Recalcitrant Symptomatic Vulvar Lichen Planus: Response to Topical Tacrolimus | Dermatology | JAMA Dermatology | JAMA Network
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June 2004

Recalcitrant Symptomatic Vulvar Lichen Planus: Response to Topical Tacrolimus

Author Affiliations

From the Department of Dermatology, Mayo Clinic, Rochester, Minn. The authors have no relevant financial interest in this article.

Arch Dermatol. 2004;140(6):715-720. doi:10.1001/archderm.140.6.715

Background  Topical tacrolimus has been reported to be an effective treatment for genital lichen planus in small case series. We retrospectively reviewed the medical records of 16 patients with symptomatic vulvar lichen planus who received treatment with tacrolimus ointment.

Observations  All patients had symptomatic vulvar lichen planus recalcitrant to other treatments. Of 16 patients, 15 (94%) experienced a symptomatic response to tacrolimus treatment within 3 months (mean, 4.2 weeks) and had a partial or complete resolution of the lesions. Six patients (38%) reported mild adverse effects, including irritation, burning, and tingling. With continued use of the medication, these adverse effects resolved. When patients stopped treatment, lichen planus returned in 10 (83%) of 12 patients within 6 months after discontinuation of therapy (median, 1 week; range, 0.3-24 weeks), but in 6 patients the lesions were less severe than the lesions before treatment; all 10 patients resumed use of topical tacrolimus.

Conclusions  In this retrospective series of 16 women with vulvar lichen planus, topical tacrolimus therapy effectively controlled symptoms and improved lesions in all but 1 patient. The effect may be temporary, requiring continued use of tacrolimus, which appears to be safe and effective in controlling disease activity.

Oral lichen planus is a relatively common condition affecting approximately 1% of the population.1-4 Lichen planus is more common in women, and in 1 study it involved the genitalia in 25% of the women with oral lichen planus.5

Genital lichen planus causes considerable discomfort, which may be debilitating. Typically, patients present in their fifth or sixth decade with pruritus, burning, pain, and dyspareunia. Physical examination findings range from erythema to erosions and frank ulcerations; in severe disease, vaginal adhesions and scarring develop, prohibiting sexual intercourse.6-9

Besides the mouth and genitalia, other mucosal sites that may be involved with lichen planus include the esophagus, conjunctiva, and ear canals. Lichen planus in these sites may lead to scarring, resulting in disability and morbidity.10 Scarring usually does not occur with oral lichen planus.

Histopathologic examination reveals a lichenoid infiltrate, basal layer vacuolation, and scattered Civatte bodies. As expected, at mucosal sites many plasma cells may also be present. Direct immunofluorescence studies consistent with lichen planus and other lichenoid reactions reveal shaggy fibrinogen deposition at the dermal-epidermal junction, with cytoid bodies staining with 1 or more of the following conjugates: IgG, IgM, IgA, or C3.11,12

Therapeutic management is challenging. Genital lichen planus may be more severe and recalcitrant to treatment compared with oral lichen planus.9,10 Variable benefit occurs with use of topical agents, such as corticosteroids, antifungal agents, retinoids, estrogens, and cyclosporine,13-20 as well as systemic agents, such as corticosteroids, retinoids, antifungal agents, hydroxychloroquine, and dapsone.10,21-28 Frequently, systemic treatments have unproven benefit, expose the patient to adverse effects, and are expensive.

Topical tacrolimus is an effective and safe therapy for oral lichen planus.29-34 This therapy has been used for other mucosal forms of lichen planus, and there are reports of its efficacy for genital lichen planus.29,35 We prescribed topical tacrolimus for 16 consecutive patients with symptomatic vulvar lichen planus; we report their responses to treatment in this study.


We retrospectively reviewed the medical records of 16 consecutive female patients with symptomatic vulvar lichen planus who were treated with topical tacrolimus. All patients were evaluated and treated in the Department of Dermatology at Mayo Clinic in Rochester, Minn, by the same clinician (R.S.R.) between April 2000 and November 2002.

Patients fulfilled the following criteria: (1) vulvar lichen planus was diagnosed on the basis of history, physical examination, and, if available, histopathologic features of lichenoid mucositis with or without supportive direct immunofluorescence studies and (2) patients received treatment with topical tacrolimus for vulvar lichen planus.

Topical tacrolimus 0.1% ointment (Protopic; Fujisawa Healthcare, Inc, Deerfield, Ill) was prescribed for all patients. They were instructed to apply the ointment to affected areas twice daily. Before this product was available, 8 patients initially used topical tacrolimus prepared by the Mayo Clinic pharmacy: tacrolimus capsules (Prograf; Fujisawa) were compounded in a bland ointment base (Aquaphor; Beiersdorf, South Norwalk, Conn) in 2 concentrations, 0.1% (3 patients) and 0.03% (5 patients), until the commercial form became available. Neither the physician nor the patient perceived a difference between the Protopic ointment and the compounded product.

Follow-up data were obtained by means of a patient telephone questionnaire. The use of this questionnaire was approved by the Mayo Foundation Institutional Review Board. The topics of the questions included symptoms and lesions, use of the ointment, and patient satisfaction (Figure 1).

Patient telephone questionnaire for follow-up of patients who were using tacrolimus ointment (Protopic; Fujisawa Healthcare, Inc, Deerfield, Ill).

Patient telephone questionnaire for follow-up of patients who were using tacrolimus ointment (Protopic; Fujisawa Healthcare, Inc, Deerfield, Ill).

Response to treatment was evaluated according to change in symptoms and clearance of lesions. Symptoms were graded on the following scale: much better, somewhat better, about the same, somewhat worse, or much worse. Patients who responded that their symptoms were much better or somewhat better were considered to have had a symptomatic response.

Patients were asked whether the lesions were completely gone, almost gone, the same, or increased after treatment. Lesions were considered completely resolved if the patient believed that the lesions were completely gone; lesions were considered partially resolved if the patient believed that the lesions were almost gone. In addition to the patient questionnaire, a retrospective review of the patients' medical charts was performed to obtain clinical examination findings after the use of topical tacrolimus.

If use of the medication was discontinued, the patient was asked whether the disease relapsed, when the relapse occurred, and how the severity of the relapse compared with the episode before treatment (worse than before, the same as before, or much better than before). Patient satisfaction with the use of tacrolimus was determined (very satisfied, somewhat satisfied, neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied).


Demographic and clinical data from the patients studied are summarized in Table 1. All 16 patients were white women. Age ranged from 47 to 75 years (mean, 63 years). All patients had painful, erosive lesions of vulvar lichen planus. Reported symptoms included pain in 16 patients, soreness in 4, burning in 3, and bleeding in 1. The diagnosis of lichen planus was confirmed with biopsy results in 12 (75%) of the 16 patients. Of these 12 patients, 5 had direct immunofluorescence findings that showed changes consistent with lichen planus. One patient had nondiagnostic findings on direct immunofluorescence testing. Clinical diagnosis in others was made on the basis of the presence of concomitant oral, cutaneous, otic, or esophageal lichen planus.

Table 1. 
Data for Patients Using Topical Tacrolimus for Vulvar Lichen Planus
Data for Patients Using Topical Tacrolimus for Vulvar Lichen Planus

The introitus was involved in 14 patients, and the vulva in 6. Labial involvement was present in 6 patients; in 2 of these patients the inflammation and destruction from lichen planus had obliterated the labia minora and majora. Lichen planus involved extragenital sites in most of these patients (Table 1): oral mucosa in 14 patients, skin in 5, ear in 3, esophagus in 2, and the perianal region in 2.

The mean duration of disease before initiation of therapy with topical tacrolimus was 4.3 years (range, 1-12 years). All patients had recalcitrant disease, and all patients had tried at least 1 form of treatment before receiving tacrolimus therapy. Prior treatments included use of topical corticosteroids (13 patients), antifungal medications (7 patients), topical estrogen (5 patients), systemic corticosteroids (5 patients), and hydroxychloroquine (4 patients). Two patients continued to receive systemic therapy during topical tacrolimus therapy: 1 received oral corticosteroids and the other received hydroxychloroquine. Both patients were able to decrease the dose of systemic medication when topical tacrolimus therapy was initiated.

A summary of the responses of the patients to initiation of therapy with topical tacrolimus is presented in Table 2. Of the 16 patients, 15 (94%) experienced a symptomatic response to treatment within 3 months (mean, 4.2 weeks; range, 0.3-12 weeks). These 15 patients also noted partial or complete resolution of the vulvar lesions. One had no symptomatic improvement. Patients were followed up for at least 2 months (mean, 15.7 months; range, 2-28 months).

Table 2. 
Response to Topical Tacrolimus Therapy*
Response to Topical Tacrolimus Therapy*

Clinical examination findings are available in Table 2. Of the 16 patients, 13 returned for follow-up appointments. Of these 13, 10 had no clinical evidence of erosions and 3 had smaller erosions that were healing. Follow-up examination occurred in an average of 3 months (range, 1-12 months) after initiation of topical tacrolimus therapy.

Twelve patients stopped applying topical tacrolimus for various reasons (Table 3): 7 stopped because the lichen planus resolved, 3 forgot to apply it, 1 stopped because of adverse effects (burning and irritation), and 1 believed that the medicine was not helping. In 10 patients the lesions recurred within 6 months after discontinuation of therapy with topical tacrolimus (median, 1 week; range, 0.3-24 weeks). The recurrent lesions, compared with lesions before therapy, were less severe or of the same severity in 9 patients. One patient believed that her lesions recurred in a more severe form, and 1 patient believed that her lesions were unchanged during topical tacrolimus therapy (therefore, stopping the therapy did not result in any change in her lesions). Remission of lichen planus occurred in 1 patient (duration of follow-up, 25 months).

Table 3. 
Recurrence of Lichen Planus in Patients Who Discontinued Use of Topical Tacrolimus*
Recurrence of Lichen Planus in Patients Who Discontinued Use of Topical Tacrolimus*

Minor adverse effects occurred in 6 patients, including irritation, burning, and tingling. One patient discontinued using topical tacrolimus because of adverse effects, but when the lesions recurred, she reapplied it and had no adverse effects. The patients who experienced adverse effects stated that they resolved with continued use of tacrolimus.

At present, 14 patients continue to use topical tacrolimus: 2 apply it twice daily, 7 apply it once daily, 1 applies it 3 times weekly, and 4 apply it weekly. Fifteen patients reported satisfaction with the treatment.


Topical tacrolimus ointment was remarkably effective in controlling the symptoms of recalcitrant vulvar lichen planus in all but 1 of the patients studied. Of the 16 female patients, 15 (94%) reported that their symptoms and lesions had improved. However, in most patients the benefit was not sustained. Soon after the patients stopped the treatment, the lesions and symptoms returned; in most patients, however, the lesions were less severe than the lesions before treatment, and the lesions responded when topical therapy was resumed. The tacrolimus was well tolerated; symptoms of burning resolved with continued use of the ointment.

Our results are consistent with results from previous reports of recalcitrant genital lichen planus that responded to topical tacrolimus (Table 4). However, we report a larger number of patients than that previously reported, and we describe a relatively long duration of follow-up (mean, 15.7 months).

Table 4. 
Previously Reported Cases of Genital Lichen Planus Responding to Therapy With Topical Tacrolimus*
Previously Reported Cases of Genital Lichen Planus Responding to Therapy With Topical Tacrolimus*

We believe that our results are valid: the diagnosis of lichen planus was made in a consistent manner (diagnosed by 1 physician; confirmed in more than two thirds of the cases with oral, vulvar, or esophageal biopsy); the treatment was consistently prescribed and advised; and follow-up data were obtained by 1 physician in a consistent, standardized manner. All but 2 of the patients with vulvar lichen planus had lichen planus at multiple sites. These patients had oral, cutaneous, otic, esophageal, perianal, or perineal lichen planus in addition to genital involvement. Many of the patients had the vulvovaginal-gingival variant of erosive lichen planus, which has been reported to be more recalcitrant to treatment. All patients had not had a response with other treatments.

We recognize that a retrospective review of clinical material is not optimal; however, we benefited from the consistency of 1 expert physician making the diagnosis. Follow-up data were obtained by means of a telephone survey, which has its own shortcomings because the patients are subject to recall bias and memory lapses. However, we tried to avoid creating bias in our telephone survey. The survey was the only practical means of following up our patients because many of them lived too far from our institution to conveniently return for follow-up. Yet the patients who returned for follow-up had improvement on clinical examination that was consistent with the questionnaire responses.

Genital lichen planus is well recognized as a debilitating condition for many patients. Symptoms of genital pruritus, burning, pain, and dyspareunia may have detrimental psychological effects. Erosions and ulcerations due to lichen planus may lead to scarring and adhesions that prohibit sexual intercourse.

Treatment options are limited by the lack of consistently effective and safe drugs. Surgical procedures to reconstruct the stenotic, fibrosed vaginal vault have been performed; however, scarring frequently recurs after the procedure.10 Tacrolimus is a macrolide immune modulator produced by Streptomyces tsukubaensis, which has been reported to be effective in treating oral lichen planus.29-34 Tacrolimus has also been reported to be effective for treatment of erosive vulvovaginal lichen planus.29,35 Although the exact mechanism of action in treating lichen planus is unknown, topical tacrolimus has been shown to inhibit T-lymphocyte activation by inhibiting the phosphatase activity of calcineurin. Without calcineurin to dephosphorylate the nuclear factor of activated T cells, gene transcription for lymphokines, interleukin 2, and γ-interferon is inhibited, leading to a decrease in numbers of these lymphocytes.36,37

In this retrospective review of 16 consecutive female patients with vulvar lichen planus, therapy with topical tacrolimus was safe and effective in controlling the symptoms and improving lesions in most (94%) of the patients. Topical tacrolimus is a promising new treatment option for this often recalcitrant and problematic disease.

Corresponding author and reprints: Mark D. P. Davis, MD, Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

Accepted for publication January 20, 2004.

Boyd  ASNeldner  KH Lichen planus  J Am Acad Dermatol. 1991;25593- 619PubMedGoogle ScholarCrossref
Bouquot  JEGorlin  RJ Leukoplakia, lichen planus, and other oral keratoses in 23,616 white Americans over the age of 35 years  Oral Surg Oral Med Oral Pathol. 1986;61373- 381PubMedGoogle ScholarCrossref
Axell  TRundquist  L Oral lichen planus: a demographic study  Community Dent Oral Epidemiol. 1987;1552- 56PubMedGoogle ScholarCrossref
Eisen  D The clinical features, malignant potential, and systemic associations of oral lichen planus: a study of 723 patients  J Am Acad Dermatol. 2002;46207- 214PubMedGoogle ScholarCrossref
Eisen  D The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88431- 436PubMedGoogle ScholarCrossref
Pelisse  MLeibowitch  MSedel  DHewitt  J A new vulvovaginogingival syndrome: plurimucous erosive lichen planus  Ann Dermatol Venereol. 1982;109797- 798PubMedGoogle Scholar
Pelisse  M The vulvo-vaginal-gingival syndrome: a new form of erosive lichen planus  Int J Dermatol. 1989;28381- 384PubMedGoogle ScholarCrossref
Eisen  D The vulvovaginal-gingival syndrome of lichen planus: the clinical characteristics of 22 patients  Arch Dermatol. 1994;1301379- 1382PubMedGoogle ScholarCrossref
Rogers III  RS Erosive orogenital lichen planus in women (vulvovaginal-gingival syndrome) [abstract]  J Oral Pathol Med. 1998;27362Google Scholar
Rogers III  RSEisen  D Erosive oral lichen planus with genital lesions: the vulvovaginal-gingival syndrome and the peno-gingival syndrome  Dermatol Clin. 2003;2191- 98PubMedGoogle ScholarCrossref
Weedon  DWeedon  Ded The lichenoid reaction pattern  Skin Pathology. Edinburgh, Scotland Churchill Livingstone Inc1997;31- 37Google Scholar
Helander  SDRogers III  RS The sensitivity and specificity of direct immunofluorescence testing in disorders of mucous membranes  J Am Acad Dermatol. 1994;3065- 75PubMedGoogle ScholarCrossref
Voute  ABSchulten  EALangendijk  PNKostense  PJvan der Waal  I Fluocinonide in an adhesive base for treatment of oral lichen planus: a double-blind, placebo-controlled clinical study  Oral Surg Oral Med Oral Pathol. 1993;75181- 185PubMedGoogle ScholarCrossref
Boisnic  SBranchet  MCPascal  FBen Slama  LRostin  MSzpirglas  H Topical tretinoin in the treatment of lichen planus and leukoplakia of the mouth mucosa: a clinical evaluation  Ann Dermatol Venereol. 1994;121459- 463PubMedGoogle Scholar
Sieg  PVon Domarus  HVon Zitzewitz  VIven  HFarber  L Topical cyclosporin in oral lichen planus: a controlled, randomized, prospective trial  Br J Dermatol. 1995;132790- 794PubMedGoogle ScholarCrossref
Frances  CBoisnic  SEtienne  SSzpirglas  H Effect of the local application of ciclosporine A on chronic erosive lichen planus of the oral cavity [letter]  Dermatologica. 1988;177194- 195PubMedGoogle ScholarCrossref
Eisen  DEllis  CNDuell  EAGriffiths  CEVoorhees  JJ Effect of topical cyclosporine rinse on oral lichen planus: a double-blind analysis  N Engl J Med. 1990;323290- 294PubMedGoogle ScholarCrossref
Becherel  PAChosidow  OBoisnic  S  et al.  Topical cyclosporine in the treatment of oral and vulvar erosive lichen planus: a blood level monitoring study  Arch Dermatol. 1995;131495- 496PubMedGoogle ScholarCrossref
Borrego  LRuiz-Rodriguez  ROrtiz de Frutos  JVanaclocha Sebastian  FIglesias Diez  L Vulvar lichen planus treated with topical cyclosporine  Arch Dermatol. 1993;129794PubMedGoogle ScholarCrossref
Eisen  DGriffiths  CEEllis  CNNickoloff  BJVoorhees  JJ Cyclosporin wash for oral lichen planus  Lancet. 1990;335535- 536PubMedGoogle ScholarCrossref
Hersle  KMobacken  HSloberg  KThilander  H Severe oral lichen planus: treatment with an aromatic retinoid (etretinate)  Br J Dermatol. 1982;10677- 80PubMedGoogle ScholarCrossref
Sehgal  VNAbraham  GJMalik  GB Griseofulvin therapy in lichen planus: a double-blind controlled trial  Br J Dermatol. 1972;87383- 385PubMedGoogle ScholarCrossref
Massa  MCRogers III  RS Griseofulvin therapy of lichen planus  Acta Derm Venereol. 1981;61547- 550PubMedGoogle Scholar
Eisen  D Hydroxychloroquine sulfate (Plaquenil) improves oral lichen planus: an open trial  J Am Acad Dermatol. 1993;28609- 612PubMedGoogle ScholarCrossref
Kumar  BKaur  IBhattacharya  M Dapsone in lichen planus [letter]  Acta Derm Venereol. 1994;74334PubMedGoogle Scholar
Setterfield  JFBlack  MMChallacombe  SJ The management of oral lichen planus  Clin Exp Dermatol. 2000;25176- 182PubMedGoogle ScholarCrossref
Cribier  BFrances  CChosidow  O Treatment of lichen planus: an evidence-based medicine analysis of efficacy  Arch Dermatol. 1998;1341521- 1530PubMedGoogle Scholar
Edwards  PCKelsch  R Oral lichen planus: clinical presentation and management  J Can Dent Assoc. 2002;68494- 499PubMedGoogle Scholar
Vente  CReich  KRupprecht  RNeumann  C Erosive mucosal lichen planus: response to topical treatment with tacrolimus  Br J Dermatol. 1999;140338- 342PubMedGoogle ScholarCrossref
Lener  EVBrieva  JSchachter  MWest  LEWest  DPel-Azhary  RA Successful treatment of erosive lichen planus with topical tacrolimus  Arch Dermatol. 2001;137419- 422PubMedGoogle Scholar
Rozycki  TWRogers III  RSPittelkow  MR  et al.  Topical tacrolimus in the treatment of symptomatic oral lichen planus: a series of 13 patients  J Am Acad Dermatol. 2002;4627- 34PubMedGoogle ScholarCrossref
Kaliakatsou  FHodgson  TALewsey  JDHegarty  AMMurphy  AGPorter  SR Management of recalcitrant ulcerative oral lichen planus with topical tacrolimus  J Am Acad Dermatol. 2002;4635- 41PubMedGoogle ScholarCrossref
Morrison  LKratochvil III  FJGorman  A An open trial of topical tacrolimus for erosive oral lichen planus  J Am Acad Dermatol. 2002;47617- 620PubMedGoogle ScholarCrossref
Olivier  VLacour  JPMousnier  AGarraffo  RMonteil  RAOrtonne  JP Treatment of chronic erosive oral lichen planus with low concentrations of topical tacrolimus: an open prospective study  Arch Dermatol. 2002;1381335- 1338PubMedGoogle ScholarCrossref
Kirtschig  GVan Der Meulen  AJIon Lipan  JWStoof  TJ Successful treatment of erosive vulvovaginal lichen planus with topical tacrolimus  Br J Dermatol. 2002;147625- 626PubMedGoogle ScholarCrossref
Kelly  PABurckart  GJVenkataramanan  R Tacrolimus: a new immunosuppressive agent  Am J Health Syst Pharm. 1995;521521- 1535PubMedGoogle Scholar
Ruzicka  TAssmann  THomey  B Tacrolimus: the drug for the turn of the millennium?  Arch Dermatol. 1999;135574- 580PubMedGoogle ScholarCrossref