What is the differential diagnosis for a postmenopausal female presenting with chronic vulvar itching, burning, and irritation, accompanied by nocturnal itching, small cuts, bleeding, and dyspareunia (painful sexual intercourse)?

Differential Diagnosis for Chronic Vulvar Symptoms in a 54-Year-Old Female

The most likely diagnosis is lichen sclerosus, given the constellation of chronic vulvar itching (especially nocturnal), burning, fissuring with bleeding, and dyspareunia in a postmenopausal-age woman. 1

Primary Differential Diagnoses

Lichen Sclerosus (Most Likely)

• Classic presentation includes intractable pruritus that worsens at night, vulvar soreness, dyspareunia, and characteristic fissures/tears with bleeding 1
• Occurs most commonly in postmenopausal women (fifth to sixth decade), affecting 85-98% in the anogenital area 1
• Physical examination typically reveals porcelain-white plaques, fragile atrophic skin, and fissures in a figure-eight pattern around vulva and anus 1
• The "small cuts and bleeding" described are pathognomonic for the fragile, easily traumatized skin of lichen sclerosus 1
• Critical pitfall: Can be confused with sexual abuse in younger patients, but the chronic nature and age make lichen sclerosus the primary concern 1

Lichen Planus

• Presents with vulvar burning, soreness, and dyspareunia similar to lichen sclerosus 1
• Distinguished by erosive lesions, potential vaginal involvement (unlike lichen sclerosus which spares vagina), and possible introital stenosis 1
• Often part of lichen sclerosus/lichen planus overlap syndrome 1
• Less likely given the absence of vaginal symptoms in this case 1

Vulvovaginal Candidiasis (Less Likely)

• Characterized by intense pruritus and external dysuria, but typically presents with thick white "cottage cheese" discharge 1, 2
• Normal vaginal pH (≤4.5) helps distinguish from other causes 1, 2
• The chronic duration (>1 month) and absence of discharge make uncomplicated candidiasis less likely 1
• If candidiasis is present, the chronicity would classify it as complicated or recurrent VVC requiring extended therapy 1, 2

Contact Dermatitis/Lichen Simplex Chronicus

• Can present with chronic itching and vulvar irritation 3, 4, 5
• Lichen simplex chronicus develops from chronic scratching and rubbing, creating a self-perpetuating itch-scratch cycle 4, 5
• Less likely to cause the characteristic fissuring and bleeding seen with lichen sclerosus 4

Genitourinary Syndrome of Menopause (Vulvovaginal Atrophy)

• Common in postmenopausal women, causing vulvar dryness, burning, and dyspareunia 6
• Typically presents with vaginal dryness rather than intense nocturnal itching 6
• Can coexist with other vulvar dermatoses 6

Diagnostic Approach

Essential Physical Examination Findings to Assess

• Look for porcelain-white plaques or patches with atrophic, thinned skin in vulvar/perianal distribution (lichen sclerosus) 1
• Assess for fissures, ecchymosis, and architectural changes including labial fusion, buried clitoris, or introital narrowing (lichen sclerosus) 1
• Examine for erosions or violaceous lesions that might suggest lichen planus 1
• Check vaginal mucosa: sparing suggests lichen sclerosus; involvement suggests lichen planus 1

Confirmatory Testing

• Biopsy is mandatory if diagnosis is uncertain, disease fails to respond to treatment, or there is suspicion of neoplastic change (hyperkeratosis, persistent erosion, warty lesions) 1
• Biopsy is not always essential when clinical features are typical, particularly in resource-limited settings 1
• Vaginal pH testing and wet mount can rule out infectious causes: pH >4.5 suggests bacterial vaginosis or trichomoniasis; pH ≤4.5 with yeast/pseudohyphae confirms candidiasis 1, 2

Management Priorities

If Lichen Sclerosus is Confirmed

• Ultrapotent topical corticosteroids (clobetasol propionate 0.05%) are first-line treatment 1
• Long-term maintenance therapy is typically required to prevent progression and scarring 1
• Surveillance for malignant transformation is essential, as lichen sclerosus carries a small risk of squamous cell carcinoma 1, 7

If Candidiasis is Suspected

• For uncomplicated VVC: single-dose fluconazole 150 mg orally or topical azoles for 3-7 days 1, 2, 8
• For complicated/recurrent VVC (>1 month duration): extended therapy with topical azoles for 7-14 days, followed by maintenance fluconazole 150 mg weekly for 6 months 1, 2

Critical Red Flags

• Persistent hyperkeratotic areas, erosions, or nodules require immediate biopsy to exclude vulvar intraepithelial neoplasia or squamous cell carcinoma 1
• Failure to respond to appropriate treatment within 3 months mandates reassessment and biopsy 1
• The chronic nature and nocturnal itching pattern strongly favor a dermatologic condition over infection 1