Noninvasive vulvar lesions: An illustrated guide to diagnosis and treatment

FIGURE 1

Lichen sclerosus affects all ages

3-year-old child. Note the inflammation secondary to excoriations.

20-year-old woman. The glans clitoris has begun the hooding process.

70-year-old woman. The introitus has shrunk, making intercourse impossible.

Signs and symptoms

In lichen sclerosus, the skin of the vulva appears very thin, atrophic, and dry, resembling parchment. It is also white, with loss of pigmentation.

Pruritus is the most common symptom and is usually the presenting symptom. Scratching during sleep may create ulcerations and areas of ecchymosis, and there is generalized shrinking of the vulvar skin, with eventual loss of the labia minora.

The edema and shrinking that occur around the clitoris cause a “hooding” of the glans clitoris. If the process continues unchecked, it can involve the labia majora as well as the skin of the inner thigh and anal region.

Prescribe clobetasol ointment

The patient should be instructed to use clobetasol 0.05% ointment on a continuing basis. This drug is so successful it has eclipsed the use of testosterone propionate for this indication. Lorenz and colleagues² found very high success rates in 81 symptomatic patients with biopsy-proven disease who had failed previous therapy.

For reasons that are unknown, persistent use of this steroid on vulvar skin does not cause the atrophy commonly seen with prolonged use of high-potency steroids on other areas of the skin.

Start with twice-daily application and taper to less frequent use as the symptoms come under control. Most patients in remission can be maintained with twice-weekly application. Pruritus should disappear completely, and the skin itself will become less “leathery.”

Surgical treatment is not advised

Surgery does not appear to have a role because lichen sclerosus often recurs outside excised areas. Several reports have even described the return of disease in skin grafts used to replace large diseased areas.

I do not recommend surgery except in dire circumstances, when symptom relief is essential to the patient’s quality of life and all other therapies have failed.

Squamous cell hyperplasia

This disease is probably the same entity as lichen simplex chronicus. Changes in vulvar skin appear to result from chronic scratching secondary to intense pruritus. This complaint often involves a vicious cycle of scratching, increased pruritus, and more scratching, until excoriations occur. The aim of therapy is to eliminate the pruritus (FIGURE 2).

FIGURE 2

Squamous cell hyperplasia

75-year-old woman. The skin is thickened and may be leathery.

Intense pruritus and aggressive scratching lead to excoriations.

Signs and symptoms

Vulvar skin is typically white or pink. Biopsy will confirm the diagnosis, revealing a markedly thickened keratin layer (hyperkeratosis) and irregular thickening of the Malpighian ridges (acanthosis).

Inflammatory changes are also present, especially when there are areas of excoriation.

Treatment is similar to therapy for lichen sclerosus

Potent topical corticosteroids are the backbone of treatment; clobetasol is the preferred drug. The frequency of application is identical to that described for lichen sclerosus, and response to therapy usually takes 2 months. In the interim, it is advisable to prescribe other medications for the pruritus.

Lichen sclerosus and squamous cell hyperplasia sometimes coincide. Fortunately, the therapies are quite similar and both conditions tend to respond.

Vulvodynia

This disorder consists of chronic vulvar discomfort due to itching, burning, and/or pain that causes physical, sexual, and psychological distress.^3,4 Once referred to as essential vulvodynia, it now is defined as generalized vulvar dysesthesia.

Signs and symptoms

Women with this condition tend to have difficulty localizing their pain. They often present with a complaint of recurrent yeast infection or constant irritation at the introitus. Dyspareunia may or may not be a presenting symptom, although intercourse often triggers this condition. Tight pants or rough undergarments also may trigger symptoms.

Common symptoms. In a study by Sadownik,⁵ women with vulvar dysesthesia reported the following symptoms:

Women with vulvar dysesthesia who appear to have urinary tract symptoms should undergo a urine culture, though it will often be negative and antibiotic therapy will have little effect.

A diagnosis of exclusion

The pain of dysesthesia appears to be neuropathic in origin in that it mimics pain of the sensory nervous system. It may be diffuse or focal, unilateral or bilateral, constant or sporadic. Thus, it is a diagnosis of exclusion.

Recommended therapies

Vulvar dysesthesia should be regarded as a chronic pain syndrome and treated accordingly, with emphasis on generalized improvements in health and attitude rather than single-therapy approaches.

Potent topical corticosteroids are usually of no benefit. Nor does topical estrogen produce long-term relief.

Once all possible causes of symptoms are excluded, refer the patient for education, support, and treatment of depression, if present. Occasionally, topical anesthetics will provide short-term relief.