What is the diagnosis and treatment for a female patient with uniform circular white lesions and surrounding erythema (redness) on the labia minora that are painful?

Diagnosis: Lichen Sclerosus

The clinical presentation of uniform circular white lesions with surrounding erythema and pain on the labia minora is most consistent with lichen sclerosus (LS), an autoimmune inflammatory dermatosis that characteristically affects the genital skin. 1, 2

Clinical Features Supporting This Diagnosis

The described presentation matches the classic features of vulvar LS:

• Porcelain-white papules and plaques are the hallmark appearance, often with areas of ecchymosis (which may appear as surrounding erythema) 1, 2
• Labia minora involvement is a characteristic site, along with the interlabial sulci, clitoral hood, and perineal body 1
• Pain occurs when erosions or fissures are present, though itch is typically the predominant symptom 1, 2
• Follicular delling may be prominent in active disease 1

Diagnostic Approach

Biopsy is not always necessary when typical clinical features are present, but should be strongly considered in this case for several reasons 1:

• The patient presents with pain rather than the more typical itch, suggesting possible erosive disease 1
• Histological confirmation is recommended before starting treatment in young adult women of reproductive age 1
• Biopsy is essential if there is any diagnostic uncertainty or atypical features 1

If biopsy is performed, take it from the most active sclerotic area and ensure good clinicopathological correlation with the pathologist 1.

Treatment Algorithm

First-Line Treatment: Ultra-Potent Topical Corticosteroids

The cornerstone of treatment is ultra-potent topical corticosteroids, which should be initiated promptly to prevent disease progression and scarring 1:

• Clobetasol propionate 0.05% ointment is the standard treatment 1
• Apply once daily to affected areas initially 1
• Treatment duration and tapering schedule should be individualized based on response, but typically continues for at least 3 months 1

Treatment Goals

The primary objectives are to 1:

• Alleviate symptoms (pain, itch, dyspareunia)
• Prevent anatomical changes and scarring
• Prevent malignant transformation (vulvar squamous cell carcinoma occurs in 4-5% of women with LS) 1

Additional Considerations

Microbiology swabs should be obtained if erosive disease is present or if the condition is resistant to topical steroids, to exclude herpes simplex or Candida as complicating factors 1.

Autoantibody screening is only useful if there are clinical features suggesting an associated autoimmune disorder, as LS has known associations with other autoimmune diseases 1.

Critical Pitfalls to Avoid

• Do not dismiss this as a simple infection requiring only antimicrobial therapy—LS requires long-term management with topical corticosteroids 1
• Do not delay treatment while awaiting biopsy results if clinical features are typical, as early treatment prevents irreversible scarring 1
• Do not assume asymptomatic disease is inactive—some patients have ongoing disease activity evidenced by progressive scarring despite lack of symptoms 1
• Do not confuse with candidiasis—while both can cause white lesions, candidiasis presents with cottage cheese-like discharge and responds to antifungals, whereas LS has fixed white plaques requiring corticosteroids 3

Long-Term Management

Lifelong surveillance is essential due to the risk of malignant transformation 1:

• Regular follow-up examinations to monitor for disease activity and early detection of malignancy 1
• Patients should be educated about the chronic nature of the condition and the importance of adherence to treatment 1
• Biopsy any persistent areas of hyperkeratosis, erosion, erythema, or new warty/papular lesions to exclude squamous cell carcinoma 1