Experimental treatments show promise in managing a condition but have not been thoroughly evaluated for efficacy, safety, and acceptability. Think of it like a non-approved treatment option; it may or may not work. In the context of lichen sclerosus, when discussing experimental treatment options, I mean interventions, medications, or procedures that have not yet shown to be fully effective as a treatment but show promise in helping with symptom management. In our last post, I discussed platelet-rich plasma as an experimental treatment for lichen sclerosus. Today, we continue the experimental treatment series by looking at laser therapy for lichen sclerosus.
We often get questions about laser therapy for lichen sclerosus. For example, folks ask, “Someone on a forum mentioned they got laser therapy for lichen sclerosus; what is laser therapy anyway?” or “Is laser therapy an effective treatment for lichen sclerosus?”. Another question I hear is, “Why has my doctor never mentioned laser therapy as a treatment before?” In today's post, I will take a deep dive into laser therapy by addressing what it is, what the procedure involves, and what the science says.
Importantly, today's post is about ablative lasers and lichen sclerosus; we will post on non-ablative lasers and lichen sclerosus in a couple of weeks.
*This post is evidence-based; I draw on the medical literature to share what you need to know about laser therapy for lichen sclerosus. Importantly, what I share is my interpretation of the science and data.
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What is Laser Therapy for Lichen Sclerosus?
If you are in any support forums or spaces online, chances are you have heard someone mention they get laser therapy for lichen sclerosus before.
However, you may wonder, “What on earth is laser therapy for lichen sclerosus?”
There are many different types of lasers out there. Today, we are going to look at ablative lasers.
Ablative lasers use a beam of light energy that creates small holes in the top layer of the skin (aka the epidermis). Further, the beam of light energy also heats the underlying skin (aka the dermis). Together, the interruption of the top layer and heat to the middle layer of vulvar skin is supposed to stimulate collagen and elastin, which trigger the skin's natural healing process (Mitchell et al., 2021).
What Does the Procedure Involve?
Now, if you are sitting there thinking, “Destroy the top layer of skin and heat the underlying layers?! That sounds incredibly painful; I do not want that for my vulva,” you are not alone.
While it certainly sounds painful, most clinicians who offer this therapy will use a topical numbing cream to numb the vulva first. After you are numbed up, they will go over the surface of the vulva with their laser machine.
Most of the studies I've read claim the procedure is generally well-tolerated, with most patients reporting mild discomfort and ‘heating' sensations. Anecdotally, I have heard some folks say it was only a little uncomfortable, and others say it was painful for them. It's always important to remember that everyone's pain tolerance is different, so always take other people's experiences with a grain of salt; you may have a different reaction.
After the procedure, discomfort, and pain are typically well-managed with a combination of acetaminophen (Tylenol, Paracetamol) and Ibuprofen (Advil). Applying ice to the area may be another helpful option to calm inflammation and pain.
You may also want to go commando and wear loose clothing a couple of days after if you experience sensitivity/discomfort.
You should be able to work, however, everyone is different; listen to your body.
Most people are able to drive themselves or take public transit home after the procedure. However, if you are worried, it may not be a bad idea to arrange for a lift or schedule an Uber.
Cost and Frequency
Both cost and frequency are determined on a case-by-case basis. Cost depends on where you live, the clinic's pricing structure, and whether insurance can cover some of it. In Canada, where I live, an individual laser session can run you upward of 1000$.
How often you need treatments depends on the severity of your case and how you respond to treatment. I've heard from a few people that they needed 3-5 treatments upfront and one yearly treatment as maintenance.
What Does the Science Say about Laser Therapy for Lichen Sclerosus
CO2 Fractional Laser
CO2 fractional lasers are the more common mainstream lasers for lichen sclerosus. For example, the Mona Lisa laser is an ablative, CO2 fractional laser.
Unfortunately, there are not many quality studies on CO2 laser therapy for lichen sclerosus, but let's review a couple.
The Balchander et al. (2020) Study
A study by Balchander et al. (2020) included 40 people with vulvar lichen sclerosus who were unresponsive to topical steroids. Balchander et al. used a Co2 fractional laser to evaluate its impact on lichen sclerosus. The study showed overall symptom improvement, with 72.5% of the participants saying they found a significant improvement in their symptoms. Hypopigmentation (aka those areas of skin that appear lighter than the rest of the vulva) also decreased by approximately 20% post-laser treatment.
On the surface, these results are promising and look good. However, the quality of the study could have been more reliable. For example, the study was not a placebo/sham-controlled study. Placebo or sham-controlled studies involve two or more groups of people where one group gets the active treatment or procedure, and the other receives the inactive treatment. This is important because, with these measures, it's easier to determine if the results are from the laser itself or are a coincidence. The study was not blinded, which means patients and clinicians knew the treatment they were receiving/giving, which runs the risk of biasing the results. Therefore, based on this study, we cannot really conclude whether or not laser therapy is effective for lichen sclerosus.
The Mitchell et al. (2021) Study
A randomized, double-blinded, sham-controlled study by Mitchell et al. (2021) included 40 patients to evaluate whether the Mona Lisa laser effectively treated lichen sclerosus. 20 of the patients received a sham laser, and the other 20 received the Mona Lisa laser. Biopsies were taken before and after the laser treatments. A blinded expert dermatopathologist analyzed the biopsies and found no significant change from the before to the after biopsies (ibid, 5). This means the Mona Lisa laser did not reduce the inflammation caused by lichen sclerosus. The authors conclude that treating exclusively with the Mona Lisa laser is ineffective for lichen sclerosus.
An Important Caveat
Like PRP, patients did report some improvement in their symptoms with the laser treatments. Therefore, if you cannot control your symptoms, this could be an avenue for you to explore. I have spoken with a handful of folks who say their symptoms were significantly improved with the Mona Lisa laser. Controlling and improving symptoms differs from treating the condition, but both are crucial for improved quality of life. Therefore, laser therapy could be a helpful add-on/adjunct therapy in addition to steroids or calcineurin inhibitors.
CO2 Laser for Refractory Lichen Sclerosus
Interestingly, a Co2 fractional laser was also used in a small case study of 5 individuals whose vulvar lichen sclerosus was unresponsive to topical steroids (aka refractory lichen sclerosus). (Lee, Lim, and Fischer, 2015). Of the five participants, one had no symptoms at the time of treatment, and the other four reported itch and pain with sex. Of the four with symptoms, all reported a resolution of symptoms. All five participants responded well to the laser and could return to topical steroids to maintain remission (3).
The authors conclude that Co2 fractional laser may help with severe cases of lichen sclerosus that do not initially respond to steroids. The authors note that after laser treatments are complete, participants are to return to using steroids. It seems that the laser helps break down those hyper-thickened areas of skin, allowing for the steroids to get in there and do their job. This may be a good option for folks with thickened patches of skin or whose lichen sclerosus is unresponsive to steroids.
Ablative Yag Laser
So far, we have been looking at CO2 fractional lasers. However, there is another type of ablative laser – the Erbium Yag laser. The main difference is that the Erbium Yag laser is milder and tends to be used more to reduce acne scarring. The Erbium Yag laser does not penetrate the skin as deep as the CO2 lasers.
Let's see if the Erbium Yag laser (hereafter Yag laser) fares any better than its CO2 counterpart.
Case Study Report
Hobson et al. (2018) published a case study of two people with vulvar lichen sclerosus who were unresponsive to topical corticosteroids. They used the Yag laser on these patients to see if it would improve the clinical signs and symptoms of lichen sclerosus.
The first individual was a 58-year-old with vulvar lichen sclerosus. The person had been managing with intralesional triamcinolone injections and daily Clobetasol. However, they developed thickened patches of skin that did not resolve with treatment. The individual received one Yag laser treatment and recovered a few days later. The thickened patches resolved, and one-year post-treatment, the person had no symptoms and maintained remission with topical corticosteroids.
The second individual in the case report was a 73-year-old with vulvar lichen sclerosus. The person had been treated with Clobetasol two times a day and used topical lidocaine – a numbing cream for pain – to manage symptoms. This person presented with significant scarring over the clitoris and thickened areas of skin that would not resolve with treatment. They received 3 treatments with the Yag laser and recovered after a few days. The thickened skin improved, and at the one-year follow-up, their lichen sclerosus was well controlled with topical corticosteroids.
What's the takeaway on the Yag laser? Well, for one thing, this is a case report with only 2 individuals. Ideally, we would want a randomized control trial with a larger group of participants to understand if Yag laser is a good treatment option for LS.
Further, both patients in the case study used steroids throughout the 1-year duration of the case study, so it becomes next to impossible to know just how much of the improvement is due to the laser alone. We definitely need more research on this modality. Again, it may be a good option for cases of LS that do not resolve with or worsen with topical corticosteroids.
So, what's the verdict? Is Laser Therapy an Effective Treatment for Lichen Sclerosus?
Unfortunately, our current studies are limited and have yet to demonstrate a significant reduction in inflammation that many doctors look for when they counsel patients on primary treatments. For this reason, the majority of LS specialists do not recommend laser therapy as a monotherapy or primary treatment.
Nonetheless, it's important to note that some patients report an improvement in their symptoms after laser treatment. And let's be honest, LS symptoms are awful, and symptom management and reduction are fundamental to our quality of life.
Therefore, you may consider laser as an add-on/adjunct therapy that you use in conjunction with steroids or calcineurin inhibitors. I have, anecdotally, heard some folks tell me laser made a big difference in their symptoms and overall quality of life. Thus, there may be a place for laser for folks who cannot tolerate steroids to help manage symptoms or as an add-on/adjunct therapy.
In sum, the research shows laser therapy is ineffective as a primary treatment but may have its place as an add-on therapy in conjunction with steroids or calcineurin inhibitors. Always consider cost and lifestyle when deciding to pursue laser or not. At the end of the day, it is your individual decision on how you treat your LS. We at LSSN strive to share evidence-based information so you can make informed decisions about what is best for you and your body.
Let us know in the comment section if you have done laser and if you found it helpful.
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Balchander D, Nyirjesy P. Fractionated CO2 Laser as Therapy in Recalcitrant Lichen Sclerosus. J Low Genit Tract Dis. 2020 Apr;24(2):225-228. doi: 10.1097/LGT.0000000000000512. PMID: 32068618.
Hobson, Julia G et al. “Recalcitrant Vulvar Lichen Sclerosus Treated With Erbium YAG Laser.” JAMA dermatology vol. 155,2 (2019): 254-256. doi:10.1001/jamadermatol.2018.4461
Mitchell L, Goldstein AT, Heller D, Mautz T, Thorne C, Joyce Kong SY, Sophocles ME, Tolson H, Krapf JM. Fractionated Carbon Dioxide Laser for the Treatment of Vulvar Lichen Sclerosus: A Randomized Controlled Trial. Obstet Gynecol. 2021 Jun 1;137(6):979-987. doi: 10.1097/AOG.0000000000004409. PMID: 33957648; PMCID: PMC8132913.
Tasker, Kirby, Grindlay, Lewis, and Simpson. “Laser Therapy for Genital Lichen Sclerosus: A Systematic Review of the Current Evidence-Based”. Skin Health and Disease, 2021. DOI https://doi.org/10.1002/ski2.52