Correspondence (reply): In Reply

As Professor Haufs quite rightly comments, one of the main factors is complete pubic hair removal—as practiced primarily by younger people, for different reasons—such as zeitgeist/fashion, religion, or (pseudo) hygiene. Regarding the positive correlation between intimate shaving and sexually transmitted infections, as pointed out by Haufs, especially the association between intimate shaving and vulvar dysplasia deserves to be mentioned. Schild-Suhren et al. (1) e.g. found a quadrupled risk for developing vulvar intraepithelial neoplasia (VIN) or vulvar cancer in patients who practice complete pubic hair removal (OR 4,04 [95% CI: 1.63; 10.01], p = 0.003). A likely explanation is the “easier access” for human papillomaviruses (HPV) as a result of skin injuries during hair removal.

We strongly support the comment of Dr Forck: avoiding panty liners is an essential component in the prevention and therapy of vulvar pruritis. Drying-out as well as exposure to irritants are the problems associated with this form of intimate hygiene. Patients should therefore practice both: they should stringently avoid using panty lines and they should wear cotton or silk underwear. Unfortunately, the experience around panty liners is only “eminence based”, robust data on the subject currently are not available. In addition, there are data from a randomized double blind trial reported by D’Antuono (2), showing that symptoms such as burning and pruritus in patients with lichen sclerosus improve significantly when silk underwear is being worn.

Transplanting autologous fat, as explained by Prof Mirastschijski and Dr Schwenke, is a possible alternative once conservative measures have been exhausted. Kim et al. showed that lipofilling with platelet-rich plasma (PRP) is associated with improvements to the skin condition and clinical symptoms in vaginal atrophy and vulvar lichen sclerosus (3). Furthermore, the pluripotent stem cells in the fatty tissues harvested by liposuction are increasingly regarded as important. A review by Eshtiaghi included seven studies with a total of 98 patients with treatment refractory lichen sclerosus that investigated the effectiveness of lipofilling with stem cells as well as with PRP (4). The results of the review showed for both treatment methods improvements to the quality of life and a clinical benefit in the sense of an amelioration of symptoms, as well as a histopathologically confirmed reduction of the dermal sclerosis, hyperkeratosis, and chronic inflammatory reaction (p<0.001).