      • Goldstein A.T.
      • Marinoff S.C.
      • Christopher K.
      • Srodon M.
      Prevalence of vulvar lichen sclerosus in a general gynecology practice.
      ,
      • Leibovitz A.
      • Kaplun V.V.
      • Saposhnicov N.
      • Habot B.
      Vulvovaginal examinations in elderly nursing home women residents.
      ]: calculated incidences range between 1:300 and 1:1000 new patients referred to a general hospital. In general gynecological practice the rate of histologically proven LS is about 1.7% [
      • Goldstein A.T.
      • Marinoff S.C.
      • Christopher K.
      • Srodon M.
      Prevalence of vulvar lichen sclerosus in a general gynecology practice.
      ,
      • Eberz B.
      • Berghold A.
      • Regauer S.
      High prevalence of concomitant anogenital lichen sclerosus and extragenital psoriasis in adult women.
      ], and 54% are postmenopausal (mean age 52.6 years) and 39% are asymptomatic [
      • Goldstein A.T.
      • Marinoff S.C.
      • Christopher K.
      • Srodon M.
      Prevalence of vulvar lichen sclerosus in a general gynecology practice.
      ]. The prevalence of LS is probably underestimated since a third of cases are asymptomatic [
      • Goldstein A.T.
      • Marinoff S.C.
      • Christopher K.
      • Srodon M.
      Prevalence of vulvar lichen sclerosus in a general gynecology practice.
      ]. There can also be delays in seeking medical advice and a range of specialists consulted who may be unfamiliar with the condition. Common misdiagnoses includes Candida albicans vulvitis and postmenopausal atrophy and leading to delays of in diagnosis of up to 5 years [
      • Cooper S.M.
      • Gao X.H.
      • Powell J.J.
      • Wojnarowska F.
      Does treatment of vulvar lichen sclerosus influence its prognosis?.
      ].

      3. Etiology

      The etiology of LS remains unknown, but several mechanisms have been studied and suggest a multifactorial origin, including a genetic, auto-immune, and infectious background. Genetic predisposition to LS has been shown in family and twin studies [
      • Meyrick Thomas R.H.
      • Kennedy C.T.
      The development of lichen sclerosus et atrophicus in monozygotic twin girls.
      ,
      • Cox N.H.
      • Mitchell J.N.
      • Morley W.N.
      Lichen sclerosus et atrophicus in non-identical female twins.
      ]. Sherman et al. studied 1052 women with LS (80% histologically confirmed) using family clustering, and reported that 126 (12%) women had a positive family history of the condition [
      • Sherman V.
      • McPherson T.
      • Baldo M.
      • Salim A.
      • Gao X.H.
      • Wojnarowska F.
      The high rate of familial lichen sclerosus suggests a genetic contribution: an observational cohort study.
      ].
      There is a strong association between LS and autoimmune disease [
      • Cooper S.M.
      • Ali I.
      • Baldo M.
      • Wojnarowska F.
      The association of lichen sclerosus and erosive lichen planus of the vulva with autoimmune disease: a case–control study.
      ,
      • Kazandi M.
      • Sahin C.
      • Terek M.C.
      • Cirpan T.
      • Oztekin K.
      Clinical evaluation of vulvar lichen sclerosus: case series.
      ] in adults. LS-associated immune system disorders include scleroderma, Hashimoto thyroiditis, rheumatoid arthritis, psoriasis, and alopecia areata [
      • Eberz B.
      • Berghold A.
      • Regauer S.
      High prevalence of concomitant anogenital lichen sclerosus and extragenital psoriasis in adult women.
      ,
      • Cooper S.M.
      • Ali I.
      • Baldo M.
      • Wojnarowska F.
      The association of lichen sclerosus and erosive lichen planus of the vulva with autoimmune disease: a case–control study.
      ,
      • Kreuter A.
      • Wischnewski J.
      • Terras S.
      • Altmeyer P.
      • Stücker M.
      • Gambichler T.
      Coexistence of lichen sclerosus and morphea: a retrospective analysis of 472 patients with localized scleroderma from a German tertiary referral center.
      ]. In a series of 211 patients with confirmed LS, 29.9% had thyroid disease and this was not age-dependent and higher than that reported in the general population [
      • Birenbaum D.L.
      • Young R.C.
      High prevalence of thyroid disease in patients with lichen sclerosus.
      ].
      Genital LS may coexist with morphea or local scleroderma and with systemic sclerosis. In a series of 472 patients with local scleroderma LS was more frequent as indicated by an odds ratio of 18.1 [
      • Kreuter A.
      • Wischnewski J.
      • Terras S.
      • Altmeyer P.
      • Stücker M.
      • Gambichler T.
      Coexistence of lichen sclerosus and morphea: a retrospective analysis of 472 patients with localized scleroderma from a German tertiary referral center.
      ]. A possible association between LS and psoriasis has also been reported [
      • Eberz B.
      • Berghold A.
      • Regauer S.
      High prevalence of concomitant anogenital lichen sclerosus and extragenital psoriasis in adult women.
      ,
      • Simpkin S.
      • Oakley A.
      Clinical review of 202 patients with vulval lichen sclerosus: a possible association with psoriasis.
      ]. Thus, the prevalence of psoriasis in LS women (7.5%) is higher than in the general population. Oral lichen planus (LP) and vulvar LS may coexist. However, prevalence of oral LP in women with vulvar lichen sclerosus (0.6%) is similar to that reported for oral LP in the general population (1–2%) [
      • Saunders H.
      • Buchanan J.A.
      • Cooper S.
      • Hollowood K.
      • Sherman V.
      • Wojnarowska F.
      The period prevalence of oral lichen planus in a cohort of patients with vulvar lichen sclerosus.
      ].
      Women with LS may have other bladder, bowel and pain comorbidities. Thus in a series of 308 women with LS seen at a vulvar clinic, self-reported conditions were overactive bladder 15.3%, stress urinary incontinence 27.9%, constipation 32.5%, irritable bowel syndrome 19.5%, thyroid dysfunction 33.1%, fibromyalgia 9.1%, temporomandibular joint disorder 13.0% and vulvar pain 83.1% [
      • Berger M.B.
      • Damico N.J.
      • Menees S.B.
      • Fenner D.E.
      • Haefner H.K.
      Rates of self-reported urinary, gastrointestinal, and pain comorbidities in women with vulvar lichen sclerosus.
      ].
      Infection, such as with Borrelia burgdorferi (BB), has been implicated but the evidence is contradictory [
      • Eisendle K.
      • Grabner T.
      • Kutzner H.
      • Zelger B.
      Possible role of Borrelia burgdorferi sensu lato infection in lichen sclerosus.
      ,
      • Zollinger T.
      • Mertz K.D.
      • Schmid M.
      • Schmitt A.
      • Pfaltz M.
      • Kempf W.
      Borrelia in granuloma annulare, morphea and lichen sclerosus: a PCR-based study and review of the literature.
      ]. The Koebner phenomenon, which is described as the occurrence of lesions at sites of injured or traumatized skin, is a well-known manifestation of LS. Thus repeated trauma and irritation to the area may actually be precipitating factors to the expression of this disease [
      • Funaro D.
      Lichen sclerosus: a review and practical approach.
      ].

      4. Clinical characteristics

      Careful history taking and clinical examination are important [
      • Funaro D.
      Lichen sclerosus: a review and practical approach.
      ]. Vulvar LS most commonly presents with progressive pruritus, dyspareunia, dysuria, or genital bleeding. It usually affects the ano-vulvar epithelium, although in 20% of patients other areas are involved such as the upper trunk, axillae, buttocks and lateral thigh. It does not affect the vagina and cervix. Initially the vulva is itchy, sore, bright and red. Hemorrhagic bullae may be also present in the genital area, which can be confused with other vulvar ulcerative disease.
      After several years, the vulva becomes ivory with atrophic changes leading to loss of labia minora, burying of the clitoris, obstruction of urinary outflow, reduction of the vaginal introitus and fourchette adhesions. Chronic scratching secondary to pruritus can result in subepithelial hemorrhaging. Perianal involvement can create the classic “figure of eight” shape. Constipation and painful defecation may be a feature. LS can have a negative effect on sexual function, including dyspareunia, apareunia and difficulty to reach orgasm. Assessment should also include investigation for autoimmune disease.

      5. Histopathological diagnosis

      Although LS can be diagnosed on clinical examination, histological confirmation should be sought. Biopsy should be performed of hyperkeratotoic areas, erosions that do not improve with treatment or sites with altered pigmentation.
      Differential diagnosis could include LP, vitiligo, immunobullous disorders such as cicatricial pemphigoid, and vulvar intraepithelial neoplasia (VIN). Squamous cell hyperplasia (SCH), which increases the risk of vulvar malignancy, may be present in acanthotic areas. Patients with lichen sclerosus have an increased risk of developing squamous cell carcinoma. Women with LS associated vulvar cancer are significantly older than women with LS alone, and SCH is independently associated with vulvar carcinoma. The duration of symptoms and loss of vulvar architecture are indicators of cancer risk [
      • Jones R.W.
      • Scurry J.
      • Neill S.
      • MacLean A.B.
      Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics.
      ].

      6. Treatment

      As there is no cure for LS, the endpoints of treatments are symptoms relief and improvement of anatomical changes. Treatments may be pharmacological or surgical, but there are few randomized trials [
      • Chi C.C.
      • Kirtschig G.
      • Baldo M.
      • Brackenbury F.
      • Lewis F.
      • Wojnarowska F.
      Topical interventions for genital lichen sclerosus.
      ,
      • Abramov Y.
      • Elchalal U.
      • Abramov D.
      • Goldfarb A.
      • Schenker J.G.
      Surgical treatment of vulvar lichen sclerosus: a review.
      ]. Ultra-potent topical corticosteroid creams such as clobetasol propionate are the treatment of choice [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ,
      • Chi C.C.
      • Kirtschig G.
      • Baldo M.
      • Brackenbury F.
      • Lewis F.
      • Wojnarowska F.
      Topical interventions for genital lichen sclerosus.
      ], with topical calcineurin inhibitors second line [
      • Royal College of Obstetricians and Gynaecologists
      The management of vulval skin disorders. Green-top Guideline 58.
      ,
      • Goldstein A.T.
      • Creasey A.
      • Pfau R.
      • Phillips D.
      • Burrows L.J.
      A double-blind, randomized controlled trial of clobetasol versus pimecrolimus in patients with vulvar lichen sclerosus.
      ]. Once LS is controlled, maintenance treatment is based on the use of corticosteroids or moisturizers [
      • Bradford J.
      • Fischer G.
      Long-term management of vulval lichen sclerosus in adult women.
      ,
      • Simonart T.
      • Lahaye M.
      • Simonart J.M.
      Vulvar lichen sclerosus: effect of maintenance treatment with a moisturizer on the course of the disease.
      ]. Psychosexual counseling should be discussed and offered as LS can affect sexual function [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ]. Vaginal dilators may be helpful. It is generally advised to avoid bubble baths, scented soap, detergents, perfumes, etc. as these may irritate the vulva but the evidence base for this is scant.

      6.1 Local corticosteroids

      Clobetasol propionate cream (0.05%) significantly reduces symptoms and improves skin characteristics compared with placebo [
      • Chi C.C.
      • Kirtschig G.
      • Baldo M.
      • Brackenbury F.
      • Lewis F.
      • Wojnarowska F.
      Topical interventions for genital lichen sclerosus.
      ]. A recommended regimen for a newly diagnosed case is clobetasol propionate 0.05% ointment applied once daily, at night, for 4 weeks, then on alternate nights for 4 weeks, and then twice weekly for a further 4 weeks, before review. About 60% of patients experience complete remission of their symptoms. Others will continue to have flares and remissions; they are advised to use clobetasol propionate 0.05% as required [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ].
      The less potent steroid mometasone furoate (0.1% cream) is also effective [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ,
      • Cattaneo A.
      • De Magnis A.
      • Botti E.
      • Sonni L.
      • Carli P.
      • Taddei G.L.
      Topical mometasone furoate for vulvar lichen sclerosus.
      ]. Triamcinolone ointment has also been reported to reduce LS symptoms in a small study [
      • LeFevre C.
      • Hoffstetter S.
      • Meyer S.
      • Gavard J.
      Management of lichen sclerosus with triamcinolone ointment: effectiveness in reduction of patient symptom scores.
      ]. Intralesional injection of triamcinolone acetonide has been proposed as an alternative treatment to topical treatment of LS, but again the studies are small [
      • Stücker M.
      • Grape J.
      • Bechara F.G.
      • Hoffmann K.
      • Altmeyer P.
      The outcome after cryosurgery and intralesional steroid injection in vulvar lichen sclerosus corresponds to preoperative histopathological findings.
      ].
      Pruritic LS has also been treated with topical corticosteroids or combined corticosteroid and monthly anesthetic/corticosteroid subdermal injection. In this 5-year study, time to recurrence was longer with the combined treatment, although women were less satisfied with the injections [
      • Ventolini G.
      • Swenson K.M.
      • Galloway M.L.
      Lichen sclerosus: a 5-year follow-up after topical, subdermal, or combined therapy.
      ].
      The side effects of topical corticosteroids include irritation, burning, dryness, hypopigmentation, and dermal atrophy.

      6.2 Calcineurin inhibitors

      Calcineurin inhibitors (CIs) are immunomodulators that block the release of inflammatory cytokines from T lymphocytes. Topical tacrolimus and pimecrolimus have been reported to be associated with good clinical response in anogenital LS [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ]. However studies have involved a small number of patients [
      • Goldstein A.T.
      • Creasey A.
      • Pfau R.
      • Phillips D.
      • Burrows L.J.
      A double-blind, randomized controlled trial of clobetasol versus pimecrolimus in patients with vulvar lichen sclerosus.
      ,
      • Luesley D.M.
      • Downey G.P.
      Topical tacrolimus in the management of lichen sclerosus.
      ,
      • Kim G.W.
      • Park H.J.
      • Kim H.S.
      • et al.
      Topical tacrolimus ointment for the treatment of lichen sclerosus, comparing genital and extragenital involvement.
      ,
      • Hengge U.R.
      • 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.
      ,
      • Kauppila S.
      • Kotila V.
      • Knuuti E.
      • Väre P.O.
      • Vittaniemi P.
      • Nissi R.
      The effect of topical pimecrolimus on inflammatory infiltrate in vulvar lichen sclerosus.
      ]. Use is recommended in women with corticosteroid-resistant disease or intolerance to these compounds. The long-term safety profile of these compounds is not established and there are concerns about the increased risk of neoplasia [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ].

      6.3 Topical androgens and progesterone

      Testosterone propionate cream (2%), dihydrotestosterone cream (2%) and progesterone cream have been compared with placebo treatment in randomized controlled trials [
      • Chi C.C.
      • Kirtschig G.
      • Baldo M.
      • Brackenbury F.
      • Lewis F.
      • Wojnarowska F.
      Topical interventions for genital lichen sclerosus.
      ]. Two of these studies used testosterone for 3 months and one year, respectively, without significant differences as compared with placebo. A very small randomized placebo-controlled trial of dihydrotestosterone for 3 months found no significant improvement. Similarly topical progesterone was of no benefit.

      6.4 Surgical management

      Surgical management of LS such as vulvectomy or cryosurgery is reserved for women with malignancy or postinflammatory sequelae [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ,
      • Virgili A.
      • Corazza M.
      • Bianchi A.
      • Mollica G.
      • Califano A.
      Open study of topical 0.025% tretinoin in the treatment of vulvar lichen sclerosus. One year of therapy.
      ]. As studies are limited, there is a need to increase the evidence base.

      6.5 Other treatments

      6.5.1 Other pharmacologic treatments

      Retinoids may reduce hyperkeratinisation and have anti-inflammatory properties. Topical tretinoin (0.025%) has been used in a small group of women with histologically proven LS. Symptoms, macroscopic and histological characteristics significantly improved after 4–13 months [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ,
      • Bradford J.
      • Fischer G.
      Surgical division of labial adhesions in vulvar lichen sclerosus and lichen planus.
      ,
      • Virgili A.
      • Corazza M.
      • Bianchi A.
      • Mollica G.
      • Califano A.
      Open study of topical 0.025% tretinoin in the treatment of vulvar lichen sclerosus. One year of therapy.
      ]. As retinoids are teratogenic, they are contra-indicated in pregnancy; they may also be associated with local skin reactions [].
      The antihistaminic and anti-inflammatory compound oxatamide has topically studied in a placebo-control comparative study in vulvar LS. It seems that oxatamide had a better anti-itching effect than placebo but not on other clinical endpoints [
      • Origoni M.
      • Ferrari D.
      • Rossi M.
      • Gandini F.
      • Sideri M.
      • Ferrari A.
      Topical oxatomide: an alternative approach for the treatment of vulvar lichen sclerosus.
      ].
      Since an infectious etiology has been implicated in vulvar LS, antibiotics have been studied but the numbers of patients have been small. An observational study of 15 women, who had previously responded poorly to topical corticosteroids, tested the use of penicillin or cephalosporins. Rapid relief of pain, pruritus and burning was noted [
      • Shelley W.B.
      • Shelley E.D.
      • Amurao C.V.
      Treatment of lichen sclerosus with antibiotics.
      ].

      6.5.2 Photodynamic therapy

      An open study of photodynamic therapy (PDT) (topical 5-aminolaevulinic acid with argon laser light) found that 10 out of 12 patients had significant improvement [
      • Hillemanns P.
      • Untch M.
      • Pröve F.
      • Baumgartner R.
      • Hillemanns M.
      • Korell M.
      Photodynamic therapy of vulvar lichen sclerosus with 5-aminolevulinic acid.
      ]. Another study demonstrated good symptomatic benefit in 6 of 10 patients treated with aminolaevulinic acid PDT using a bioadhesive patch [
      • Zawislak A.A.
      • McCluggage W.G.
      • Donnelly R.F.
      • et al.
      Response of vulval lichen sclerosus and squamous hyperplasia to photodynamic treatment using sustained topical delivery of aminolevulinic acid from a novel bioadhesive patch system.
      ].

      7. Follow-up and prognosis

      There is no consensus with respect to the follow-up of women with vulvar LS [
      • Jones R.W.
      • Scurry J.
      • Neill S.
      • MacLean A.B.
      Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics.
      ]. The risk of malignancy in uncomplicated female genital LS that has been diagnosed and treated is small being less than 5% [
      • Neill S.
      • Lewis F.M.
      • Tatnall F.M.
      • et al.
      British Association of Dermatologists’ guidelines for the management of lichen sclerosus 2010.
      ,
      • Jones R.W.
      • Scurry J.
      • Neill S.
      • MacLean A.B.
      Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics.
      ]. After initial diagnosis and treatment, follow-up at 3 and 6 months to assess response is recommended. If women continue to use a topical steroid annual follow-up would be prudent. Long-term follow-up in specialist clinics rather than primary care is appropriate for women with troublesome symptoms, localized skin thickening, previous cancer or VIN. Women should be encouraged to examine their vulva for any changes though this may be difficult in older women with co morbidities such as osteoarthritis, visual problems and obesity. In women with both estrogen deficient urogenital atrophy and LS, treatment for both conditions can be concurrent, but there are no randomized controlled trials. In this setting low dose vaginal estrogens [
      • Rees M.
      • Pérez-López F.R.
      • Ceasu I.
      • et al.
      EMAS clinical guide: low-dose vaginal estrogens for postmenopausal vaginal atrophy.
      ] could be used along with vulvar corticosteroids.

      8. Recommendations

      • Women presenting with vulvar pruritus and pain should be examined by a health professional with expertise in vulvar skin disorders.
      • Diagnosis may need to be confirmed by biopsy, particularly in those cases that do not respond to corticosteroid treatment, to exclude VIN or vulvar cancer.
      • First line treatment is topical clobetasol propionate cream (0.05%) and calcineurin inhibitors (tacrolimus or pimecrolimus) are second line.
      • Surgical management such as vulvectomy or cryosurgery is reserved for women with malignancy or post-inflammatory sequelae.
      • While women should be encouraged to examine their vulva for any changes this may be difficult or impossible in the elderly with co-morbidities, hence careful inspection of the external and internal genitalia is recommended during every gynecologic consultation, particularly in postmenopausal women.

      Contributors

      FRPL prepared the initial draft which was circulated to all EMAS board members for comment and approval, production was coordinated by MR and FRPL.

      Competing interests

      None declared.

      Funding

      Nil.

      Provenance and peer review

      EMAS clinical guide.

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