What is the workup for chronic excoriation of the labia?

Workup for Chronic Excoriation of the Labia

The workup for chronic labial excoriation must prioritize identifying lichen sclerosus through biopsy, as this is the most critical diagnosis requiring confirmation, followed by systematic evaluation for infectious, dermatologic, and psychiatric etiologies.

Initial Clinical Assessment

History Taking

• Duration and pattern of symptoms: Document chronicity, cyclical nature, and any periods of remission 1
• Primary symptom characterization: Distinguish between pruritus (suggesting lichen sclerosus), pain with erosions/fissures, or compulsive picking behavior 1, 2
• Sexual history and STI risk factors: Essential for identifying infectious causes 1
• Autoimmune disease history: Lichen sclerosus has autoimmune associations 2
• Psychiatric comorbidities: Screen for excoriation disorder, anxiety, depression, and obsessive-compulsive features 3, 4
• Trauma history: Including piercings, injuries, or sexual trauma 2

Physical Examination Specifics

• Inspect for lichen sclerosus hallmarks: Porcelain-white papules and plaques, areas of ecchymosis, involvement of interlabial sulci and labia minora 1, 2
• Evaluate for infectious signs: Erythema, tenderness, ulcerations (herpes), flesh-colored papules (syphilis), or Bartholin gland swelling 2
• Document excoriation patterns: Self-induced lesions, lichenification from chronic scratching 5
• Assess for anatomic changes: Labial fusion, introital narrowing, clitoral hood adhesions 1
• Examine vagina and cervix: Cytologic smears to evaluate for multifocal squamous intraepithelial neoplasia 1

Mandatory Diagnostic Testing

Biopsy - The Critical First Step

Biopsy of the affected area is mandatory before initiating treatment to confirm lichen sclerosus and rule out squamous cell carcinoma 1. This is non-negotiable given:

• The 3.5-5% malignant transformation risk in lichen sclerosus 1
• The need to distinguish lichen sclerosus from other dermatoses 1
• Histopathologic confirmation guides all subsequent management 1

Infectious Workup

• STI testing: Gonorrhea and chlamydia nucleic acid amplification tests, particularly if Bartholin or Skene gland involvement 2
• Viral culture for HSV: When ulcerations are present 2
• Serologic testing for syphilis: RPR/VDRL with confirmatory treponemal testing if papules present 2
• Vaginal cultures: For recurrent symptoms to identify Candida species, especially non-albicans species 1

Additional Laboratory Studies

• CBC, liver and renal function tests: Baseline assessment 1
• Autoimmune screening: Consider if lichen sclerosus confirmed, given autoimmune associations 2

Imaging Considerations

• Generally not indicated for isolated labial excoriation unless:
  • Suspicion of deeper tissue involvement or mass lesions 1
  • Evaluation for metastatic disease if malignancy suspected 1

Psychiatric Evaluation

If excoriation disorder suspected (compulsive picking behavior with awareness but inability to stop):

• Formal psychiatric assessment: Document distress, functional impairment, and comorbidities 3, 4
• Screen for body-focused repetitive behaviors: Including trichotillomania 6
• Evaluate triggers: Negative mood states, anxiety, stress 6

Critical Diagnostic Pitfalls

Do Not Miss Lichen Sclerosus

• In prepubertal girls: Ecchymosis may mimic sexual abuse but could be lichen sclerosus 2
• Bimodal presentation: Peaks in prepubertal and postmenopausal women 1, 2
• Chronic progressive nature: Requires long-term management and surveillance for malignancy 1

Do Not Overlook Infectious Causes

• Always assess for STI pathogens with glandular infections 2
• Severe vulvovaginitis with extensive erythema, edema, and excoriation requires 7-14 days of topical azole therapy or fluconazole 1

Do Not Dismiss Psychiatric Component

• Excoriation disorder is a primary psychiatric condition requiring multidisciplinary treatment including psychotherapy and pharmacotherapy 3, 4
• Quality of life impact: Both lichen sclerosus and excoriation disorder significantly affect sexual function and psychological well-being 1, 4

Algorithmic Approach Summary

1. Perform biopsy first to confirm or exclude lichen sclerosus and malignancy 1
2. Complete infectious workup with STI testing, viral cultures, and vaginal cultures as indicated 1, 2
3. Psychiatric evaluation if compulsive picking behavior evident 3, 4
4. Baseline laboratory studies including CBC and metabolic panel 1
5. Autoimmune screening if lichen sclerosus confirmed 2