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.
• The condition also affects prepubertal girls (perianal soreness, constipation, soiling).
• In men it affects the uncircumcised glans and prepuce, where it was previously called balanitis xerotica obliterans.
• Extragenital sites are occasionally affected.
• Lichen sclerosus is roughly ten times more common in women than men.
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.
• Suspect it 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 |
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