Characterising Prognosis in Women with Chronic Vulvovaginal Lichen Planus to Identify Treatments that Achieve Best Possible Improvements in Quality of Life

Abstract

Vulvovaginal lichen planus (VLP) is an idiopathic inflammatory disease of the anogenital skin

affecting mostly post-menopausal women.Treatments aimed at attenuating recurrent genital

erosions that cause debilitating pain, pruritus and dyspareunia with topical corticosteroids (TCS) are unsuccessful in 40% of cases and require systemic immunosuppression.Worse quality of life (QoL) and increased rates of anxiety, depression and sexual dysfunction are seen in VLP

compared to vulval lichen sclerosus.There is a paucity of data on predictors for women with VLP requiring systemic treatment and QoL utilising a vulval specific QoL tool.This thesis aims to fill these gaps, as identifying predictors of systemic treatment and QoL between different treatments can allow accurate prognostication.Predictors of systemic treatment for VLP were investigated first. A multivariable binary logistic

regression model used non-Caucasian ethnicity, younger age at diagnosis, and vulval pruritus as

significant predictors of systemic treatment with a specificity of 95%, highlighting characteristics that may require prompt consideration for systemics. The second study assessed QoL in women treated with TCS against systemics using the Vulvar Quality of Life Index (VQLI), showing women treated with tildrakizumab (n=24) and systemic agents (n=11) had worse QoL due to higher VQLI scores at baseline and during the follow-up period compared to TCS (n=77). Women treated with tildrakizumab had significant reductions in total and domain VQLI scores compared to other systemics. These results show worse QoL in 12 women requiring systemic treatment, and identify tildrakizumab as an alternative where conventional systemics failed to improve VQLI scores. The final study is a case series of 24 women with recalcitrant VLP that achieved successful remission with tildrakizumab, where 45.8% maintained remission whilst successfully weaning off other systemics, highlighting tildrakizumab as an option to improve QoL.