Fractional / Pixel CO2 Laser Treatment of Vulvar Atrophy and Lichen Sclerosus
Condition: Vaginal Atrophy; Lichen Sclerosus
MeSH terms: Lichen Sclerosus et Atrophicus; Atrophy
Study type: Interventional

Summary: 
      The study will examine the effects of fractional/pixel CO2 laser treatment in vaginal atrophy
      and in vulvar lichen sclerosus by means of histological and immuno-histochemical
      characterization of the epithelial layers and markers of tissue aging. The tissue
      characterization will be performed by biopsies of the vaginal or vulvar tissue at three
      different points of time: prior to treatment, two weeks after the third and last treatment,
      and one year after the last treatment.
    

Detailed description: 
      Many studies have been published recently describing the use of a fractional/pixel CO2 laser
      for the treatment of various disorders of the vulva and the vagina, such as atrophy due to
      estrogen deficiency, urinary stress incontinence, skin diseases (lichen sclerosus) and more.

      The results of the studies that investigated this technology in relation to vaginal atrophy
      and urinary stress incontinence have shown improvement in symptoms after a series of only 3
      treatments.

      The proposed effect of the fractional CO2 laser is based on studies performed on non-genital
      tissues [Daffon, Capon], which demonstrated changes in the connective tissue and
      proliferation of fibroblasts, as well as formation of collagen and elastic fibers. The
      suggested explanation is based on the theory that heat shock proteins are involved in the
      process and arise due to thermal tissue damage, and this in turn activate tissue cytokines,
      growth factors and fibroblasts. These theories have not been proven for vulvar and vaginal
      tissues, and except for the demonstration of histologic and morphologic changes in the
      irradiated tissues [Salvatore, Menopause 2015], the cellular mechanism of action and the
      nature of the process mediating the changes in uro-genital tissues has not yet been examined.

      The technology known as fractional CO2 has been used for many years in dermatology and
      plastic surgery. In this method, the laser beam splits while passing through a lens to 81
      dots (9 x 9 pixels) onto approximately 1 cm2. The laser beam penetrates the tissue and causes
      minimal evaporation around each spot of the fractionated beams and release of heat only at
      the desired tissue depth. The method of energy transfer to tissues in tiny dots leads to the
      creation of various thermal effects in the focus of the beam, around the focus, and in the
      areas between these heat foci. Following the tissue irradiation, different processes occur:
      epithelial cell proliferation and thickening of the epithelial layer, migration and
      proliferation of endothelial cells, creation of neo-vasculature in the lamina propria,
      creation of collagen and elastic fibers, and accumulation of glycogen in the cells
      [Salvatore, Menopause 2015]. The result of these processes is improved tissue elasticity and
      plasticity as well as regeneration of the epidermis layer. Previous studies demonstrated that
      the effect of this treatment on the atrophic vagina is identical to long-term local estrogen
      treatment, with improved cytological index, improved lubrication, alteration of the vaginal
      flora, and reduced acidity to the level of "estrogenic" levels (approx. pH 4 -4.5)
      [Salvatore, Menopause, 2015;Perino; Gasper; Salvatore, Climacteric, 2015].

      Considering the multitude of recently published articles presenting impressive clinical
      results, the investigators decided to examine the effects of the treatment with a fractional
      CO2 laser on the vaginal and vulvar tissue at a cellular level for two conditions: vaginal
      atrophy due to estrogen deficiency and lichen sclerosus. These two conditions were chosen due
      to the magnitude of recent publications dealing with clinical and histological improvement in
      these two pathological conditions following laser treatment. Understanding the cytological
      processes will enable the foundation of knowledge about the basic mechanism of action, and
      propose methods to improve the current therapeutic protocols. It will also enable the
      observation of the duration of the treatment effect, and the assessment of whether these
      changes are associated with undesired events, such as increased risk of malignant tissue
      transformation.

      Patients The investigators intend to recruit 10 women for each group (10 women with atrophy
      and 10 with lichen sclerosus). Considering the availability of efficient and safe medical
      treatment, most women diagnosed with lichen sclerosus or vaginal atrophy are treated with
      medical preparations to their satisfaction. Therefore, the investigators will recruit the
      following types of patients for the trial: women with low compliance for the medical
      treatment, women who have developed intolerance to the treatment (such as chronic candida
      vulvovaginitis under long-term estrogen treatment, hypersensitivity reactions to the steroid
      ointment or estrogen preparation, or drug allergy) or women with only partial response to
      treatment, for whom there is no satisfactory therapeutic alternative.

      The study includes 6 appointments:

      T0-recruitment: ascertain eligibility, sign informed consent form, complete a questionnaire
      including epidemiologic and clinical details, gynecological examination, cytological smear
      (maturation index), determination of the acidity level of the vaginal secretions (pH),
      determination of vaginal health index score [Bachmann].

      A punch biopsy will be taken from the mid-third of the vagina (in vaginal atrophy) or the
      vulva (in lichen sclerosus).

      T1-Visit 2 (2-4 weeks from recruitment) The treatment protocol includes a series of three
      laser treatments, 4-6 weeks apart.

      The first laser treatment will be performed during Visit 2. In the vagina, the treatment is
      performed by a special vaginal transducer enabling 360° treatment; the irradiation of the
      vagina is performed in adjacent "squares" along the entire vaginal circumference, by turning
      the handle while slowly withdrawing the transducer from the vaginal canal. The duration of
      treatment is 5-7 minutes. The vaginal treatment is not associated with pain. The treatment of
      the introitus will be performed by a transducer enabling treatment around 360° named
      FemiLift.

      The treatment will be performed by a fractional micro-ablative CO2 laser system manufactured
      by Alma Laser in accordance with the accepted protocol (laser mode: pulse, energy: 40-80
      mj/pulse).

      For lichen sclerosus, a handgrip of the FemiLift transducer will be used, which transmits the
      "pixel print" directly and not under a 90° angle. Since the vulvar skin is pain sensitive, it
      will be treated prior to the laser application, with EMLA anesthetic cream. The duration of
      treatment is 3-7 minutes and it is performed by the same device with energy levels of 20-60
      mj/pulse.

      During Visit 3 (T2) and Visit 4 (T3), identical treatment to that described above will be
      performed.

      In the framework of the study, the below follow-up procedures will be performed:

        1. Biopsy - three biopsies will be taken from the lateral mid-third of the vagina: prior to
           treatment (T0), two weeks after the third and final treatment (T4) and one year after
           the completion of the treatment series (T5). The biopsy will be a punch biopsy with a 5
           mm diameter. The biopsies will be performed under local anesthesia with 2% lidocaine.

        2. In the course of each of the follow-up examinations (T 0 - 5), the following will be
           performed (In vaginal atrophy):

             -  Gynecological examination with speculum

             -  Smear taken from the mid-third of the vagina with a cotton tip applicator, which
                will be used for a cytological smear and to determine the acidity level of the
                vaginal secretions.

             -  The vaginal health index score will be determined, including the evaluation of 5
                parameters: elasticity, pH, integrity of the epithelium, moisture and fluid volume.
                Each parameter is scored on a scale of 1 to 5, and if the total score is lower than
                15, the vagina is considered atrophic [Bachmann].

             -  The patient will be requested to grade symptoms (dryness, itching, burning,
                discomfort, dyspareunia, dysuria) on a VAS (visual analog scale) with "very
                disturbing" and "not disturbing at all" at its limits.

             -  The patient will be requested to grade the extent of her satisfaction with the
                treatment results (very satisfied. satisfied, not sure, not satisfied, very
                unsatisfied).

             -  The patient will be requested to report side effects.

      In lichen sclerosus patients:

      - External examination of the vulva and a photograph of the results for follow-up.

      The biopsies will be sent to the Institute of Pathology at Hadassah Hospital, where the
      following examinations will be performed:

        1. Routine hematoxylin-eosin staining.

        2. Immunohistochemistry staining for P16 protein.

        3. Immunohistochemistry staining for the KI-67 protein.

        4. Immunohistochemistry staining for the p63 protein,\.

        5. Staining for alpha and beta estrogen receptors and progesterone receptors.
    

Intervention name(s): Fractional / Pixel CO2 Laser
Intervention type(s): Device
Intervention description(s): The laser energy is transferred in a fractioned manner: the laser beam splits while passing through a lens to 81 dots (9 x 9 pixels) onto approximately 1 cm2, so the laser rays hit the tissue in small spots.
For gynecological applications, the treatment is performed by a transducer, which was specifically designed for vaginal application.
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Basic Science