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.
- Chronic inflammation can resorb labia minora, bury the clitoris and narrow the introitus; early control aims to prevent further scarring but may not reverse established architecture.
- Diagnosis is often clinical, but biopsy is needed for diagnostic uncertainty, non-response or any persistent ulcer, induration, hyperkeratosis, new lump or suspected neoplasia.
- First-line induction is clobetasol propionate 0.05% ointment: once nightly for four weeks, alternate nights for four weeks, then twice weekly for four weeks, with review and technique check.
- A 30 g tube is usually sufficient for the 12-week adult induction when applied correctly; excess or very low use should trigger review of technique and disease extent.
- Many patients need individualised maintenance, often twice weekly, to prevent relapse and scarring; controlled use is safer than leaving active disease untreated.
- Offer a mirror-based monthly self-check where appropriate and at least annual clinical review, with earlier assessment for any focal change because vulval squamous-cell carcinoma risk is increased.
- Use trauma-informed language, explicit consent, offered chaperone and the minimum necessary exposure; discuss sexual, urinary and bowel effects without assumptions about gender, partners or practices.
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.
A persistent hard lump, ulcer, warty or thick keratotic area, focal erosion or bleeding that differs from surrounding disease requires urgent biopsy.
Investigation priorities
Confirm morphology, distribution and architectural change and locate any neoplastic focus.
Management branches
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.
- Review around 12 weeks for symptom, texture, fissure and architecture response, check the tube and technique and biopsy any focal lesion that persists despite correct therapy.