What is the diagnosis and treatment for severe vaginal itching with erosion and bleeding due to scratching?

Severe Vaginal Itching with Erosion and Bleeding from Scratching

Most Likely Diagnosis

The most likely diagnosis is lichen sclerosus (LS), a chronic inflammatory dermatosis that characteristically causes severe pruritus leading to excoriation, erosions, and bleeding, particularly when symptoms are severe enough to cause tissue damage from scratching. 1

Key Diagnostic Features of Lichen Sclerosus

• Porcelain-white papules and plaques are the hallmark lesions, often associated with areas of ecchymosis (bruising) that can be mistaken for trauma 1
• Severe nocturnal itching is the predominant symptom, often sufficiently severe to disturb sleep and lead to excoriation 1
• Erosions and fissures develop as a consequence of scratching and the disease process itself, which can bleed 1
• Characteristic distribution involves the interlabial sulci, labia minora, clitoral hood, and perineum in a figure-of-eight pattern 1
• The vagina is always spared - this is a critical distinguishing feature from other conditions 1

Diagnostic Approach

When to Perform Biopsy

• Biopsy is mandatory if there is any suspicion of neoplastic change, persistent hyperkeratosis, erosion, or if the disease fails to respond to adequate treatment 1
• Biopsy may not be practical in all cases, particularly in children, and is not essential when clinical features are typical 1
• However, given the severity described (erosion and bleeding), biopsy is strongly recommended to confirm diagnosis and exclude malignancy 1

Rule Out Infectious Causes First

Before concluding this is lichen sclerosus, you must systematically exclude infectious vaginitis:

• Measure vaginal pH using narrow-range pH paper: pH ≤4.5 suggests candidiasis; pH >4.5 suggests bacterial vaginosis or trichomoniasis 2, 3
• Perform saline wet mount to identify clue cells (bacterial vaginosis) or motile trichomonads (trichomoniasis) 2, 3
• Perform KOH wet mount to assess for fishy odor (whiff test) and identify yeast or pseudohyphae 2, 3

Treatment Algorithm

If Lichen Sclerosus is Confirmed

The British Association of Dermatologists guidelines establish ultrapotent topical corticosteroids as first-line treatment for lichen sclerosus. 1

• Apply ultrapotent topical corticosteroid (such as clobetasol propionate 0.05% ointment) once daily initially 1
• Treatment duration and tapering should be individualized based on response, typically starting with daily application for 1-3 months, then tapering to maintenance therapy 1
• Long-term follow-up is essential due to malignancy risk in adult women (4-6% lifetime risk of vulvar squamous cell carcinoma) 1

If Vulvovaginal Candidiasis is Confirmed

• Topical azole antifungals are more effective than nystatin, with 80-90% cure rates 1
• Clotrimazole 1% cream 5g intravaginally for 7-14 days is a recommended first-line option 1, 4
• Fluconazole 150mg orally as single dose achieves 55% therapeutic cure rate and is convenient 3, 5
• Multi-day regimens (3- and 7-day) are preferred for severe or complicated cases 1

If Bacterial Vaginosis is Confirmed

• Metronidazole 500mg orally twice daily for 7 days achieves 95% cure rate and is first-line therapy 1, 2, 3

If Trichomoniasis is Confirmed

• Metronidazole 2g orally as single dose achieves 90-95% cure rate 2, 3
• Sexual partners must be treated simultaneously to prevent reinfection 3

Critical Pitfalls to Avoid

• Do not assume this is simply infectious vaginitis when erosions and bleeding from scratching are present - this severity suggests a dermatologic condition like lichen sclerosus 1
• Do not apply topical steroids empirically without proper diagnosis, as this can mask other conditions and delay appropriate treatment 6
• Do not use antifungals for all vulvar symptoms - many vulvar conditions can mimic vulvovaginitis 6
• If treatment is not working, reconsider the diagnosis rather than continuing ineffective therapy 6
• Do not overlook the possibility of multiple coexisting conditions - infectious vaginitis and lichen sclerosus can occur simultaneously 7

When Infectious Causes Are Excluded

If all infectious testing is negative and symptoms persist:

• Consider lichen sclerosus as the primary diagnosis, especially with the described severity of symptoms 1
• Consider desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia as alternative diagnoses 8
• Refer to dermatology or gynecology for biopsy and specialized management 1
• Eliminate potential irritants including discontinuation of douching, harsh soaps, and tight clothing 2, 7