Objective: Characterize the presentation of vulvar lichen scleorsus (LS) among premenopausal women. Design: Cross-sectional study. Setting: An international web-based survey distributed on social media support groups and in two urban gynecology offices specializing in LS. Population: A total of 503 premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50. Methods: Participants completed an anonymous 28-question web-based survey between January to March 2021. Main Outcome Measures: Symptoms, timing and accuracy of diagnosis, and presence of concomitant autoimmune conditions. Results: Symptoms reported to be most present and affect the individual were dyspareunia (68%; 44%) and tearing with intercourse or vaginal insertion (63%; 39%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%), and tearing with intercourse or vaginal insertion (26%). Most common skin changes included hypopigmentation (81%), vulvar fissures (72%) and labial resorption (60%), with fissures affecting the individual the most (48%). There was a 4-year delay in diagnosis with an average age of symptom onset of 27 years and average age of diagnosis of 32 years. Sixty-six percent of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). There is an increased incidence of hypothyroidism, vitiligo, pernicious anemia, and celiac disease. Conclusion: Premenopausal women with vulvar LS more commonly present with dyspareunia and tearing with intercourse, less often than vulvar pruritis. This condition should be considered and evaluated in women of all ages presenting with vulvar symptoms and sexual pain. Funding: None Keywords: lichen sclerosus; vulvar dermatoses; vulvar pruritis; dyspareunia

Objective To determine the efficacy of fractional carbon dioxide laser (FXCO2) therapy for vulvar lichen sclerosus (VLS). Design Prospective, double-blind, sham-controlled, randomized trial. Setting Clinic specializing in vulvovaginal disorders. Population Forty women with active VLS confirmed with biopsy who abstaining from topical and/or systemic treatments for at least 4 weeks. Methods Women were randomized in a 1:1 ratio to receive either five sham laser treatments or five FXCO2 treatments in a 24-week period. Pre- and post-treatment biopsies were obtained on all participants. Study participants, treating clinicians, and evaluating pathologist were blinded. Main Outcome Measures Primary: pre- and post-treatment biopsy Histopathologic Scale (HS) findings. Secondary: Clinical Scoring System for Vulvar Lichen Sclerosus (CSS) Results There was a 0.12 reduction (improvement) in HS from baseline in the active treatment group (95%CI = -1.01, 0.78, p=0.79) and a 0.06 increase from baseline in the sham treatment group (95%CI - -0.81, 0.92, p=0.90). The change in HS between the active and sham arm was not statistically significant (-0.17; 95%CI = -1.14, 1.06, p=0.78). There was a 6.82-point reduction (improvement) in the patients’ CSS from baseline in the active (95% CI = -11.28, -2.37, p= 0.004) and a 4.83-point reduction in the sham treatment group (95% CI = -9.16, -0.51, p=0.03). In the clinicians’ CSS, there was a 0.82 increase (worsening) in the active (95% CI = -0.46, 2.11, p=0.20) and a 0.28 reduction in the sham treatment group (95% CI = -1.53, 0.97, p=0.65). Conclusions. FXCO2 is not an effective monotherapy treatment for VLS