lichen sclerosus ( ls ) is a chronic inflammatory skin disease of unknown etiology . at present
, the typical first line of treatment for ls includes various topical steroids to control inflammation .
its epidemiology is probably underestimated , but it has been calculated to have a prevalence of 0.10.3% among all patients referred to a community - based dermatology department .
although the underlying cause is unknown , researchers have linked the disease to autoimmune mechanisms . a recent study analyzed serum autoantibody profiles in patients with ls versus healthy controls .
this study found the presence of circulating autoantibodies to a specific skin protein , extracellular matrix protein 1 ( ecm1 ) , in most patients with ls .
they concluded that ecm1 is a plausible target antigen for autoimmune mechanisms observed in ls pathology .
this is the main rationale for the off - label use of ketamine infusions for the treatment of neuropathic pain .
however , ketamine exhibits extensive polypharmacological effects , which has led it to be regarded as 
it also exhibits robust immunoinhibitory effects that have been studied mainly in the context of developing a novel antidepressant .
entourage effect that could be uniquely beneficial for the treatment of painful inflammatory conditions with a possible autoimmune component such as ls .
a 66-year - old female patient presented to the florida spine institute ( fsi ) as a referral from her dermatologist for the treatment of chronic pain in her bilateral lower limbs .
she had begun having pain in her lower limbs approximately 8 years prior to her first visit to the fsi .
the patient had developed a rash that encompassed large portions of her lower limbs and anus .
the patient had been diagnosed with ls et atrophicus at the department of dermatology and cutaneous surgery of the university of south florida ( tampa , fla . ,
there , the patient had been treated with steroids , with little improvement . over time , the patient had developed significant skin scarring , skin atrophy , and edema .
her pain was treated with a common neuropathic pain agent ( gabapentin ) and an opiate ( hydrocodone ) .
this pain regimen gave the patient mild relief , but her ability to perform physical activities was only minimally affected .
the patient stated that pain , weakness , and edema in her lower limbs were her main complaints and the reason for her intolerance of physical activity .
the pain was described as constant burning with deep aching pain and sporadic sharp pains . on a visual analog scale ( vas ) ,
she stated that if her pain were controlled , she would be able to increase her physical activity and performance . on physical exam ,
the patient 's skin revealed skin atrophy , scarring , and plaques consistent with ls et atrophicus located in both legs , thighs , buttocks , and the anus ( fig .
her lower limbs also demonstrated edema , color changes , and temperature changes in the distal parts of the legs ( when compared to the hands and upper thighs ) .
the major muscle groups in her lower limbs were considerably weak , but she had a manual muscle strength grade of at least 4 out of 5 .
thus , the patient was treated as a case of possible neuropathic pain , which was likely a complication of the patient 's ls .
the patient 's pain started after months of having her rash and escalated to a severity at which her ambulation and ability to perform her activities of daily living were significantly affected .
in addition , the patient 's sensory , vasomotor , and motor dysfunction as well as edema started months after the rash had started . at the time of her first visit ,
methadone was chosen because , in addition to being an opioid analgesic , it acts as a mild nmda receptor antagonist , a novel target for neuropathic pain .
the patient 's pain improved over the next month ( to vas 5/10 ) . despite the improvement in the patient 's pain , the main goal for the patient and treating physician was ultimately to discontinue opiate medications while maintaining adequate pain control
it has the ability to provide conscious sedation , but , more importantly , it is a potent nmda receptor antagonist . in may 2014 ,
the patient was started on the ketamine infusion protocol set forth by the fsi . on day 1 ,
the patient was infused for approximately 4 h with 200 mg ketamine , 200 mg lidocaine , and 6 mg midazolam in a 100-ml bag of saline .
the ketamine dosage was increased by 200 mg each day until 800 mg was reached .
the overall clinical course of the patient in this case study is plotted in fig .
2 . four days following the last ketamine infusion during a follow - up visit , the patient reported improvement in her pain levels ( to vas 4/10 ) .
one month after the ketamine infusions , the patient was seen for another follow - up .
areas that had previously been causing much discomfort due to sclerotic plaques and lesions showed drastic improvement .
in addition , the patient reported decreased allodynia , hyperpathia , and hypersensitivity in her lower limbs .
the patient volunteered to undergo 2 ketamine booster infusions over the course of 2 days . in july 2014 ,
her pain had significantly reduced ( to vas 1/10 ) from her pre - ketamine infusion state , and her ls rash and edema continued to be significantly reduced ( fig .
the patient 's ability to perform activities of daily living and ambulation were greatly improved .
over the course of 8 months , she received ketamine booster infusions every 23 months .
her pain continues to be controlled without the use of opiates ( vas 1/10 ) .
the patient 's rashes , edema , allodynia , and hypersensitivity continue to be significantly improved compared to the pre - ketamine infusion state .
she has undergone physical therapy with significant improvement in ambulation ability and exercise / physical activity tolerance .
the patient claims to be at a level of pain control and physical activity similar to her premorbid state .
a 66-year - old female patient presented to the florida spine institute ( fsi ) as a referral from her dermatologist for the treatment of chronic pain in her bilateral lower limbs .
she had begun having pain in her lower limbs approximately 8 years prior to her first visit to the fsi .
the patient had developed a rash that encompassed large portions of her lower limbs and anus .
the patient had been diagnosed with ls et atrophicus at the department of dermatology and cutaneous surgery of the university of south florida ( tampa , fla . ,
there , the patient had been treated with steroids , with little improvement . over time , the patient had developed significant skin scarring , skin atrophy , and edema .
her pain was treated with a common neuropathic pain agent ( gabapentin ) and an opiate ( hydrocodone ) .
this pain regimen gave the patient mild relief , but her ability to perform physical activities was only minimally affected .
the patient stated that pain , weakness , and edema in her lower limbs were her main complaints and the reason for her intolerance of physical activity .
the pain was described as constant burning with deep aching pain and sporadic sharp pains . on a visual analog scale ( vas ) ,
she stated that if her pain were controlled , she would be able to increase her physical activity and performance . on physical exam ,
the patient 's skin revealed skin atrophy , scarring , and plaques consistent with ls et atrophicus located in both legs , thighs , buttocks , and the anus ( fig .
her lower limbs also demonstrated edema , color changes , and temperature changes in the distal parts of the legs ( when compared to the hands and upper thighs ) .
the major muscle groups in her lower limbs were considerably weak , but she had a manual muscle strength grade of at least 4 out of 5 .
thus , the patient was treated as a case of possible neuropathic pain , which was likely a complication of the patient 's ls .
the patient 's pain started after months of having her rash and escalated to a severity at which her ambulation and ability to perform her activities of daily living were significantly affected .
in addition , the patient 's sensory , vasomotor , and motor dysfunction as well as edema started months after the rash had started . at the time of her first visit ,
methadone was chosen because , in addition to being an opioid analgesic , it acts as a mild nmda receptor antagonist , a novel target for neuropathic pain .
the patient 's pain improved over the next month ( to vas 5/10 ) . despite the improvement in the patient 's pain , the main goal for the patient and treating physician was ultimately to discontinue opiate medications while maintaining adequate pain control
it has the ability to provide conscious sedation , but , more importantly , it is a potent nmda receptor antagonist .
in may 2014 , the patient was started on the ketamine infusion protocol set forth by the fsi . on day 1 , the patient was infused for approximately 4 h with 200 mg ketamine , 200 mg lidocaine , and 6 mg midazolam in a 100-ml bag of saline .
the ketamine dosage was increased by 200 mg each day until 800 mg was reached .
the overall clinical course of the patient in this case study is plotted in fig . 2 .
four days following the last ketamine infusion during a follow - up visit , the patient reported improvement in her pain levels ( to vas 4/10 ) .
one month after the ketamine infusions , the patient was seen for another follow - up .
areas that had previously been causing much discomfort due to sclerotic plaques and lesions showed drastic improvement .
in addition , the patient reported decreased allodynia , hyperpathia , and hypersensitivity in her lower limbs .
the patient volunteered to undergo 2 ketamine booster infusions over the course of 2 days . in july 2014 ,
her pain had significantly reduced ( to vas 1/10 ) from her pre - ketamine infusion state , and her ls rash and edema continued to be significantly reduced ( fig .
the patient 's ability to perform activities of daily living and ambulation were greatly improved .
over the course of 8 months , she received ketamine booster infusions every 23 months .
her pain continues to be controlled without the use of opiates ( vas 1/10 ) .
the patient 's rashes , edema , allodynia , and hypersensitivity continue to be significantly improved compared to the pre - ketamine infusion state .
she has undergone physical therapy with significant improvement in ambulation ability and exercise / physical activity tolerance .
the patient claims to be at a level of pain control and physical activity similar to her premorbid state .
a recent case - control study suggested that ls is characterized by aberrant autoimmune function .
that study compared a total of 190 women with adult - onset ls with healthy controls .
the authors found that patients with ls more frequently had autoimmune disorders ( 28 vs. 9% ; p < 0.001 ) , supporting an autoimmune association with ls .
thus , pharmacotherapies that address inflammation and autoimmune responses should be particularly useful for the treatment of ls . to our knowledge , there have been no other reports on the effects of ketamine in patients with ls until now . in our case study
, we report that the pain and dermatological pathology associated with ls in one patient were significantly reduced following ketamine infusion therapy that was employed for neuropathic pain .
even though this is an extremely rare case , we felt that these serendipitous observations related to the effects of ketamine in ls might spark further research to better understand its etiology .
moreover , this case study provides evidence that supports intravenous ketamine as an alternative treatment option for patients who can not manage their ls with topical steroids . that intravenous ketamine infusions drastically improved symptoms of ls in one patient is scientifically interesting , in part due to its debatable etiology .
ketamine is known to exert analgesic , anesthetic , bronchodilatory , immunomodulatory , neuroprotective , and antidepressant effects , probably via multiple pharmacological modalities .
although extensive efforts are already underway to repurpose ketamine for medical use beyond anesthesia , no other studies have looked at ls . as described in this case study , intravenous ketamine infusion not only provided rapid and sufficient analgesia but it also produced drastic and unexpected improvements in lesions associated with severe ls .
we believe that these therapeutic effects could be due to not yet fully understood immunomodulatory properties of ketamine . nonetheless , the results achieved for this patient merit further investigation .
moreover , we hope that future studies reveal the importance of ketamine 's polypharmacological effects in the context of various disease states , rather than fearing the drug 's nonspecificity .
 a patient reported to the florida spine institute ( clearwater , fla . , 
 usa ) with severe lichen sclerosus of the anogenital region and legs . 
 the patient 's pain presentation was neuropathic with hypersensitivity , allodynia , swelling , and weakness . 
 the patient had failed multiple pain management modalities including opioid therapy , anticonvulsants , and antidepressants . 
 the patient completed a standard intravenous ketamine infusion regimen developed at the florida spine institute and reported complete abolishment of her pain syndrome . 
 for the first time , we report that ketamine infusions also dramatically improved a patient 's lichen sclerosus . that ketamine is known to have immunomodulatory properties , and given the clinical observations described in this case report , suggests that ketamine should be explored as a possible new therapeutic option for managing lichen sclerosus , especially in cases that are refractory to conventional therapies . 
Introduction
Case Report
Patient History and Examination
Intravenous Ketamine Administration
Treatment Outcomes
Discussion and Conclusion
Statement of Ethics
Disclosure Statement