Vulval Skin Disorders: Management
Classification
Non-infective vulval disease falls into three broad groups: inflammatory dermatoses, vulval pain syndromes (vulvodynia), and pre-malignant squamous intraepithelial lesions.
Lichen sclerosus (LS): chronic inflammatory dermatosis causing white, atrophic, often figure-of-eight perianal/perivulval plaques, fissuring, and architectural change (fusion of the labia minora, clitoral burying). Associated with pruritus, dyspareunia, and a small but real risk of malignant transformation.
Lichen planus (LP): immune-mediated dermatosis with erosive, papulosquamous, or hypertrophic vulval variants. The erosive form causes painful vulval and vaginal erosions with a Wickham's striae border and can lead to vaginal adhesions/stenosis; it is part of the vulvo-vaginal-gingival syndrome.
Vulval intraepithelial neoplasia (VIN): per ISSVD 2015 terminology, split into HSIL (usual-type VIN — warty, basaloid, or mixed), which is HPV-driven and linked to smoking and immunosuppression, and differentiated VIN (dVIN), which is HPV-independent, typically arises on a background of lichen sclerosus, and carries a higher and more rapid risk of progression to squamous cell carcinoma despite often being a smaller, more subtle lesion.
Diagnostic Approach and Biopsy Indications
Diagnosis is primarily clinical, but biopsy under local anaesthetic is required when:
- Diagnostic uncertainty exists or presentation is atypical
- Suspicion of dVIN, VIN, or squamous cell carcinoma arises (any ulcerated, indurated, fixed, or non-healing area)
- Lichen sclerosus fails to respond to an adequate trial of first-line topical steroid
- Persistent hyperkeratosis, ulceration, or a new focal lesion develops within known LS/LP
- Lichen planus diagnosis is unclear — biopsy is taken across the edge of an erosion, where characteristic changes are most likely found
- Younger patients present with suspected LS, where histological confirmation is favoured
Biopsy is not routinely required for classic, symptom-typical vulval eczema.
Management
Lichen sclerosus: first-line is ultrapotent clobetasol propionate — once daily for one month, then alternate days for one month, then twice weekly for one month; mometasone furoate is an effective alternative. Most patients then move to as-needed dosing, though some need ongoing once/twice-weekly maintenance to limit scarring. Follow-up at 3, 6, and 12 months; stable disease reverts to GP care with re-referral if symptoms change, given the risk of vulval carcinoma.
Lichen planus: erosive/classic vulval disease uses the same ultrapotent steroid taper as LS. Vaginal involvement additionally needs steroid via a dilator or vaginal suppositories to prevent adhesions/stenosis. Reassess at 2–3 months; erosive LP needs long-term specialist follow-up.
VIN: management is individualised — wide local excision (also excludes occult invasion), topical imiquimod, laser ablation, or surveillance in selected cases, with a lower threshold for excision in dVIN given its stronger link to invasive carcinoma.
High-Yield Exam Points
- GTG 58 is archived; the current authoritative reference for vulval dermatoses is the BASHH UK national guideline (2014, updated 2024) — cite BASHH rather than RCOG GTG 58 in a live exam answer.
- Lichen sclerosus: figure-of-eight white atrophic plaques, architectural change, small risk of SCC — first-line clobetasol propionate with a tapering (daily → alternate-day → twice-weekly) regimen over 3 months.
- Biopsy lichen sclerosus if it fails to respond to adequate steroid treatment, or if ulceration/hyperkeratosis/a focal lesion develops — these are red flags for dVIN/SCC.
- Differentiated VIN (dVIN) arises on lichen sclerosus, is HPV-negative, and progresses to SCC faster than usual-type VIN (HSIL), which is HPV-driven and linked to smoking/immunosuppression.
- Erosive lichen planus is part of the vulvo-vaginal-gingival syndrome and needs vaginal (not just vulval) steroid treatment to prevent stenosis.
- Any suspicious, ulcerated, or treatment-resistant vulval lesion warrants biopsy to exclude malignancy — do not treat empirically and observe indefinitely.
Source: RCOG Green-top Guideline No. 58 (Archived — RCOG directs readers to the British Association for Sexual Health and HIV (BASHH) UK National Guideline on the Management of Vulval Conditions, most recently updated 2024) (RCOG GTG 58 was due for review 22 February 2011 and has since been formally archived with no republished RCOG edition; successor BASHH guideline dated 2024)
Read the original on rcog.org.uk
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