GPAtlas🧭 When to suspect
Lichen sclerosus is a chronic inflammatory dermatosis with a strong predilection for the anogenital skin. The classic presentation is a postmenopausal woman with severe, intractable vulval pruritus, but it also affects prepubertal girls (perianal soreness, constipation, soiling), men (uncircumcised glans and prepuce, where it was previously called balanitis xerotica obliterans), and occasionally extragenital sites. It is roughly ten times more common in women than men.
The single most useful instinct in primary care is to think beyond thrush: lichen sclerosus is repeatedly mislabelled as recurrent candidiasis or genitourinary syndrome of the menopause (GSM), and the diagnosis is frequently delayed for years. Suspect it whenever vulval symptoms persist despite treatment for those conditions, or when white patches or a change in the shape of the vulval skin are described. The two clinical tasks are to recognise and treat it early, and to never miss malignant change.
| Feature | Lichen sclerosus | GSM | Candidiasis |
|---|---|---|---|
| Itch | Yes, often severe | Yes | Yes |
| Skin colour | White / porcelain | Pale pink | Red when inflamed |
| Vaginal involvement | No | Yes | Yes |
| Architectural change | Yes – often marked; labial fusion, clitoral phimosis | Mild, symmetrical | No |
| Perianal involvement | Yes (figure-of-eight) | No | No |
| Discharge | No | Possible | Often |
Source: BAD · DermNet
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