A systematic review of laser therapy for vulvar skin conditions

To the Editor: While laser devices have been utilized for a variety of vulvar skin conditions, much of the literature focuses on laser use in vulvovaginal atrophy or genitourinary syndrome of menopause.1Song S. Budden A. Short A. Nesbitt-Hawes E. Deans R. Abbott J. The evidence for laser treatments to the vulvo-vagina: making sure we do not repeat past mistakes.Aust N Z J Obstet Gynaecol. 2018; 58: 148-162Google Scholar,2Pitsouni E. Grigoriadis T. Falagas M.E. Salvatore S. Athanasiou S. Laser therapy for the genitourinary syndrome of menopause. A systematic review and meta-analysis.Maturitas. 2017; 103: 78-88Google Scholar Prior reviews have also shown limited evidence for clinical efficacy and safety of laser treatments in female gynecologic and urologic conditions.3Preti M. Vieira-Baptista P. Digesu G.A. et al.The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: an ICS/ISSVD best practice consensus document.Neurourol Urodyn. 2019; 38: 1009-1023Google Scholar Herein, we conducted a systematic review of laser devices for neoplastic and inflammatory vulvar skin conditions. A literature search was conducted using PubMed, Ovid, and CINAHL using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with search terms “vulvar” or “vulva” and “laser”. Inclusion criteria consisted of articles published in English after 1990. Studies on rejuvenation and genitourinary syndrome of menopause were excluded. We identified 90 articles consisting of 2072 vulvar cases, comprising 23 diagnoses, treated by laser as monotherapy or in combination with other therapies (Supplementary Table I, available via Mendeley at https://doi.org/10.17632/f9sgx9nt2t.2, Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/f9sgx9nt2t.2). Of these 2072 cases, 1615 (78%) were neoplastic and 160 (7.7%) were inflammatory conditions. The remaining 297 (14%) were cases of vulvodynia. The most common neoplastic condition was vulvar intraepithelial neoplasia (VIN) (660/1615, 41%). The most common inflammatory condition was lichen sclerosus (LS) (154/160, 96%). For both VIN and LS, CO2 laser was the most common laser utilized in 79% (520/660) and 66% (102/154) of cases, respectively. Of 10 unique lasers used for vulvar conditions, CO2 lasers were most common overall (1674/2072, 81%). CO2 laser was at least partially effective for the following diagnoses: VIN (n = 468), LS (n = 100), Bartholin gland cyst/abscess (n = 689), condyloma acuminata (n = 79), extramammary Paget disease (n = 34), squamous cell hyperplasia/carcinoma (n = 27), vulvar papillomatosis (n = 16), lymphangioma/lymphangiectasia (n = 9), Buschke Lowenstein tumor (n = 3), vulvar syringoma (n = 3), vulvar tumor unspecified (n = 2), inflammatory linear verrucous epidermal nevus (n = 2), bowenoid papulosis (n = 1), vulvar adenosis (n = 1), lymphedema (n = 1), papular acantholytic dyskeratosis (n = 1), epidermoid cyst (n = 1), trichoadenoma of Nikolowski (n = 1), and vulvar pigmented follicular cyst (n = 1). While neither neoplastic or inflammatory, we found CO2 laser was also reported to be partially effective for vulvodynia (n = 96), Thirty-five (38.9%) studies reported at least 1 side effect, the most common being mild or transient pain and discomfort. Conventional treatments for vulvar inflammatory and malignant conditions include surgical excision, photodynamic therapy, and laser ablation. This review specifically highlights the use of laser therapies for vulvar conditions, with the most evidence for CO2 laser for VIN and LS. The heterogeneity of the studies precludes us from providing a standard of care in laser type and laser settings. While most studies reported minimal short-term complications, there is a paucity of data on long-term outcomes. The majority of the studies did not specify Fitzpatrick skin type of patients, limiting our ability to comment on the safety of laser-based devices across a broader range of skin types. More robust studies are needed to ultimately establish guidelines for optimal recommendations for use of lasers in vulvar inflammatory and neoplastic skin conditions. None disclosed.