Intended for healthcare professionals

Rapid response to:

Clinical Review

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

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7214.899 (Published 02 October 1999) Cite this as: BMJ 1999;319:899

Rapid Response:

Childhood vulval lichen sclerosus and sexual abuse: an increasingly common problem

EDITOR—In lesson of the week, Wood and Bevan point out that failure
to recognise lichen sclerosus can lead to distressing allegations of
abuse. We agree with this fact, and in our cohort of 72 girls with early
onset lichen sclerosus, sexual abuse had been raised by the GP or within
the family in over 70% of cases1.

However, we would like to raise 3 further issues.

Firstly, we have
found that the increased anxiety and awareness of sexual abuse has lead to
increased and earlier referral of children to our paediatric vulval
clinic in recent years and resulted in earlier diagnosis and treatment
than even 5 years ago.

Secondly, it is important to remember that the 2
diagnoses are not mutually exclusive. 12 cases of lichen sclerosus were
found in proven cases of sexual abuse in Newcastle,2. Some authors have
speculated that the trauma and increased infection related to sexual abuse
may even act as a trigger to developing lichen sclerosus3, related to
Koebnerisation which is known to occur in this disease4. In view of this,
making a diagnosis of lichen sclerosus should not prevent further abuse
investigations if these remain warranted.

Lastly, our retrospective and
prospective studies on these children have shown that treatment initially
with potent or very potent topical steroids as previously reported in
adults5 and in children1,6 causes very few side effects. More importantly
it leads to faster resolution of symptoms, less likelihood of recurrence,
and lower total use of steroid because ‘maintenance’ treatment is so much
less than if mild topical steroids (such as 1% hydrocortisone as mentioned
in the article) are used. Successful treatment regimens are described
elsewhere.7

Jenny Powell
Specialist Dermatology Registrar

Fenella Wojnarowska
Professor of Dermatology.

Department of Dermatology, The Churchill, Oxford Radcliffe Hospitals, OX3
7LJ. UK

References.

1. Powell J, Marren P, Wojnarowska F, Prepubertal lichen sclerosus,
presentation, course and management. Br J Dermatol 1998; supp 51: p23
(abstr).

2. Warrington S, San Lazaro C. Lichen sclerosus and sexual abuse. Arch Dis
Child 1996; 75: 512-516.

3. Ridley CM. Genital lichen sclerosus in childhood and adolescence. J Roy
Soc Med 1993; 86: 69-75.

4. Todd P, Halpern S, Kirby J et al. Lichen sclerosus and the Koebner
phenomenon. Clin Exp Dermatol. 1994; 19: 262-263.

5. Dalziel K, Wojnarowska F, Millard P. The treatment of lichen sclerosus
with a very potent topical steroid (clobetasol proprionate 0.05%). Br J
Dermatol 1991; 124: 461-464.

6. Fischer G, Rogers M.. Treatment of Childhood Vulvar Lichen Sclerosus
with potent topical corticosteroid. Ped. Derm. 1997:14; 235-238.

7. Powell J, Wojnarowska F. Lichen Sclerosus – a seminar. The Lancet 1999:
353; 1777-1783.

Competing interests: No competing interests

03 November 1999
Jenny Powell
specialist registrar in dermatology
The Churchill, Oxford, UK