What is the best course of treatment for an elderly woman with vulvar pruritus and red lesions with white plaques on the vulva, who has been on estrogen (hormone replacement therapy) and progesterone therapy for 9 months?

Discontinue Current Hormone Therapy and Initiate Topical Clobetasol Propionate

The most appropriate management is to stop the estrogen and progesterone therapy and start topical clobetasol propionate 0.05% ointment twice daily, as the clinical presentation of red lesions with white plaques on the vulva strongly suggests lichen sclerosus, which is the standard of care treatment and superior to hormonal approaches. 1, 2

Diagnostic Considerations

The clinical presentation of vulvar pruritus with red lesions and white plaques is highly characteristic of lichen sclerosus (LS), a chronic inflammatory dermatosis that commonly affects postmenopausal women 1, 3. Key diagnostic steps include:

• Obtain a vulvar biopsy to confirm the diagnosis histologically before initiating treatment, as this will guide appropriate therapy and rule out malignancy 1, 4
• Exclude infectious causes by taking swabs from the vulva and vagina if discharge or specific odor is present 1
• Consider estrogen hypersensitivity as a rare but documented cause of vulvitis in patients on hormone replacement therapy, particularly when symptoms developed after HRT initiation 5

First-Line Treatment: Topical Corticosteroids

Clobetasol propionate 0.05% ointment applied twice daily for 2-3 months is the gold standard treatment for lichen sclerosus, with gradual dose reduction after symptom control is achieved 1. The evidence supporting this approach includes:

• Topical corticosteroids have been shown to reverse histological changes seen in LS and provide superior symptom relief compared to other treatments 1
• In a randomized controlled trial, clobetasol propionate demonstrated significantly better clinical outcomes than topical progesterone, with mean clinical LS scores improving more substantially (difference 1.61; 95% CI 0.44 to 2.77, p = 0.009) 2
• Complete remission was achieved in 81.3% of patients treated with clobetasol versus 60% with progesterone 2

Important Safety Considerations

• Advise aggressive hand washing after application to avoid spreading medication to sensitive areas like the eyes and to prevent partner exposure 1
• Monitor for side effects including cutaneous atrophy, hypopigmentation, contact sensitivity, burning, itching, and dryness 1
• Potent steroids should be used cautiously and with appropriate follow-up 1

Why Discontinue Current Hormone Therapy

The patient's current estrogen and progesterone therapy is likely contributing to rather than alleviating the problem:

• Estrogen hypersensitivity can cause treatment-resistant vulvitis, particularly in patients who develop symptoms after commencing HRT 5
• In documented cases, vulvitis related to HRT recovered when hormone therapy was discontinued 5
• Topical progesterone has been proven inferior to clobetasol propionate for treating vulvar LS in clinical trials 2
• While older studies suggested testosterone and progesterone might be effective 6, more recent high-quality evidence demonstrates clobetasol's clear superiority 2

Alternative Considerations if Hormones Are Needed

If the patient requires hormone replacement for other menopausal symptoms after LS treatment:

• Vaginal estrogens may be considered for atrophic vaginitis symptoms, but should be used cautiously and only after LS is controlled 1
• Non-hormonal vaginal lubricants such as Replens may be effective alternatives for vaginal dryness without the risks of systemic or local estrogen 1
• If systemic HRT is deemed necessary, it should be prescribed at the lowest effective dose for the shortest duration consistent with treatment goals 7

Follow-Up and Monitoring

• Reassess in 2-3 months to evaluate treatment response and compliance 1
• If symptoms persist or worsen despite treatment, repeat biopsy to rule out squamous cell carcinoma, as LS carries a small but significant malignancy risk 1
• Once symptoms are controlled, gradually taper the corticosteroid dose to the minimum effective maintenance regimen 1
• Consider dermatology referral for refractory cases or diagnostic uncertainty 1, 3

Critical Pitfall to Avoid

Do not increase or continue the current hormone therapy in an attempt to treat these symptoms, as this contradicts evidence-based management and may worsen the condition if estrogen hypersensitivity is present 7, 5. The FDA specifically recommends against increasing estrogen doses beyond standard recommendations 7.