Evaluating the effectiveness of various treatment modalities in vulvar high-grade squamous intraepithelial lesions (vHSIL): a systematic review

• Systematic review comparing treatments for vulvar intraepithelial neoplasia • Evaluates excision, laser ablation, and topical imiquimod therapy. • Synthesizes global evidence to guide individualized treatment strategies. • Highlights need for standardized follow-up and long-term outcome reporting. • Identifies gaps for future research in vulvar precancer management. Vulvar high-grade squamous intraepithelial lesion (vHSIL) is a premalignant condition caused by persistent infection with high-risk human papillomavirus (HPV), with approximately 10% of cases progressing to vulvar carcinoma within ten years. This systematic review evaluates the effectiveness of surgical excision, CO 2 laser ablation, and imiquimod cream in terms of complete response (CR) and recurrence rates. A systematic review was performed following PRISMA guidelines, with literature searches conducted in Medline, Embase, and Web of Science (PROSPERO: CRD42024578702). Eligible studies included adult women (≥18 years) with histopathologically confirmed vHSIL requiring treatment. Two independent reviewers performed study selection and data extraction, and risk of bias was assessed using the Cochrane tools. Due to substantial study heterogeneity, a formal meta -analysis was not performed. Instead, pooled CR and recurrence rates were calculated using weighted averages, with 95% confidence intervals. Statistical heterogeneity was assessed with the I 2 statistic and Chi 2 test. 26 studies involving 1,705 patients were included. Pooled CR rates ranged from 55 to 100% for excision, 44–85% for CO 2 laser, and 25–81% for imiquimod. Recurrence rates varied from 0 to 83%, with the lowest recurrence observed in HPV-negative patients treated with imiquimod. Excision resulted in rapid CR but had high recurrence rates, particularly with positive surgical margins. Imiquimod caused local adverse effects (burning, erythema, irritation), but preserved anatomy, as did CO 2 laser ablation, which lacked histological control. No single treatment modality proved superior, with all showing high recurrence rates. These results emphasize the importance of individualized treatment strategies and further research to reduce recurrence.