Clinical review

Lesson of the week Child sexual abuse enquiries and unrecognised vulval lichen sclerosus et atrophicus

P L Wood, consultant,  T Bevan, paediatric nurse. 

Paediatric and Adolescent Gynaecology Clinic, Kettering General Hospital NHS Trust, Kettering NN16 8UZ

Correspondence to: Mr Wood PLWoldvic{at}compuserve.com

Lichen sclerosus et atrophicus in young girls can present as haemorrhagic areas on the vulva. Failure to consider this diagnosis and to treat the condition appropriately may lead to a misdiagnosis of child sexual abuse, resulting in a lengthy and distressing investigation for all concerned, particularly the parents. There was extensive publicity surrounding these issues in the United Kingdom after events in Cleveland in 1987. We present three patients with lichen sclerosis et atrophicus. In each case, investigations into child sexual abuse had been instigated before an appropriate referral and correct diagnosis were made.

	Case reports

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Case 1
A 6 year old girl was admitted to hospital as an emergency under the care of the paediatricians. There was a history of a suspected accidental fall, after which the girl's mother noticed blood staining on her daughter's underwear. The girl lived with her mother and her mother's partner and visited her natural father once a week.

View larger version (180K): [in this window] [in a new window]   Typical vulval changes of lichen sclerosus et atrophicus in a young girl

Case 2
A general practitioner telephoned the paediatric gynaecology clinic about a patienta 6 year old girl whose condition might be explained by "abuse of some sort." He had identified bleeding from the labial area and at follow up had noticed bruising of the labia and introitus.

Case 3
A 4 year old girl with a history of vulval infections over the previous 9-10 months was referred to the paediatric gynaecology clinic by her general practitioner. The infections had been associated with bruising and a "blood blister," and her family had wondered about the possibility of sexual abuse to the extent that her father had telephoned social services for help and advice. The parents had noticed that their daughter had been lying on top of her teddy bear and rubbing herself. She had had several episodes of these symptoms, which were treated with courses of antibiotics. The girl's general practitioner remarked that she had been shocked by the vulval redness, inflammation, bruising, and ulceration. The child's parents were anxious and distressed and requested a further opinion.

	Comment

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Lichen sclerosus et atrophicus generally affects the anogenital region. It is most often found in women but is also seen in young girls and was first reported in young girls about 30 years ago.¹ Because the condition is uncommon before puberty, however, general practitioners and paediatricians who have not come across lichen sclerosus et atrophicus in children may have a low index of suspicion and may fail to recognise the typical appearances. This lack of awareness persists despite recent reports highlighting the existence of the condition in children and noting confusion with regard to the misdiagnosis of childhood sexual abuse, of which there is an increased general awareness. ^{2 3}

The symptoms of itching and soreness can be troublesome, and a young child may try various ways of obtaining relief, some of which may be mistakenly interpreted as masturbatory behaviour.⁴ Masturbation is not uncommon in children,⁵ but rubbing may lead to concerns over possible sexual abuse if it is perceived as inappropriate childhood behaviour.

The appearances of lichen sclerosus et atrophicus include localised haemorrhages (figure).⁶ A clue to the true diagnosis is the delineation of thinned skin, which gives a well demarcated parchment-type appearance, often in an hourglass shape.

The presence of lichen sclerosus et atrophicus may, in itself, increase the susceptibility to trauma, since the skin becomes thin and easily damaged. As a result, the effect of minor injuries may be magnifiedfor example, wiping with toilet tissue may cause bruising.³

Vulval bruising, which is not always accompanied by the more typical symptoms of lichen sclerosus et atrophicus such as soreness or pruritus, can raise suspicions of possible childhood sexual abuse. These suspicions warrant an appropriate investigation, which can be upsetting for all concerned. Failure to recognise that the underlying changes are caused by lichen sclerosus et atrophicus, and to treat these accordingly, can therefore lead to inappropriate investigations. Nevertheless, the condition and sexual abuse may coexist. Hymenal trauma is an important marker in helping to determine whether sexual abuse has occurred, regardless of the presence of lichen sclerosus et atrophicus.⁷ Expert diagnosis is necessary to ensure a correct diagnosis, relevant further investigations, and treatment (box).

All the families concerned in these cases were greatly relieved when the correct diagnosis was identified. There was also a degree of upset and resentment that a child sexual abuse inquiry had unnecessarily been initiated because of a failure to recognise the underlying disorder. The misdiagnosis of lichen sclerosus et atrophicus in young girls remains a problem. Despite previous published reports, general practitioners and paediatricians are still failing to consider the diagnosis or recognise its typical appearances.

	Acknowledgments

   Contributors: Both authors were involved in the care of the patients. TB carried out the literature searches; PLW wrote the paper and will be guarantor.

	References

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1.	Clark JA, Muller SA. Lichen sclerosus et atrophicus in children. Arch Dermatol 1967; 95: 476-482[Medline].
2.	Handfield-Jones SE, Hinde FRJ, Kennedy CTC. Lichen sclerosus et atrophicus in children misdiagnosed as sexual abuse. BMJ 1987; 294: 1404-1405.
3.	Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma. Am J Dis Children 1990; 144: 1319-1322[Abstract].
4.	Levene MI, ed. Jolly's diseases of children. 6th ed. Oxford: Blackwell Scientific, 1991.
5.	Hull D, Johnston D, eds. Essential paediatrics. 3rd ed. Edinburgh: Churchill Livingstone, 1993.
6.	DiSilverio A, Serri F. Generalised bullous and haemorrhagic lichen sclerosus et atrophicus. Br J Dermatol 1975; 93: 215-217[Medline].
7.	Warrington SA, de San Lazaro C. Lichen sclerosus et atrophicus and sexual abuse. Arch Dis Child 1996; 75: 512-516[Abstract].

(Accepted 18 February 1999)