Practice Easily Missed?

Lichen sclerosus

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c731 (Published 15 February 2010) Cite this as: BMJ 2010;340:c731
  1. Kate Dalziel, honorary consultant dermatologist 1,
  2. Sarah Shaw, general practitioner2
  1. 1Royal Cornwall Hospital, Truro TR1 3LJ
  2. 2Stennack Surgery, St Ives
  1. Correspondence to: K Dalziel kate.dalziel{at}rcht.cornwall.nhs.uk
  • Accepted 25 January 2010

Case scenario

An 89 year old woman presents with severe vulval itch that wakes her at night. She had previously been prescribed topical clotrimazole cream and subsequently oestrogen cream with no response.

Examination shows white plaques, areas of purpura, and excoriation of the skin around the vulva and perianal region. You suspect lichen sclerosus and refer her to the vulval clinic. You also prescribe a moderately potent topical steroid and an emollient and check her thyroid function. At the vulval clinic a diagnosis of vulval lichen sclerosus with scarring is confirmed by vulval biopsy, and very potent topical steroids are prescribed, with excellent clinical response.

Lichen sclerosus is a chronic inflammatory skin disease usually involving the anogenital skin. It is most common in postmenopausal women but occurs in both sexes at all ages.1 The cause is unknown, but lichen sclerosus is strongly associated with autoimmune disorders, particularly thyroid disease, in almost 30% of patients.2

How common is lichen sclerosus?

  • No good prevalence data exist for lichen sclerosus in either sex

  • Lichen sclerosus is one of the most frequently seen conditions in vulval clinics.1 It is the commonest underlying skin disease in elderly women presenting with squamous carcinoma of the vulva3

  • It has been found in 60% of boys requiring circumcision for acquired phimosis4

Why is it missed?

Lack of familiarity with the condition and failure to examine the genital skin properly can lead to long delays in diagnosis. Reticence and embarrassment on the part of patient and doctor may hinder the taking of a full history and examination. Common mistaken diagnoses in women are candida infection and postmenopausal vulval atrophy. Candida vulvovaginitis is usually confined to women of childbearing years5 and is unusual in older women unless there are additional risk factors such as diabetes. The delay to diagnosis in one case series of 327 …

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