Vulvar Lichen Sclerosus: Comparison Between Clobetasol Propionate, Photodynamic Therapy and Low-Intensity Laser

Study Overview
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Brief Summary
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Vulvar lichen sclerosus (VLS) is a lymphocyte-mediated disease of unknown etiology that can cause intense itching as well stenosis, hindering the evacuation and urination. It can also limit the sex life due to severe local pruritus, pain and dyspareunia (pain during sexual intercourse). The standard treatment for this disease is the use of topical corticosteroids to reduce the clinical symptoms and to try to increase disease-free intervals. Photodynamic therapy (PDT), a treatment that associates a light radiation with a photosensitizing agent and low-level laser therapy (LLLT) are therapies that can promote effective immunomodulatory responses at the application site by means of photophysical and photochemical phenomena from the molecular to the systemic level, which promote their use in chronic dermatoses. The aim is to study and compare the effects of PDT, LLLT, and topical corticosteroid in VLS evaluating clinical, histological, immunohistochemical and spectroscopic responses. The study will be prospective, randomized, and controlled, in a population of 60 women with histological diagnoses of VLS, enrolled on the outpatient clinic of Genitoscopy Department of the Pérola Byington Hospital in São Paulo. There will be 3 treatments groups: PDT, LLLT and topical corticosteroid, where will be allocated by randomization 20 patients in each one. The clinical course will be monitored by measuring local temperature, itching, clamping (atrophy), and the appearance of the lesion. Histologically, the slides will be classified according to the Hewitt grading and will have the ordering of collagen fibers quantified. Immunohistochemical analysis will be done using the markers IFN-γ, TGF-β, CD4, CD8, IL-1, p53 and Ki-67. Finally, the spectroscopic evaluation will be done by reflectance. Descriptive and inferential statistical analyses will be conducted to compare the groups and for associations between different responses.

Detailed Description
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Dosimetry and Experimental Groups: There is no dosimetric protocol established for the treatment of VLS with PDT, nor with LLLT. According to the literature, energy densities range from 9 to 150 J/cm2 and power densities from 40 to 700 mW/cm2, not to mention work that do not report the dosimetry used. As such, the dosimetry to be used in this study is based on a pilot clinical study performed by our group. The patients will be randomized into 3 groups with 20 patients in each one: Group GC: Corticosteroid over the whole vulva. Clobetasol propionate 0.05% ointment applied once daily at a dose of 1 g/application (1 g sachets) for 4 weeks. Group GPDT: Localized photodynamic therapy at 8 points of the vulva. Methylene blue 0.01% intralesional, λ = 660 ± 10 nm, P = 100 mW, PD = 510 mW/cm2, E = 4 J, ED = 20 J/cm2, t = 40 s, once a week for 4 weeks. Group GLLLT: Localized low-level laser therapy at 8 points of the vulva. The same parameters as for GPDT, except for the methylene blue, once a week for 4 weeks. Analyses: The histological and immunohistochemical analyses will be performed before and 30 days after the start of treatment, whereas clinical analysis will be performed weekly on treatment days for the GPDT and GLLLT groups. The control group will not be seen weekly because the standard treatment is performed by the patients themselves, in their own homes, for 30 days as recommended by the International Society for the Study of Vulvar Disease (ISSVD). After treatments the patients will be followed for verification of recorrence during one year, at minimum.

Official Title
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Vulvar Lichen Sclerosus: Therapeutic Comparison Between Clobetasol Propionate, Photodynamic Therapy and Low-Intensity Laser

Conditions
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Vulvar Lichen Sclerosus

Intervention / Treatment
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* Drug: Clobetasol propionate
* Radiation: Photodynamic therapy
* Radiation: Low level laser therapy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: adult female patients (aged over 18 years); vulvar lichen sclerosus diagnosed histologically; normal level of cortisol confirmed by blood test. Exclusion Criteria: adult female patients under the age of 18; patients with any kind of ongoing cancer and/or AIDS or coagulopathy, pregnant or breastfeeding women; patients using corticosteroids, immunosuppressants or anticoagulants; patients with renal, hepatic or pulmonary-cardiovascular failure; patients who have undergone any kind of organ transplantation in the last three years.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Corticosteroid<br>Clobetasol propionate 0.05% ointment applied once daily at a dose of 1 g/application (1 g sachets) for 4 weeks. | Drug: Clobetasol propionate<br>* Clobetasol propionate 0.05% ointment applied once daily at a dose of 1 g/application (1 g sachets) for 4 weeks.<br>* Other names: Corticosteroid;|
| Experimental: Photodynamic therapy<br>Methylene blue 0.01% intralesional, λ = 660 ± 10 nm, P = 100 mW, PD = 510 mW/cm2, E = 4 J, ED = 20 J/cm2, t = 40 s, once a week for 4 weeks. | Radiation: Photodynamic therapy<br>* Methylene blue 0.01% intralesional, λ = 660 ± 10 nm, P = 100 mW, PD = 510 mW/cm2, E = 4 J, ED = 20 J/cm2, t = 40 s, once a week for 4 weeks<br>* Other names: PDT;|
| Experimental: Low level laser therapy<br>λ = 660 ± 10 nm, P = 100 mW, PD = 510 mW/cm2, E = 4 J, ED = 20 J/cm2, t = 40 s, once a week for 4 weeks. | Radiation: Low level laser therapy<br>* λ = 660 ± 10 nm, P = 100 mW, PD = 510 mW/cm2, E = 4 J, ED = 20 J/cm2, t = 40 s, once a week for 4 weeks<br>* Other names: LLLT;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from baseline in biopsies at 1 month. | Biopsies will be performed at two points: at baseline to confirm the VLS and subsequent inclusion in the research protocol, and at the end of 30 days to investigate the prognosis after treatment. | Participants will be followed for 1 month during VLS's treatment. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Count cells per mm2 by immunohistochemical reaction of IFN-γ, TGF-β, CD4, CD8, IL-1, p53 and Ki-67. | Once deparaffinized, the tissue samples will be subjected to antigen retrieval, endogenous enzyme blocking, background blocking, incubations of antibodies, and counter-staining according to the instructions of the manufacturers. The cells that are positively stained by the immunohistochemical reaction will be counted with the aid of ImageJ software (National Institutes of Health, Maryland, USA) by two independent pathologists without prior knowledge of the experimental groups. | Participants will be followed for 1 month during VLS's treatment. | 
| Percentage of relative reflectance as assessed by In-Vivo Reflectance Spectroscopy. | A portable spectrophotometer (400-900 nm) comprising a light source and a fiber-optic probe will be used directly on the surface of the vulvar skin in areas affected by VLS and in healthy areas of the same patients. Relative spectra will be obtained for the wavelengths corresponding to those of the therapeutic window, and the percentage of relative reflectance will be calculated. | Participants will be followed for 1 month during VLS's treatment. | 
| Temperature, as assessed by infrared thermographic camera, in Celsius degrees. | Measurements will be recorded as images in all sessions before, during, and after irradiation to observe the thermal fluctuation in the procedures. | Participants will be followed for 1 month during VLS's treatment. | 
| Itching, as assessed by Visual Analog Scale. | In each session, the patients will be asked about the intensity of vulvar itching to assess its severity and duration, before and after irradiation, according to a visual analog scale. | Participants will be followed for 1 month during VLS's treatment. | 
| Clamping, as assessed by digital caliper, in mm. | The clamping of the lesion to monitor skin atrophy will be done before irradiation at each session, using a digital caliper, transversely and longitudinally in relation to the labia majora. | Participants will be followed for 1 month during VLS's treatment. | 
| Area, as assessed by digital camera, in cm2. | The appearance and area of the lesion will be monitored with a digital camera at every session, before irradiation. To facilitate measurements, a metric scale will be rested on all vulvas for the photos. The areas of the lesions will be quantified using ImageJ software (National Institutes of Health, Maryland, USA). | Participants will be followed for 1 month during VLS's treatment. | 
| Collagen birefringence, as assessed by polarized light microscope, in nm. | The correlation between birefringence and collagen ordering has been used since the 1960s. To the present date, polarized-light microscopy is an efficient method to quantify the change in collagen birefringence due to the effects of different agents. Since atrophy of the skin is a characteristic symptom of patients with VLS, the more detailed study of collagen fibers will elucidate the interaction of radiation with this type of tissue. | Participants will be followed for 1 month during VLS's treatment. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Vulvar lichen sclerosus, Photodynamic therapy, Low-level laser therapy, Clobetasol propionate