Photo Rounds

Genital itching and burning

After having itching and mild burning pain in the genital area for the previous 6 months, a 53-year-old woman went to see her family physician. She had stopped having her period 2 years ago and denied having any extramarital relationships, vaginal bleeding, or discharge.

What's your diagnosis?


The patient was given a diagnosis of lichen sclerosus, which is recognized by the hour-glass configuration of the atrophy around the vulva and perianal region. (Some atrophic changes of the vulva that can be mistaken for the atrophy of estrogen deficiency.)

Lichen sclerosus is not contagious and typically affects postmenopausal women. It's unclear what causes the condition.

Lichen sclerosus is treated with a high-potency steroid ointment (such as clobetasol) rather than estrogen or topical testosterone. Studies have demonstrated that high-potency topical steroid ointments are the most effective treatment and do not cause atrophy as an adverse effect. While topical testosterone was used in the past, it has not been proven effective and should no longer be prescribed.

The topical steroid should be applied twice daily and tapered to once daily followed by an as-needed regimen based on symptoms.

There is a higher risk of vaginal intraepithelial neoplasia and squamous cell carcinoma in patients with genital lichen sclerosus. Yearly examination for premalignant and malignant changes of the external genitalia is recommended. Areas with thick leukoplakia, mucosal ulcerations, and erythroplakia should be biopsied to rule out malignancy.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Atrophic vaginitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:489-493.

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