INTRODUCTION

Lichen sclerosus is a chronic inflammatory skin condition that primarily affects the anogenital region, causing significant discomfort and potential complications. Lichen sclerosus typically presents with white atrophic patches and can lead to scarring, fusion of genital structures, and increased risk of squamous cell carcinoma [1]. Traditional management involves the use of potent topical corticosteroids; however, some patients remain refractory to this treatment [2]. In recent years, standard fat grafting has emerged as a potential alternative to treat resistant cases [3]. Nanofat, obtained through the mechanical processing of harvested fat, contains a high concentration of regenerative cells and growth factors while eliminating mature adipocytes [4]. The combination of a standard fat graft and nanofat graft was reported to be effective in the treatment of vulvar lichen sclerosus in one case report [5]. The report details the successful treatment of a 42-year-old woman with severe anogenital symptoms and an ulcer on the posterior fourchette that did not respond to topical corticosteroids using only a nanofat graft. By presenting this case, we hope to stimulate further research into this promising technique and its potential to improve outcomes in patients with this challenging condition.

CASE REPORT

A 42-year-old woman presented to our dermatology outpatient clinic with complaints of severe itching, burning, and pain in the anogenital region, resulting in the inability to have sexual intercourse. She reported that her symptoms had been present for three years and had worsened over the past several months. The diagnosis of lichen sclerosus was confirmed by a punch biopsy (Fig. 1).

Figure 1: Compact orthokeratosis, epidermal atrophy with basal layer vacuolization, and homogenized papillary dermal collagen fibers.

On examination, vulvar atrophy was observed, with significant loss of labia minora and hyperkeratosis around the vulva and anus. An ulcer of approximately 1 cm in length was observed on the posterior fourchette (Fig. 2). The patient did not benefit from 0.05% clobetasol 17-propionate ointment that was used for several months prior to presentation. Chronic inflammation was detected in the punch biopsy specimen obtained from the ulceration to exclude malignancy. Given the patient’s lack of response to conventional treatments, nanofat grafting is considered a novel therapeutic approach. Nanofat grafting was performed according to the procedure described by Tonnard et al. [4]. For fat graft harvesting, approximately 2 hours before the procedure, EMLA cream was applied to a 30 × 15 cm area marked on the lower abdomen (infraumbilical region) and wrapped with a cling film. To 500 cc of isotonic solution, 25 mL of 2% lidocaine, 1/2 ampoule of 1 mg/mL adrenaline, and 1/2 ampoule of 8.4% 10 mL sodium bicarbonate were added. Tumescent anesthesia was administered to the subcutaneous tissue of the marked area of the abdomen using the prepared tumescent solution. After one hour, mild sedation (2 mg intravenous midazolam and 50 μg intravenous fentanyl) was administered under the supervision of an anesthesiologist, and 0.5% lidocaine was injected into the perianal and vulvar skin. Fat graft harvesting and nanofat grafting were performed. For fat graft harvesting, a cannula with a diameter of 3 mm and numerous sharp-edged holes with a diameter of 1 mm on the surface was used. A 20 cc Luer-lock syringe was attached to the cannula, and the fat graft was harvested by applying gentle negative pressure (not exceeding 3 cm³). The fat graft was placed on sterilized nylon with very fine holes that only allowed water to pass through and was washed with saline solution to remove erythrocytes and local anesthetic. The washed fat graft remaining on the nylon was cleared of the fibrous tissue using forceps. The fat graft was then placed in 10cc Luer-lock syringes, and using a three-way stopcock, an empty syringe of the same type was attached to the other end. The fat graft in the syringe was passed through a three-way stopcock 30 times from one syringe to another to further emulsify it, transforming it into a fluid emulsion known as a nanofat. Using a three-way stopcock, the emulsion was transferred into 1cc Luer-lock syringes. Approximately 20cc of nanofat graft was injected intradermally into the vulva and perianal region at a dose of approximately 0.1 mL per 1 cm² area using a 27 G syringe (Fig. 3). A much higher volume (approximately 1 mL per 1 cm² area) was injected under the ulceration.

	Figure 2: Ulceration on the posterior fourchette and atrophy of the external genitalia.
	Figure 3: Intradermal injection of the nanofat graft.

At one-year follow-up, she reported no severe itching, burning pain, or dyspareunia; only mild and occasional itching was noted. Upon examination, the ulcer on the posterior fourchette had healed completely. On the left interlabial sulcus and on the anterior labial commissure, there were two painless fissures measuring approximately 1.5 cm and 1 cm in length, respectively. The patient was unaware of the fissures and had no relevant complaints. Skin thickening was observed (Fig. 4). An epithelializing cream was prescribed for the fissures and a topical corticosteroid for hyperkeratosis. The patient was invited to undergo follow-up examination.

Figure 4: Healed ulcer on the posterior fourchette, skin thickening, asymptomatic fissures on the left interlabial sulcus and anterior labial commissure.

DISCUSSION

The improved outcome of our patient aligns with findings from various studies exploring fat grafting techniques for lichen sclerosus treatment [3,5,6].

Tamburino et al. reported satisfactory results using a combination of nanofat and standard-fat grafts [5]. This dual approach combines the advantages of both graft types, potentially enhancing overall treatment efficacy. Standard fat grafts provide volume and structural support, whereas nanofat contributes to tissue regeneration and revascularization.

Boero et al. achieved long-term success with standard fat grafting applied to all adipose tissue layers down to the deep fascia, recommending a week of rest for graft establishment [3]. This comprehensive approach targets multiple tissue layers and potentially addresses the full extent of the lichen sclerosus-related changes. The recommended rest period is crucial for allowing grafted fat to establish proper connections with the surrounding tissues and vasculature, thereby enhancing graft survival and integration.

Recent research has further expanded the application of fat grafting techniques, with one study demonstrating satisfactory outcomes using nanofat grafting specifically for penile lichen sclerosus [6]. This finding is particularly significant because it extends the potential benefits of fat grafting to male patients who may have limited treatment options for genital lichen sclerosus.

Given that lichen sclerosus primarily affects the dermis and epidermis, targeting these layers with nanofat grafting appears to be a promising approach. This targeted application may enhance treatment effectiveness by directly addressing the affected tissue areas, potentially improving outcomes in patients with lichen sclerosus. The precise delivery of regenerative cells and growth factors to the superficial skin layers may help counteract the characteristic thinning and sclerosis associated with this disease. Nanofat appears to be appropriate for patients who do not require structural and volumetric support. The advantage of nanofat grafting over standard fat grafting is the ease of intradermal application under local anesthesia.

CONCLUSION

In conclusion, the positive outcome observed in this case and supported by the existing literature suggests that fat grafting techniques, particularly nanofat grafting, hold significant promise for the treatment of lichen sclerosus. By targeting affected tissue layers and using the regenerative properties of adipose-derived cells, these approaches may offer new hope to patients struggling with this challenging condition.

REFERENCES

1.Kirtschig G, Kinberger M, Kreuter A, Simpson R, Günthert A, van Hees C, et al. EuroGuiderm guideline on lichen sclerosus-introduction into lichen sclerosus. J Eur Acad Dermatol Venereol. 2024;38:1850-73.

2.Kirtschig G, Kinberger M, Kreuter A, Simpson R, Günthert A, van Hees C, et al. EuroGuiderm guideline on lichen sclerosus:Treatment of lichen sclerosus. J Eur Acad Dermatol Venereol. 2024;38:1874-909.

3.Boero V, Di Loreto E, Cetera GE, Cetera GE, Cipriani S, Boggio F, et al. Fat grafting in vulvar lichen sclerosus:Long-term follow-up. J Low Genit Tract Dis. 2023;27:365-72.

4.Tonnard P, Hamdi M, Cornelissen M, Hamdi M, Cornelissen M, Declercq H. Nanofat grafting. Plast Reconstr Surg. 2013;132:1017-26.

5.Tamburino S, Lombardo GA, Tarico MS, Perrotta RE. The role of nanofat grafting in vulvar lichen sclerosus:A preliminary report. Arch Plast Surg. 2016;43:93-5.

6.Brambilla M, Benzecry V, Maronese CA, Barberi F, Cusini M, Boero V, et al. Effectiveness of nanofat in treatment-refractory penile lichen sclerosus:Results from a pilot retrospective single-center case series. Ital J Dermatol Venerol. 2025;160:116-22.