From the Guidelines
The best next step in evaluation of this patient is to perform a vulvar biopsy to confirm the diagnosis of lichen sclerosus and rule out other conditions. This 67-year-old woman presents with symptoms and physical examination findings consistent with lichen sclerosus, a chronic inflammatory dermatosis affecting the anogenital region. The characteristic findings include thin, white, plaque-like vulvar skin, loss of labia minora, clitoral hood retraction, and excoriations. While the clinical presentation strongly suggests lichen sclerosus, a vulvar biopsy is necessary to confirm the diagnosis and rule out other conditions such as lichen planus, vulvar intraepithelial neoplasia, or early-stage vulvar cancer, as recommended by the British Association of Dermatologists guidelines for the management of lichen sclerosus 1.
According to the guidelines, after confirming the diagnosis, the patient should be offered clobetasol propionate 0.05% ointment on a specific regimen, combined with a soap substitute and a barrier preparation 1. The guidelines also emphasize the importance of discussing the amount of topical treatment to be used, the site of application, and the safe use of an ultrapotent topical steroid with the patient 1.
Key points to consider in the management of this patient include:
- Confirming the diagnosis through biopsy to rule out other conditions
- Initiating treatment with clobetasol propionate 0.05% ointment as recommended by the guidelines 1
- Monitoring the patient's response to treatment and adjusting the regimen as needed to maintain disease control and prevent scarring
- Considering referral to a specialist vulval clinic if the patient does not respond to topical steroid treatment or if surgical management is being considered 1
From the Research
Evaluation of the Patient
The patient presents with severe vulvar itching and burning, thin, dry, white, plaque-like vulvar skin, and loss of the labia minora, which are characteristic symptoms of vulvar lichen sclerosus (VLS) 2, 3.
Best Next Step in Evaluation
The best next step in the evaluation of this patient would be to:
- Confirm the diagnosis of VLS through a physical examination and potentially a biopsy, if necessary.
- Consider the patient's medical history, including her type 1 diabetes mellitus and previous total vaginal hysterectomy.
- Discuss treatment options with the patient, including:
- Topical corticosteroids, such as clobetasol propionate 0.05% cream, which have been shown to be effective in treating VLS 4, 5.
- Topical calcineurin inhibitors, such as pimecrolimus, which may be used as an alternative to corticosteroids 2, 5.
- Other treatment options, such as antibiotics, may be considered, but the evidence for their use is limited 6.
Treatment Considerations
When considering treatment options, it is essential to:
- Assess the severity of the patient's symptoms and the extent of the disease.
- Discuss the potential benefits and risks of each treatment option with the patient.
- Develop a treatment plan that takes into account the patient's individual needs and medical history.
- Monitor the patient's response to treatment and adjust the treatment plan as necessary.