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Original Research
Use of Er:YAG laser in the treatment of vulvar lichen sclerosus
Matilde Gómez-Frieiro, MD
*
, Elena Laynez-Herrero, MD
Gabinete Médico Ginecológico, Santa Cruz de Tenerife, Spain
article info
Article history:
Received 15 November 2018
Received in revised form 17 May 2019
Accepted 24 May 2019
Keywords:
erbium laser
vulvar lichen sclerosus
abstract
Objective: The aim of this research was to evaluate the efficacy and safety of Er:YAG lasers to improve
signs and symptoms of vulvar lichen sclerosus.
Methods: The study population consisted of 28 women with symptomatic vulvar lichen sclerosus. Three
nonablative, thermal-only Er:YAG laser treatment sessions (7 J/cm
2
, 2 Hz, 7 mm spot) were performed at
4-week intervals. Each patient was asked about the presence of symptoms, such as itching, pain, and coi-
tal pain. Clinical diagnosis was established on the basis of the presence of lesions such as hypopigmen-
tation, ecchymosis, hyperkeratosis, excoriations, or fissures. The affected areas were divided by zones
(clitoris, introitus, labia minora, labia majora, perineum, labial fusion, and effacement) and were visually
evaluated. Based on the presence of symptoms, lesions, and affected zones, a scale with a maximum of 14
scores was established for use before and after treatment. The impact of lichen sclerosus on patients’ lives
before and after treatment was evaluated with an 11-point visual analogue scale, and treatment discom-
fort was assessed at each session.
Results: After analysis of each scoring component, individual statistically significant reductions were
observed in itching, pain, ecchymosis, excoriations, and hypopigmentation.
Conclusion: The Er:YAG laser is a safe, well tolerated, and effective method for the adjuvant treatment of
vulvar lichen sclerosus. Three sessions with monthly intervals using the indicated parameters can quan-
tifiably reduce the impact of lichen sclerosus on patients’ lives.
Ó2019 Published by Elsevier Inc. on behalf of Women’s Dermatologic Society. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Vulvar lichen sclerosus is a chronic inflammatory dermatologic
disease of autoimmune origin that is characterized by a lympho-
cytic response with a predilection for the skin of the genital area.
It can affect both sexes and has an association with different
autoimmune diseases (Murphy, 2010). Although vulvar lichen scle-
rosus can manifest extra-genitally, in women, the disease appears
predominantly in the vulvar area. According to age distribution,
vulvar lichen sclerosus is more frequent around the sixth decade
of life. Symptoms and signs include itching, dryness, and irritation;
consequently, the genital/sexual sphere of patients is affected by
the appearance of dysuria and coital pain (Guerra, 2010). Histolog-
ically, the disease is characterized by epidermal atrophy, hyperker-
atosis, follicular plugging, degeneration of the basal layer, and a
band of subepidermal hyalinization of collagen in the papillary
dermis above a lymphocytic infiltrate (Pérez-López and Vieira-
Baptista, 2017).
The current first-line treatment of lichen sclerosus is symp-
tomatic, aimed at palliating symptoms and delaying the recurrence
of lesions (Neill et al., 2010). The effectiveness of topical clobetasol
in improving the symptoms of lichen sclerosus has been demon-
strated by chronic application with rest periods (Diakomanolis
et al., 2002). However, the long-term use of high-potency corticos-
teroids can lead to skin thinning (Renaud-Vilmer et al., 2004). This
has led to the search for alternative therapies, often aimed at being
complementary treatments to corticosteroids. Drugs such as cal-
cineurin inhibitors already have their place in the therapy of lichen
sclerosus. Other techniques, such as the use of the CO
2
lasers, are
justified by the repair effect of the lesion area after creating an
ablative effect on the skin by stimulating the affected tissue from
the adjacent edge in the subsequent healing (Baggish, 2016;
Fillmer et al., 2009; Kartamaa and Reitamo, 1997; Lee et al.,
2016). The application of platelet-rich plasma (Behnia-Willison
et al., 2016) and the transfer of autologous fat (Onesti et al.,
2016; Tonnard et al., 2013) are other alternatives to this treatment
within the regenerative therapy group.
The use of lasers in gynecology has been investigated for more
than 50 years, with the application of this technique to treat cervi-
cal and vaginal pathology and even pelvic pathology and fertility.
https://doi.org/10.1016/j.ijwd.2019.05.007
2352-6475/Ó2019 Published by Elsevier Inc. on behalf of Women’s Dermatologic Society.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
⇑
Corresponding Author.
E-mail address: matildegomez@gamegin.es (M. Gómez-Frieiro).
International Journal of Women’s Dermatology 5 (2019) 340–344
Contents lists available at ScienceDirect
International Journal of Women’s Dermatology
In recent years, the application of energy to the vaginal walls in a
controlled manner has been observed to stimulate neovasculariza-
tion, the proliferation of glycogen, and the formation of collagen in
the lamina propria, which leads to an increase in natural lubrica-
tion and basal tone and thereby improves urinary incontinence
and vaginal hypermobility by improving the biomechanical condi-
tions of the vaginal mucosa (Gambacciani and Cervigni, 2015;
2017; Gambacciani and Levancini, 2015; Gaspar and Brandi,
2017; Gaspar et al., 2017; Jung et al., 2015; Lee, 2014; Vizintin
et al., 2015). There are published reports about the benefits of non-
ablative Erbium lasers in the treatment of vaginal relaxation syn-
drome (Lee, 2014), mild-to-moderate stress urinary incontinence
(Gaspar and Brandi, 2017; Vizintin et al., 2015), and the genitouri-
nary syndrome of menopause (Gambacciani and Cervigni, 2015;
Gambacciani and Levancini, 2015, 2017; Gaspar et al., 2017). The
Er:YAG laser with specific nonablative modality, which causes
shrinkage of collagen fibers and consequently triggers neocollage-
nesis, might be another therapeutic option for lichen sclerosus,
where an alteration in the distribution of collagen is very impor-
tant (Drnovsek-Olup et al., 2004; Farkas et al., 2010; Lins et al.,
2010; Pereira et al., 2002; Poon et al., 2005; Schmitt et al., 2017).
The indicated nonablative application of the Er:YAG laser lasts
for 250 milliseconds and consists of a fast sequence of ultra-
short pulses of 300 microseconds with intervals of 50 milliseconds.
In this way, the temperature in the mucosa can be increased
between 60°and 65°C without inducing superficial ablation. At
this temperature, collagen is denatured, which creates short colla-
gen fibers that function as a stimulus of fibroblasts; neocollagene-
sis begins to occur and happens within a maximum of 6 weeks. The
activation of procollagen I and III, interleukin 1-beta, tumor necro-
sis factor alpha, tumor necrosis factor beta-1, and metallopro-
teinases has been shown to explain this effect in low-dose lasers
(Drnovsek-Olup et al., 2004; Farkas et al., 2010; Lins et al., 2010;
Pereira et al., 2002; Poon et al., 2005; Schmitt et al., 2017).
The aim of this study is to evaluate the effect of Er:YAG laser
application on the impact of lichen sclerosus on the lives of women
diagnosed with vulvar lichen sclerosus, assessing parameters such
as extension, symptoms, clinical signs, scale of impact on life, and
tolerance to treatment.
Methods
Patients
A total of 28 patients with a clinically confirmed diagnosis of
vulvar lichen sclerosus were recruited from a gynecology clinic in
Santa Cruz de Tenerife (Gabinete Médico Ginecológico), a private
practice with a database of 23,500 patients at present. Diagnoses
were not histologically confirmed. The study protocol was con-
ducted in accordance with the Declaration of Helsinki. Written
informed consent was obtained from all patients. The inclusion cri-
teria included women age >18 years who were diagnosed with vul-
var lichen sclerosus; did not have problems with writing, reading,
or verbal comprehension; and had provided written informed con-
sent. The exclusion criteria included women with contraindica-
tions for the use of laser on the skin, those who did not sign
informed consent, or had no clear diagnosis of vulvar pathology.
At the first visit, a clinical history was obtained and any other
pathology and contraindication ruled out. Each patient was asked
about the presence of symptoms such as itching, pain, and coital
pain, and all positive responses were assigned a score of one point.
The presence of clinical signs such as hypopigmentation, ecchymo-
sis, hyperkeratosis, excoriations, or fissures were observed and
given one point if present. The affected areas were divided by
zones (clitoris, introitus, labia minora, labia majora, and perineum),
and a point was assigned to each affected zone. A photograph was
taken before treatment, and the affected area was confirmed if
there was effacement or labial fusion. A summary of the symptoms
and clinical findings established a score that ranged from 0 (mini-
mal effect) to 14 points (maximum effect). A visual analogue scale
was used to assess the impact of lichen sclerosus on patients’ lives,
with 0 being no impact and 10 the maximum impact.
Laser treatment
First, the affected area was anesthetized with Emla anesthetic
cream (lidocaine 25 mg/g + prilocaine 25 mg/g). In the first session,
the Er:YAG laser (SP Dynamis, Fotona, Slovenia) was applied with a
PS03 handpiece with fluence of 7 J/cm
2
, 2 Hz, and spot of 7 mm in
continuous application, making several passes that exceed the lim-
its of the affected area. A special Er:YAG treatment modality
(Fotona SMOOTH mode) that causes gentle coagulative heating of
the skin was used. The modality delivers laser energy onto the skin
in a fast sequence of low-fluence laser pulses inside an overall
super-long pulse of 200 ms to 350 ms. Every so often when the
area whitened, it was cleaned with gauze soaked in physiologic
fluid. The objective was to achieve uniform whitening and an
increase in local heat until erythema of the area or whitening
was observed after 10 minutes of application. Three sessions were
applied in monthly intervals. After each session, the patient was
instructed to use Palomacare vulvar gel, an external moisturizer
with hyaluronic acid, Asiatic spark, bioecolia (alpha aminoglucan),
and aloe vera, for 3 days after treatment to calm possible discom-
fort in the area.
After the procedure, patient tolerance to the treatment was
assessed via a questionnaire with four options (i.e., very tolerable,
tolerable, slightly tolerable, and unacceptable). One month after
the last session, the patient was summoned for a final survey
and documentary verification by means of a photograph of the
treated area, which was added to the database.
Statistical evaluation
All data were collected through the public domain program EPI
INFO, which was designed by the Centers for Disease Control and
Prevention of Atlanta and allows building databases and analyzing
them for epidemiological studies. Means and standard deviations
were calculated to describe the quantitative variables, and medi-
ans were measured to describe the variables deemed not normal
according to the Kolmogorov-Smirnov test. For the comparison of
scales, the nonparametric Wilcoxon test was performed, and the
McNemar’s test was used to compare each parameter of the total
score before and after treatment. A p-value of < .05 was considered
significant. The analyses were done with SPPS version 24.
Results
The average age of patients was 58.4 years (range: 29-78 years).
Twenty-six of 28 patients had previously been pregnant, and 23
patients were menopausal. Twenty-two of 28 patients maintained
regular sexual activity, and 6 patients did not have sexual relations
due to the discomfort of their pathology. With regard to previous
treatments with corticosteroids, 23 of 28 patients reported having
had treatment on occasion, and 5 patients had never received
treatment. Patients who had received corticosteroids suspended
treatment a month before initiating Erbium laser treatment and
did not resume treatment until 1 month after the last Erbium laser
treatment,when the final assessment was made. Patients who had
never received corticosteroid treatment were either never treated
M. Gómez-Frieiro, E. Laynez-Herrero / International Journal of Women’s Dermatology 5 (2019) 340–344 341
until they reached the office and had not been diagnosed or did not
want to take corticosteroid agents.
The total score assigned to each patient before treatment ran-
ged from a minimum of 5 to a maximum of 14 (Fig. 1). The mean
value was 9.3 with a standard deviation of 2.51. One month after
the end of the three scheduled sessions, the score ranged from a
minimum of 0 to a maximum of 10, with a mean value of 4.36
(standard deviation: 2.34; Fig. 1). The most frequent symptom
before treatment was itching (82.1% of patients), pain
(60.7%), and coital pain (50.0%). After-treatment itching was pre-
sent in 14.3%, pain in 3.6%, and coital pain in 25.0% of patients
(Fig. 2).
The mean visual analogue scale score of the impact of lichen
sclerosus on patients’ lives and the mean values of the total score
decreased significantly after treatment (Table 1). Tolerance to
treatment varied between very tolerable (57.14%), tolerable
(35.71%), slightly tolerable (7.14%), or unacceptable (0%).
Statistically significant differences from before to after treat-
ment were observed with symptoms such as itching and vulvar
pain, but not coital pain, although a relationship between coital
pain and a higher final score was found (Table 2). The following
clinical signs showed statistically significant improvement after
treatment: ecchymosis, excoriations, and hypopigmentation.
Although some improvement in labial fusion and hyperkeratosis
was detected, the improvement was not statistically significant.
No improvement was seen in effacement (Figs. 3 and 4).
Discussion
To our knowledge, no report of Erbium laser treatment for vul-
var lichen sclerosus has been published to date, except for a case
report that describes the application of fractional laser on extra-
genital lichen sclerosus (Mendieta-Eckert et al., 2017) and a letter
on two cases with hyperkeratotic lichen sclerosus treated with
fractionally ablative Erbium laser (Hobson et al., 2019). In the case
of extragenital lichen sclerosus, the patient showed no symptoms
and clinical response even after 2 years of follow up.
The results of this study showed that Er:YAG laser treatment
significantly reduces symptoms of lichen sclerosus such as itching
and vulvar pain, but not coital pain. Improvement after treatment
was significant in clinical signs (ecchymosis, excoriations, and
hypopigmentation), and some improvement was detected in labial
fusion and hyperkeratosis. No improvement was observed in
effacement. Laser treatment was well tolerated by patients and sig-
nificantly reduced the impact of lichen sclerosus on patients’ lives.
Some limitations of the study include the lack of a control
group, the possibility of a placebo effect, and the subjective assess-
ment of symptoms (e.g., itching, pain, and coital pain) because
Fig. 2. Symptoms frequency before and after treatment.
Table 1
Comparison of impact of lichen sclerosus on patients’ lives and total score before and
after treatment
Mean (Standard deviation) Median p-value
Impact before treatment 5.36 (2.25) 5.5 < .0001
Impact after treatment 1.57 (1.4) 2
Total score before treatment 9.32 (2.51) 10 < .0001
Total score after treatment 4.36 (2.34) 4
The impact of lichen sclerosus on patients’ life before and after treatment was
assessed with a 0 to 10 visual analogue scale. The minimum value before treatment
was 2 and the maximum was 10. After treatment the minimum was 0 and the
maximum was 6. Contrast by Wilcoxon test.
Table 2
Comparison by component of total score before and after Er:YAG treatment
Before After p-value
Itching No 5 24 < .0001
Yes 23 4
Vulvar pain No 11 27 < .0001
Yes 17 1
Coital pain No 12 21 .146
Yes 13 7
Hypopigmentation No 2 12 .006
Yes 26 16
Ecchymosis No 8 23 < .0001
Yes 20 5
Hyperkeratosis No 21 23 .625
Yes 7 5
Excoriations No 11 24 .001
Yes 17 4
Introitus No 1 10 .004
Yes 27 18
Labia minora No 3 11 .008
Yes 25 17
Clitoris No 5 11 .002
Yes 23 17
Labia majora No 11 22 .001
Yes 17 6
Perineum No 2 16 .001
Yes 24 12
Labial fusion No 20 23 .375
Yes 8 5
Effacement No 17 17 .999
Yes 11 11
There are significant differences [p< .05] for all parameters with the exception of
coital pain, hyperkeratosis, presence of labial fusion, and effacement. Contrast with
McNemar’s test.
Fig. 1. Total score for the presence of symptoms, clinical signs, and affected areas
before treatment and 1 month after the last treatment session.
342 M. Gómez-Frieiro, E. Laynez-Herrero / International Journal of Women’s Dermatology 5 (2019) 340–344
these depend on assessment by the patient and the other 11
parameters depend on assessment by the attending physician.
Also, the initially striking results of a reduction in impact of lichen
sclerosus on patients’ lives can be attributed to patient bias
because this was not a double-blinded study and may have
involved a desire to collaborate with the doctor. Additionally, his-
tology could also benefit the confirmation of a clinical diagnosis,
but its inclusion in an adult lichen sclerosus severity scale is ques-
tionable (Sheinis and Selk, 2017). Analyzing biopsy test result
changes to treatment may be objective, but whether this outcome
is important to patients is unclear and likely should be used as an
adjunct to other measures (Sheinis and Selk, 2017).
In addition, some patients may have associated genitourinary
syndrome of menopause along with lichen sclerosus, but that
was not a factor of exclusion in this study. Per our protocol, we
did not treat the vagina but only the vulvar area, and the treatment
Fig. 3. Reduction of white lesions on the sides of the introitus before (left) and after (right) treatment.
Fig. 4. Improvement in skin quality before (left) and after (right) treatment.
M. Gómez-Frieiro, E. Laynez-Herrero / International Journal of Women’s Dermatology 5 (2019) 340–344 343
of genitourinary syndrome of menopause was not expected. For
patients who responded to both pathologies, any improvement
amounted to an additional benefit of treatment. Future work
should consider what energy dose is the most effective; in our
study we started from a choice based on tolerability by the patient
and response to these fluences in other benign cutaneous patholo-
gies, such as atrophy, scars, or stretch marks. The number of ses-
sions applied and the intervals required to obtain the best results
should also be considered. Further controlled clinical studies with
larger sample sizes and longer follow-up are necessary to confirm
the preliminary results of the effectiveness of Er:YAG laser treat-
ment of this pilot study and provide standardization of parameters.
Conclusion
The Er:YAG laser is a good method for treatment of vulvar
lichen sclerosus supplementary to topical steroids. Three sessions
with monthly intervals with the indicated parameters provided a
quantified reduction in the impact of lichen sclerosus on patients’
lives. Most patients in this study had previously used topical corti-
costeroids, and treatment with the Er:YAG laser additionally
reduced symptoms and clinical signs. Unifying criteria and descrip-
tion of the treatment guidelines for the specific lasers applied are
important to obtain consistent results and improve the quality of
future studies.
The Er:YAG laser opens a very interesting field in the regenera-
tive treatment of chronic pathologies, and we encourage doctors
who have this technology to use it as a complementary and safe
alternative that has proven effective in reducing the impact of
lichen sclerosus on a woman’s life.
Acknowledgments
The authors thank Professor Stephany Hess from the Depart-
ment of Clinical Psychology, Psychobiology, and Methodology of
the Faculty of Health Sciences of the University of La Laguna;
Mrs. Yolanda Ramallo Fariña, Biostatistics of the Evaluation Service
of the Canary Islands Health Service and advisor of the Official
College of Physicians of Tenerife; and colleagues from the Expert
Course in Functional Aesthetic Gynecology and Intimate Surgery
of Women at the University of Barcelona, Spain.
Conflict of Interest
None.
Funding
None.
Study Approval
NA.
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