|Vulval skin conditions are often embarrassing for patients to discuss and may be incorrectly diagnosed as candidiasis.
These conditions have significant capacity to affect patients’ health-related quality of life, so careful history and examination are required to ensure accurate diagnosis.
Erosive lichen planus, lichen sclerosus, lichen simplex chronicus, vulval seborrhoeic dermatitis
Vulval conditions are common at all ages, but patients are often reluctant to discuss symptoms with their doctor. Women are frequently referred to secondary care without prior clinical examination. Many have repeated courses of treatment for candidiasis with neither a definitive diagnosis, nor any benefit.
Misdiagnosis contributes to morbidity and sexual dysfunction, as well as relationship difficulties. Differentials include important conditions, such as sexual abuse.
Several distinct vulval conditions can be diagnosed clinically and appropriate information and management significantly improves the patient’s quality of life. This article focuses on four of the most common vulval dermatoses, their differential diagnoses and management.
|Lichen simplex chronicus|
|Erosive lichen planus|
When assessing a patient with vulval symptoms, a clinical history should include the following:
- Personal and family history of autoimmune disease, atopy or psoriasis
- Symptoms, such as pain, itch, rash, with exact sites involved
- Washing and self-care practices
- Impact on quality of life, including sexual activity
- Current and previous treatments, oral and topical
- Medications and allergies
Seborrhoeic dermatitis, also known as sebopsoriasis or flexural psoriasis, is one of the most common vulval dermatoses. It can be seen as an overlap between eczema and psoriasis, with a contributory role from commensal yeasts.1
Other body sites are usually involved, such as the scalp (in the form of dandruff), ears, glabella, central chest and natal cleft.
Some patients will have typical chronic plaque psoriasis of the elbows and knees, and nail pitting. Unlike other forms of eczema, the itch is usually mild and most patients present with redness and scaling. The vulva is a flexural site, so the scale is minimal. The well-circumscribed bright red erythema of the vulva, perianal skin and natal cleft is characteristic.
Lichen simplex chronicus
Lichen simplex chronicus (figures 1 and 2) is a common condition characterised by severe itch and resultant thickening (lichenification) of the skin. In the vulva, it typically affects the labia majora, either unilaterally or bilaterally.
The itch is often severe enough to disturb sleep. An underlying atopic diathesis is often present. Investigation for causes of itch can be rewarding. Iron deficiency is a common finding and so is worth testing for. Overwashing with soap or other detergents can be a contributory factor.
Figures 1 (above) and 2 (below): Lichen simplex chronicus (Images: Dr Victoria Swale)
Lichen sclerosus (figure 3) can affect patients of both sexes at any age, but in women, most are postmenopausal. The condition is usually extremely itchy, but may present with colour change or be an incidental finding during gynaecological examination.
The condition typically involves the vulval and perianal skin in a figure eight distribution, with pallor and petechiae. The petechiae can be mistaken for sexual abuse.2
Established lichen sclerosus is characterised by architectural changes (scarring), with loss of the labia minora and fusion of the clitoral hood. Approximately 4% of women with lichen sclerosus develop vulval squamous cell carcinoma.
Evidence-based guidelines for the management of patients with lichen sclerosus discuss the central role of superpotent topical steroids and emollients.3
Figure 3: Lichen sclerosus (Image: Dr Victoria Swale)
Erosive lichen planus
Erosive lichen planus (figure 4) is an important condition because although it is not common, it can cause significant pain and permanent scarring.
There may be bright red, eroded areas in the vestibule; most women also have vaginal involvement, which can cause permanent stenosis.
Referral to secondary care is important for confirmation of the diagnosis, often with a biopsy. Treatment is with superpotent topical steroids and often requires an oral immunosuppressive agent, such as methotrexate.
Figure 4: Erosive lichen planus (Image: Dr Ekaterina Burova)
Management of vulval skin conditions
Assessing the condition’s impact on quality of life is important, not least as a way of assessing response to treatment. The Dermatology Life Quality Index is a rapid means of measuring this, based on a patient questionnaire.4
Women should be advised to use an emollient, such as emulsifying ointment, for washing and moisturising several times daily. Aqueous cream is not a suitable emollient, because of the possible irritant effects of its emulsifying component, sodium lauryl sulfate.5 Bubble bath, shower gel, moist wipes and antiseptics should not be used.
A topical steroid preparation, usually an ointment, can be used for a defined period, the general principle being to use the least potent preparation effective for the shortest time required. Calcineurin inhibitors, such as tacrolimus ointment and pimecrolimus cream, are useful alternatives.
Written instructions on how to use treatments are helpful in promoting adherence. Many patients appreciate suggestions for appropriate websites from which they can obtain further information and advice (see resources). Patients with lichen sclerosus and lichen planus will need life-long follow-up.
|MANAGEMENT AND REFERRAL6|
General management of vulval skin conditions
Patient education is essential
|Stop soap and other detergents/irritants|
|Emollient, such as emulsifying ointment, as soap
substitute and regular moisturiser
|Non-irritant lubricant for sexual activity|
Topical steroid ointment for limited time
|Aqueous cream is not a suitable moisturiser|
Indications for referral to secondary care
Non-response to treatment
Severe impact on quality of life
Possible allergic contact dermatitis
- Dr Victoria Swale is consultant dermatologist at The Royal Free Hospital, The London Clinic and The Platinum Medical Centre
Competing interests: None declared
1. Neill S, Lewis F. Ridley’s The Vulva (third edition). Oxford, Wiley-Blackwell, 2009.
2. Handfield-Jones S, Hinde F, Kennedy C. Lichen sclerosus et atrophicus in children misdiagnosed as sexual abuse. BMJ 1987; 294; 1404-5.
3. Kirtschig G, Becker K, Günthert A et al. Evidence-based (S3) guideline on (anogenital) lichen sclerosus. J Euro Acad Dermatovenereol Venereol 2015; 29: e1–e43.
4. Finlay AY, Khan G. Dermatology Life Quality Index (DLQI): a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19: 210-16.
5. MHRA Drug Safety Update. Aqueous cream: may cause skin irritation.
6. Moyal-Barracco M, Wendling J. Vulvar dermatosis. Best practice and research. Clin Obstet Gynaecol 2014; 28: 946-58.