Vulval lichen sclerosus — RACGP Fellowship MCQ

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ModerateWomen's health and O&GVulval lichen sclerosusRACGP Fellowship

A 59-year-old postmenopausal woman presents with vulval itch and dyspareunia. Examination shows pale thin vulval plaques with fissuring in a figure-of-eight distribution surrounding the vulva and anus. There is no vaginal discharge. What is the most likely diagnosis?

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Correct answer: D — Lichen sclerosus

Explanation lettering: C = shown as A · E = shown as C · A = shown as E

The diagnosis is lichen sclerosus (option D). The figure-of-eight distribution is pathognomonic for this condition—it characteristically involves the vulva, perineum, and perianal area in this distinctive pattern. Combined with pale, thin, glistening ivory-white plaques and fissuring, history of pruritus and dyspareunia in a postmenopausal woman, the clinical diagnosis is definitive; biopsy is seldom required. Candidiasis (A) presents with vaginal discharge and erythema; the stem explicitly excludes discharge. Herpes (B) presents as grouped vesicles progressing to painful erosions, not thin plaques. Bartholin cyst (C) is a localized cystic mass, not diffuse plaques. Psoriasis confined to the vulva (E) is difficult to diagnose without systemic clues and does not characteristically produce the figure-of-eight distribution or cause the marked architectural changes seen here; the qualifier 'without architectural change' specifically excludes lichen sclerosus, which produces anatomical distortion through scarring.

Reference: Australian Prescriber. Vulval disease in childhood. https://australianprescriber.tg.org.au/articles/vulval-disease-in-childhood.html; RACGP AJGP, 'An itchy white vulva', October 2022. https://www1.racgp.org.au/getattachment/55343f9f-8557-474d-88d5-1f58c1c2f6e8/An-itchy-white-vulva.aspx