Not All 'Vaginal Itching' is the Same (But It's All Miserable)

Andrew M. Kaunitz, MD


June 07, 2019

This transcript has been edited for clarity.

Hello. I am Andrew Kaunitz, professor and associate chair in the Department of Obstetrics and Gynecology at the University of Florida College of Medicine in Jacksonville.

Lichen sclerosus is an inflammatory skin condition that often presents with chronic vulvar pruritus and irritation as well as sexual discomfort; less often, lichen sclerosus causes few—if any—symptoms. This disease characteristically presents in menopausal women in their 50s or older.

Among the patients in my practice with genital lichen sclerosus, symptoms have often been present for years prior to a correct diagnosis. Often, these patients had been misdiagnosed with chronic vulvar candidiasis or genitourinary syndrome of menopause.

This observation underscores the importance of recognizing that not all vulvar pruritus is caused by candidiasis or atrophy, and of inspecting the external genitals in patients with this common complaint.

Dermatologic changes suggestive of lichen sclerosus include loss of pigmentation of the labia minora and the sulcus between the labia minora and majora, resulting in a whitish appearance. In addition to these characteristic color changes, inflammation may result in loss of labia minora tissue with fusion or phimosis of the clitoral hood. The changes of lichen sclerosus may also extend to the perianal skin.

In the past, I used a handheld mirror to allow patients to inspect vulvar changes. However, many women chose not to use the mirror, and for those who did, its use could be physically awkward. The electronic medical record (EMR) used by my institution includes a mobile phone app that facilitates patient photographs, which are stored in the EMR.

In contrast with the mirror approach, I have found that my patients with lichen sclerosus and other vulvar conditions universally appreciate being able to review their external genital changes on my computer monitor in the examination room. Photos also facilitate counseling patients regarding application of ointment for treatment.

Lichen sclerosus represents a chronic condition requiring indefinite or even lifelong treatment. In this context, a biopsy confirming the diagnosis is appropriate, even when characteristic skin changes are present. Because treatment can impact histopathologic interpretation, biopsy should be performed prior to starting treatment.

Applying a very high-potency topical corticosteroid ointment, such as clobetasol, twice daily for 6 weeks predictably will reduce women's symptoms. Once the skin changes have noticeably improved, the frequency of ointment application can be reduced to two to three times weekly at night.

In my practice, I ask patients to return for an office visit 2-3 months after starting treatment. Often, as symptoms improve or resolve, women will discontinue treatment. Accordingly, seeing stable lichen sclerosus patients on a regular basis (eg, every 6 months) provides an opportunity to review the disease with the patient and encourage ongoing treatment.

The bottom line is that regular external genital examination represents an important component of the care of well women and those with vulvar symptoms. Timely, accurate diagnosis of genital lichen sclerosus and effective treatment improves the health and quality of life of our patients.

Thank you for the honor of your time. I am Andrew Kaunitz.

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