Differential Diagnosis for Vulvar Itching in an 87-year-old Woman

• Single most likely diagnosis
  • B) Lichen sclerosus: This condition is characterized by thinning of the vulvar skin, which becomes white and fragile, leading to itching and discomfort. The absence of the labia minora and the presence of small fissures at the introitus are also consistent with lichen sclerosus. It is a common cause of vulvar itching in postmenopausal women.
• Other Likely diagnoses
  • A) Escherichia coli infection: Although less likely given the description, an E. coli infection could cause vulvar itching, especially if there is an associated urinary tract infection. However, the presence of excoriated areas and the specific changes to the vulvar anatomy are less typical for an infection.
  • F) Vulvar vestibulitis: This condition involves inflammation of the vestibular glands and can cause itching and pain, particularly with touch or pressure. However, it is more commonly associated with pain during sexual intercourse and does not typically cause the architectural changes seen in this patient.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • C) Squamous cell carcinoma: Although less common, vulvar cancer can present with itching and should always be considered in the differential diagnosis of persistent vulvar symptoms, especially in older women. A biopsy would be necessary to confirm the diagnosis.
  • E) Vulvar melanoma: This is a rare but aggressive form of skin cancer that can present with itching or a new pigmented lesion. Given its potential for rapid progression and poor prognosis if not caught early, it is crucial to consider and rule out melanoma.
• Rare diagnoses
  • D) Trichomoniasis: This is a sexually transmitted infection that can cause vulvar itching but is less likely in an 87-year-old woman without a history of new sexual partners. It typically presents with a malodorous discharge and is not associated with the specific anatomical changes described.