GPAtlas🧭 When to suspect
Suspect a vulval dermatosis in any woman with persistent vulval itch, soreness, pain or burning – particularly when empirical treatment for "thrush" has repeatedly failed.
• As the British Association of Dermatologists puts it, "not all that itches is thrush".
• Symptoms are often longstanding and have a real impact on sleep, sexual function and psychological wellbeing.
• The vulva is frequently treated without ever being examined.
Examine the vulva and recognise the pattern, and never miss a malignancy.
• Most inflammatory dermatoses respond well to a soap substitute, an emollient and an appropriately-potent topical steroid.
• The diagnosis must be made first, and lichen sclerosus must not be left untreated.
| Dermatosis | Tell-tale clinical clues |
|---|---|
| Lichen sclerosus | • Porcelain-white, crinkled ("cigarette-paper") atrophic plaques • Figure-of-eight vulval/perianal pattern • Architectural loss (resorbed labia minora, buried clitoris) • Spares the vagina |
| Lichen planus (erosive) | • Glazed red erosions at the vestibule/introitus • White lacy Wickham striae • Vaginal and oral involvement • Scarring and adhesions |
| Eczema or contact dermatitis | • Erythema, scaling, fissuring and itch • Irritant (soaps, wipes, incontinence) or allergic (fragrance, medicaments) |
| Psoriasis (flexural) | • Well-demarcated red plaques, often non-scaly in the flexure • Clues at scalp, nails, elbows and natal cleft |
| Lichen simplex chronicus | • Thickened, leathery, lichenified skin from a chronic itch–scratch cycle • Often unilateral |
|
⚠️ Common pitfall • Issuing repeated antifungals for "recurrent thrush" over months or years without ever inspecting the vulva. • Candidiasis is the single commonest misdiagnosis given in place of lichen sclerosus, and it is the main reason LS is recognised late – after avoidable scarring has occurred. • If symptoms recur or antifungals do not work, examine the vulva and look for a dermatosis. |
Source: British Association of Dermatologists · DermNet
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