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, yet the vulva is frequently treated without ever being examined.
The clinical skill is twofold: 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 – but the diagnosis must be made first, and lichen sclerosus must not be left untreated.
| Dermatosis | Tell-tale clinical clues | First-line direction |
|---|---|---|
| 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 | Ultrapotent steroid + lifelong maintenance; small SCC risk |
| Lichen planus (erosive) | Glazed red erosions at the vestibule/introitus; white lacy Wickham striae; vaginal and oral involvement; scarring and adhesions | Refer; ultrapotent steroid (± vaginal/systemic) |
| Eczema / contact dermatitis | Erythema, scaling, fissuring and itch; irritant (soaps, wipes, incontinence) or allergic (fragrance, medicaments) | Remove trigger + emollient + mild–moderate steroid; patch test if allergic |
| Psoriasis (flexural) | Well-demarcated red plaques, often non-scaly in the flexure; clues at scalp, nails, elbows and natal cleft | Mild–moderate steroid, short courses |
| Lichen simplex chronicus | Thickened, leathery, lichenified skin from a chronic itch–scratch cycle; often unilateral | Break the cycle: potent/ultrapotent steroid + night sedation |
|
⚠️ 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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