Guideline sources The following summarized guidelines for the evaluation and management of vulvar lichen planus (VLP) are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2020) and the European Academy of Dermatology and Venereology (EADV 2017). 1 2 Guidelines 1. Diagnostic investigations Evaluation for oral involvement: obtain evaluation of the oral cavity because oral involvement is common in patients with erosive lichen planus. B Evaluation for comorbidities: evaluate for thyroid and other autoimmune diseases only in patients with clinical suspicion of abnormality, as those are rarely associated with VLP. B 2. Medical management Corticosteroids (topical): Offer ultrapotent topical corticosteroids such as clobetasol propionate in patients with VLP. B Insufficient evidence to recommend an optimal regimen for ultrapotent topical corticosteroids. I Corticosteroids, vaginal: As per ACOG 2020 guidelines: https://web.pathway.md/diseases/recPvT2unvZOZPiVd 1/2 6/29/23, 3:45 AM Vulvar lichen planus Pathway As per ACOG 2020 guidelines: Offer high-potency topical corticosteroid ointment as initial treatment of patients with lichen planus. B Consider offering intravaginal corticosteroids in addition to topical vulvar treatment in patients with erosive lichen planus with vaginal involvement. C As per EADV 2017 guidelines: Consider offering hydrocortisone containing rectal foam introduced into the vagina with an applicator in patients with VLP. C Consider offering prednisolone suppositories in patients with severe VLP. C Calcineurin inhibitors: consider offering topical calcineurin inhibitors in patients with lichen planus resistant to topical corticosteroids. C Management of co-occurring infections: Consider administering the following combinations of corticosteroids with antibiotics or antifungals for a short period of time for the treatment of secondary infections in patients with VLP: clobetasol with neomycin and nystatin or an alternative preparation betamethasone with fusidic acid or generic equivalent. C 3. Therapeutic procedures Vaginal dilators: advise using graded vaginal dilators in conjunction with topical intravaginal corticosteroids to prevent vaginal scarring, synechiae, and complete obliteration of the vaginal vault in patients with lichen planus. B 4. Follow-up and surveillance Follow-up: Obtain careful monitoring for all potentially toxic therapies (such as azathioprine, dapsone, griseofulvin, chloroquine, minocycline, cyclosporine, methotrexate, mycophenolate, retinoids, oral corticosteroids) preferably supervised by a dermatologist at a specialized clinic. B Assess active disease as clinically required. Ensure long-term specialized follow-up in patients with erosive VLP. B References 1. van der Meijden WI, Boffa MJ, Ter Harmsel WA et al. 2016 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol. 2017 Jun;31 6 925 941. Open 2. No authors listed. Diagnosis and Management of Vulvar Skin Disorders: ACOG Practice Bulletin, Number 224. Obstet Gynecol. 2020 Jul;136 1 222 225. Open https://web.pathway.md/diseases/recPvT2unvZOZPiVd 2/2