How can I differentiate between lichen sclerosus and other vulval conditions during a clinical examination?

Differentiating lichen sclerosus from other vulval conditions during clinical examination involves careful assessment of characteristic features and consideration of referral for specialist confirmation.

Lichen sclerosus typically presents as white, atrophic, and shiny plaques on the vulva, often involving the labia minora, clitoral hood, and perianal area, which may cause architectural changes such as fusion or scarring. The skin may appear thin, fragile, and wrinkled, sometimes described as 'cigarette paper' texture. Patients often report intense pruritus and discomfort. These features help distinguish lichen sclerosus from other vulval dermatoses such as lichen simplex chronicus, psoriasis, or contact dermatitis, which have different clinical appearances and distributions ¹.

In contrast, lichen simplex chronicus is characterised by thickened, lichenified skin due to chronic scratching, often with hyperpigmentation and excoriations, but lacks the atrophic and sclerotic changes seen in lichen sclerosus ¹. Psoriasis typically presents with well-demarcated erythematous plaques with silvery scale, and seborrhoeic dermatitis shows greasy scales on erythematous skin, usually involving other seborrhoeic areas ¹. Contact dermatitis often has an acute inflammatory appearance with erythema and vesiculation, related to irritant or allergen exposure ¹.

Because clinical features can overlap and lichen sclerosus carries a risk of vulval intraepithelial neoplasia and squamous cell carcinoma, referral to secondary care (dermatology or gynaecology with vulval expertise) is recommended to confirm diagnosis, often by biopsy ¹. Early diagnosis is important as very potent topical corticosteroids initiated by specialists are the mainstay of treatment to control symptoms and prevent progression ¹.

Recent literature emphasises the diagnostic challenges due to overlapping features among vulval dermatoses and the importance of histopathological confirmation in ambiguous cases (Hoang et al., 2016). Additionally, early recognition of premalignant changes such as vulvar intraepithelial neoplasia, which can coexist or mimic lichen sclerosus, is critical to prevent progression to squamous cell carcinoma (Scurtu et al., 2024). Thus, clinical examination should be thorough, noting lesion morphology, distribution, and any suspicious features such as ulceration or persistent lumps that warrant urgent referral ¹; (Hoang et al., 2016); (Scurtu et al., 2024).