chronic, benign inflammatory disease that causes thinning of the vulvar skin in hypoestrogenic populations
associated autoimmune disease (eg, alopecia areata).
<aside> đź’ˇ lichen sclerosus does not affect the vagina it only affects the vulva.
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“Vulvar epithelial plaque formation describes lichen sclerosus”
| **Epidemiology (**hypoestrogenic) | • Prepubertal girls & perimenopausal or postmenopausal women |
|---|---|
| Clinical features | • Thin, white (hypopigmented) papules form and eventually merge into plaques |
| • Wrinkled skin over the labia majora/minora; atrophic changes that may extend over the perineum & around the anus | |
| • Chronic inflammation→severe pruritus→Excoriations, erosions, fissures and lichenification (ie, thickened skin), and edema of the labia. | |
| • Changes in vulvar architecture | |
| • Dysuria, dyspareunia, painful defecation | |
| Workup | • Dx is clinical but must do Punch biopsy of adult-onset lesions to exclude malignancy due to the association of lichen sclerosus with vulvar cancer. |
| • Children have no associated malginancy risk → no bx and dx is clinical | |
| • If initial biopsy is deferred, biopsy required if refractory to treatment. | |
| Treatment | • Superpotent corticosteroid ointment (eg, clobetasol) (decreases inflammation, resolves symptoms, and reduces the risk of malignancy) |
| • may also use topical emollients for daily symptom management. | |
| Prognosis | • Complete resolution however may recur |
In early stages of the disease, the vulva thins, causing hypopigmented (white) areas and increasing skin sensitivity that results in intense vulvar itching and burning (and associated erosions and excoriations). Chronic irritation and scratching transform the thinned skin to thickened, white vulvar plaques (ie, lichenification), often with perianal skin thickening in a classic figure-eight pattern. In severe cases, normal anatomic structures may be obliterated or atrophied, leading to loss of the labia minora and clitoral hood retraction, which can result in dyspareunia (as in this patient) and urinary symptoms (eg, dysuria, nocturia).
Patients with lichen sclerosus often have perianal skin involvement in a figure-eight pattern that can result in painful defecation and anal fissures.
Lichenification of the perianal region can result in anal fissures and constipation.
vulvar pruritus at times is so severe that it awakens affected individuals from sleep.
In severe cases, normal anatomic structures may be obliterated or atrophied, such as loss of the labia minora and clitoral hood, which can cause narrowing of the vaginal introitus and dyspareunia.
<aside> đź’ˇ Surgery is not recommended for most cases of lichen sclerosus because postoperative scarring can exacerbate symptoms and disease progression.
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Patients with chronic lichen sclerosus have continued inflammation and hyperplasia of the vulvar epithelium that can result in malignant transformation and development of a neoplastic lesion. This lesion typically develops over the labia majora and can become pruritic, friable, and ulcerated.