Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Retention, severe infection or suspected cancer
Acute urinary retention, rapidly progressive painful swelling or necrosis, uncontrolled bleeding, severe secondary infection or a persistent indurated ulcer, lump, hyperkeratotic plaque or architectural change suspicious for vulval squamous-cell carcinoma requires urgent specialist assessment.
Action: Relieve immediate pain and urinary or infectious danger, avoid traumatic repeated examination, and arrange urgent gynaecology, paediatric, urology or vulval-oncology review; obtain representative biopsy through an experienced service when malignancy is possible.
Synopsis
Recognise vulval lichen sclerosus across the life course, examine and biopsy sensitively, deliver a safe ultrapotent-steroid regimen, preserve anatomy and function, and maintain lifelong cancer-aware surveillance.
Vulval lichen sclerosus causes itch, soreness, fissuring and fragile white or pale atrophic plaques, often in a figure-of-eight pattern around vulva and anus.
Ecchymosis, purpura and erosions reflect fragility and scratching; in a child they require careful assessment but do not by themselves prove sexual abuse.
The vagina and cervix are usually spared, which helps distinguish lichen sclerosus from erosive lichen planus and some inflammatory vaginitides.
Key red flags
A new persistent lump, thickened or warty focus, induration, ulcer, unexplained bleeding, treatment-resistant erosion, enlarged groin node, urinary obstruction, severe pain or a diagnosis that remains uncertain requires prompt vulval specialist review and usually biopsy of the suspicious focus.
Cancer-warning focus
A persistent hard lump, ulcer, warty or thick keratotic area, focal erosion or bleeding that differs from surrounding disease requires urgent biopsy.
Investigation priorities
01
Consent-led vulval and perianal examinationFirst step
Confirm morphology, distribution and architectural change and locate any neoplastic focus.
Management branches
First-line inductionSuppress active inflammation with clobetasol
Clinical or biopsy-confirmed active vulval lichen sclerosus has no untreated infection or suspicious cancer focus requiring simultaneous assessment.
Demonstrate a thin layer of clobetasol propionate 0.05% ointment to affected skin once nightly for four weeks, using a mirror or diagram and recording the treated boundary.
Reduce to alternate nights for four weeks, then twice weekly for four weeks, while continuing bland emollient protection and avoiding soap, wipes, fragrance and friction.
Key medicines
Clobetasol propionate 0.05% ointmentFor a typical adult induction, apply a thin layer to affected vulval and perianal skin once nightly for 4 weeks, on alternate nights for 4 weeks, then twice weekly for 4 weeks; about 30 g usually covers 12 weeks. Individualise paediatric and maintenance schedules through the specialist plan.
Bland emollient ointmentApply a fragrance-free ointment barrier as often as required, including before urine, after gentle washing and at a separate time from clobetasol if mixing would dilute the medicated layer.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
BAD lichen sclerosus in femalesRecognition, three-month clobetasol regimen, maintenance, self-examination and cancer-warning changes.
NHS lichen sclerosusSymptoms across adults and children, treatment, follow-up and urgent change advice.