QuestionSBA
QuestionChoice
Vulvovaginal candidiasis is one of the most common causes of vaginal itch, however does not typically cause changes in the architecture of the vulva. With vulvovaginal candidiasis, a thick, lumpy discharge is usually evident.
50031
e
Vulvovaginal candiasis
QuestionChoice
Lichen sclerosus is an inflammatory skin condition that presents with itch and soreness. The tissues can lose their normal architecture, the introitus can become narrowed, and the labia minora and clitoral hood can become fused, burying the clitoris itself. The tissues appear pale and white, and fissuring or erosions may be evident. Lichen sclerosus is associated with other atopic conditions such as asthma and eczema.
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a
Lichen sclerosus
QuestionChoice
Whilst premature ovarian failure can cause the vulva to appear white and atrophied, and also may cause dyspareunia, the tissues do not tend to become fused. In addition, she does not complain of any other symptoms of premature ovarian failure.
50028
b
Premature ovarian failure
QuestionChoice
Vaginismus occurs when the pelvic floor muscles involuntarily spasm with touch or penetration. Whilst this can cause dyspareunia, it would not cause the changes seen in the vulval skin.
50029
c
Vaginismus
QuestionChoice
Lichen planus presents in a similar way to lichen sclerosus; however, lichen planus involves the mucous membranes such as the vagina as well as the skin. The usual presentation is with white or purple raised plaques.

Lichen planus is characterised by the 6 Ps:

- Purple
- Pruritic (itchy)
- Polygonal (multiple sides)
- Planar (flat-topped)
- Papules/plaques
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Lichen planus
Concept
Chapter
# Summary
  
 
Lichen sclerosus is an inflammatory skin condition that predominantly affects the genital and anal areas, characterized by white patches which may scar. It frequently presents itself with symptoms of itchiness and pain, and is more common in females than males. Key investigations for this condition include clinical evaluation, skin biopsy, and possibly blood tests. Management strategies often include topical steroids, avoidance of soaps in affected areas, and use of emollients to alleviate dryness and itching.
  
 
# Definition
  
 
Lichen sclerosus is an inflammatory dermatological condition. It predominantly affects the genital and anal regions of the body, but it can present elsewhere. There is a noted predilection for this condition in females compared to males. The subtype, vulvar lichen sclerosus, specifically involves the inner vulva.
  
 
# Aetiology
  
 
The cause of lichen sclerosus is currently unknown, but it is likely multifactorial. Potential contributing factors could include autoimmune reactions, genetic predisposition, and hormonal factors. Some studies suggest a possible link with previous skin damage or trauma.
  
 
# Signs and Symptoms
  
 
- White patches on the skin which may progress to scarring. 
- Itchiness and pain over patches, which may be exacerbated during urination or sexual intercourse.
- Bleeding over patches, especially following sexual intercourse or passing of bowel motions. 
  
 
  
 
# Differential Diagnosis
  
 
The differential diagnosis for lichen sclerosus includes other dermatological conditions such as:
  
 
  - Lichen planus: Characterised by purple-looking, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.
  
  - Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.
  
  - Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.
  
 
# Investigations
  
**Bedside:**

- Vulval examination: This should be enough to diagnose lichen sclerosus, if characteristic lesions are present. 


No **blood tests** are required for diagnosis, but may on occasion be used to rule out other autoimmune conditions if there is clinical uncertainty. However, keep in mind that serology for autoimmune conditions often has low specificity. 

No **imaging** is required.

**Invasive:**

- Skin biopsy: May be used to confirm the diagnosis. 
  
 
# Management
  
 
The management of lichen sclerosus includes:
  
 **Conservative:**
 
 - Avoidance of soaps in the affected areas to prevent further irritation.
 - Avoid tight clothing, rubbing or scratching. 
 - Topical emollients to relieve dryness and soothe itching. 
 
**Medical:**


 - Topical corticosteroids (most often potent steroids, such as dermovate) to reduce inflammation and itching.
 - Topical cacineurin inhibitors (e.g. Tacrolimus) may be used in addition to steroids. However, they can cause burning and discomfort in the first few days of application. 
 - Topical oestrogen cream or pessaries for postmenopausal women affected by atrophic vulvovaginitis, caused or exacerbated by scarring of lesions.  
 - Oral treatment with corticosteroids, retinoids, methotrexate or ciclosporin may be indicated in severe cases that do not respond to topical therapies. 

**Surgical:**

Whilst surgical management is not usually performed, it can be used in cases of severe adhesions and advanced scarring that impacts continence and sexual intercourse, where conservative and medical measures have not helped.
Surgery would also be indicated in cases of squamous cell carcinoma (see complications). 


# Complications

- Infections: Namely Candida albicans, Staphylocuccus aureus, Herpes simplex, predisposed by breaks in the skin. 
- Squamous cell carcinoma: Affects up to 5% of patients with vulval lichen sclerosus. 
- Worsening constipation: Often as a result of pain or discomfort while passing bowel motions. 
 
 
# NICE Guildelines

[Click here for NICE Guildelines on assessment of vulval itching](https://cks.nice.org.uk/topics/pruritus-vulvae/diagnosis/assessment/)


# References
  
 
[BASHH 2014 UK National Guideline on the Management of Vulval Conditions](https://www.bashh.org/documents/UK%20national%20guideline%20for%20the%20management%20of%20vulval%20conditions%202014.pdf)

[DermNet](https://dermnetnz.org/topics/lichen-sclerosus)

[NHS UK](https://www.nhs.uk/conditions/lichen-sclerosus/)
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Lichen sclerosus
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Gynaecology
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Lichen sclerosus
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A 35-year-old woman attends her general practitioner with difficulties during penetrative sex. She describes painful penetration, which feels superficial. In addition, she states her vulva is always itchy, and she has used several over the counter thrush remedies without resolution of symptoms.

She had a spontaneous vaginal delivery two years ago, and has a past medical history of asthma which is treated with an inhaled corticosteroid inhaler.

On examination, her vulva generally appears pale, with some fissuring around the introitus. The clitoris is not visible. Digital vaginal examination is painful, and a gentle speculum examination reveals a normal vaginal mucosa with a thin, white non-odorous discharge present.

What is the most likely underlying cause of her symptoms?
a