There is new help for advanced Lichen Sclerosis and other Vulvar Pain Disorders.
I have been a licensed physician and surgeon in California for over 40 years. In my practice, I have a special focus on vulvar dystrophies such as lichen sclerosis and vulvo-vaginal pain disorders such as provoked vestibulodynia (a.k.a. vulvar vestibulitis) and other disorders involving sexual pain. Over the years there have been few new developments in treatment options for women suffering with these vulvo-vaginal pain disorders. Options such as Clobetasol, estrogen, nor- or amitriptyline, topical or systemic gabapentin are all we have had.
However, the past couple of years have produced tremendous breakthroughs!
PRP (platelet-rich plasma) and fractional CO2 laser (“FemiLift”) for treatment of lichen sclerosis and vulvar pain (vulvodynia) in California and elsewhere
Both of these protocols have been experimented with for several years, in the United States and especially in Europe and South America. Through International meetings and personal contacts with physicians such as Charles Runels (Fairhope, Alabama), Andrew Goldstein (Washington D.C. and NYC), Michael Baggish (St Helena, CA), and Oscar Aguirre (Denver, CO) in the United States; Alexandros Bader (Greece and London); July Jaimes Surez (Spain); Jorge Elias and Alejandro Carbone (Argentina); and Jorge Gaviria (Venezuela and Spain), I have been watching the development and progress of these therapies being used to delay or reverse the progression of these insidious vulvo-vaginal destroyers. I now have enough information (both anecdotal from individuals who I trust and published evidence) to feel confident in offering these therapies in my office. As always, I choose the therapies I offer on the basic medical tenet, primum non nocere (First, do no harm.)
PRP and fractional CO2 laser are vastly different from one another, and both accomplish different tissue changes. Both, either singly or in combination, appear to accomplish what no previous therapies have: actual tissue rejuvenation.
The preparation and uses of platelet-rich plasma (PRP) are well-described in another blog on this site. PRP is prepared from the patient’s own blood plasma. It is injected under the skin in the affected areas of lichenoid or atrophic changes around the vulvar vestibule, perineum, anterior and posterior fourchette, and clitoral hood. PRP has a long track record as a source of growth factors and a facilitator of vasculo-neogenesis. It develops new blood vessels that nourish these atrophic areas. This therapy shows great promise. It is the subject of a well-designed research study by my friends Drs. Runels and Goldstein. This study will soon be published in a major medical journal. The ideal number of treatments necessary to produce substantive improvement is currently unknown. At present I am using two treatments about two months apart.
Fractional CO2 Laser
(FemiLift™ or Mona Lisa Touch™)
Laser therapy has been used for several years outside of the United States, most especially by Dr. Jorge Elias in Argentina (via FemiLift). Dr. Elias has written and presented specific protocols for the use (under effective topical anesthesia and boosted by injected local anesthetic if necessary) of laser therapy to lichenoid-effected skin and/or thin, atrophic, easily-tearing skin of the vulvar vestibule (the area just outside of the vaginal opening). These are new uses of pixillated fractional Co2 laser treatments, which for a few years have been evidence based for treatment of intra-vaginal atrophic changes. Applied in this way, laser energy is known to both increase and improve the production of collagen and elastin fibers in the dermis (the generative layer of the skin) leading to enhanced stretchability and pliability of vulvar vestibular epithelium (the skin of the opening areas of a woman’s vulva and vagina). Successful therapy of this kind has recently been described by Dr. Baggish (“Fractional CO2 Laser Treatment for Vaginal Atrophy and Lichen Sclerosis,” Journal of Gynecologic Surgery, Vol. 32, # 6, 2016)
Since it appears that both therapies offer promise when used singly, it raises a question as to the effectiveness of combining the two. For initial research purposes this is not a good idea, as in evidence-based research it is important to be pure. If there is benefit from combining therapies, one could not be certain as to whether the benefit accrues from one of the two therapies or the combination of the two.
If I were participating in research involving these novel therapies for lichen sclerosis and vulvodynia I would follow the specific research protocol. I suspect that — after it is clear whether or not each of these therapies has benefit singly — a protocol will be developed to compare one and/or the other to determine which holds more promise. This can then be compared to a combination of the two therapies. Since both appear to hold promise and no significant adverse effects have been reported from either as of yet (and in an effort to best benefit my patients), I have decided to utilize both therapies concurrently in a treatment protocol that combines the recommendations for each therapy used alone.
The Protocol Treatment for Lichen Sclerosis & Vulvar Pain Disorders
I begin with a PRP treatment to the entire affected area to activate growth factors and neovasculogenesis. About two weeks later, I then follow this treatment with three laser treatments spaced at monthly intervals and finish with a second PRP treatment about 2 weeks after the final laser session. This creates a bookending effect of the standard laser protocol with two PRP treatments. This timetable is not inviolate, and may be modestly shifted. Topical anesthesia with BLT (benzocaine 20%, lidocaine 8%, tetracaine 8%) is applied prior to each laser or PRP treatment, and areas to be treated or injected are subjected to brief icing immediately prior to therapy. Local anesthesia with a tiny (30 ga.) needle is injected only if needed in any individual super-sensitive areas. The PRP treatment takes about 15 minutes to draw and prepare the blood PRP, and about 5 minutes to inject. The laser treatment takes about 15 minutes (2 passes) to complete.
Patients have not reported pain after PRP treatments. After laser, the skin may be chilled with cold packs and soothed with Aquaphor gel. BLT cream may be applied if needed, with those requiring it using it for 2-3 days. Oral analgesia with Tylenol is usually all that’s needed, although some patients will take Tramadol or hydrocodone (Vicodin) occasionally over the first few days post-treatment.
Both PRP and fractional CO2 laser for lichen sclerosis and vulvar area pain have been utilized abroad for several years and for 2 to 3 years in the U.S., with excellent anecdotal evidence of success. The therapy is considered off label and is not used in the mainstream, but it is the first to truly offer hope that goes beyond itch control and provide regression to women suffering from these skin conditions. It is not covered by any insurance plan and tends to be pricey as a result of the time and costs of the technologies it uses, costing about $5000 to $8000 for the full treatment protocol. As with many newer therapies, discounts may be available from individual physicians.