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Vulvar Lichen PlanusAka: Lichen Planus of the Vulva, Vulvovaginal-Gingival Syndrome

Definition
1. Autoimmune inflammatory condition that affects keratinized areas including vulva
Epidemiology
1. Affects patients between ages 30 to 60 years
2. Much less common than Vulvar Lichen Sclerosus as a cause for Vulvar Dermatitis
Types
1. Erosive lichen planus (most common variant)
  1. Glassy appearing white Papules and Plaques
  2. Progression to ulcers and Erosions with altered Vulvar anatomy
  3. Vagina involved in 70% of cases (vagina not involved in Lichen Sclerosus)
    1. Vaginitis characterized by friable, tissue with adhesions and serous discharge
  4. May concurrently involve vulvovaginal-Gingival syndrome
2. Papulosquamous lichen planus
  1. Poorly demarcated pink opaque Papules
3. Hypertrophic lichen planus
  1. Perineum and perianal hyperkeratotic lesions
  2. May present as Squamous Cell Carcinoma
Symptoms
1. Vulvar Pruritus or burning
2. Postcoital bleeding
3. Dyspareunia
Signs
1. See types above
2. Speculum exam is very uncomfortable in erosive lichen planus due to associated Vaginitis
Labs: Erosive Lichen Planus
1. Punch Biopsy of Erosion borders
2. KOH and wet prep to evaluate for fungal and bacterial causes of Vaginitis
Differential Diagnosis: Erosive Lichen Planus
1. Lichen Sclerosus
2. Pemphigoid
3. Pemphigous vulgaris
4. Behcet's Syndrome
5. Vaginitis
6. Drug Reaction
Management
1. Hydrocortisone suppositories for vaginal lesions
2. Topical Corticosteroid for vulvar lesions (or applied on vaginal dilator for erosive Vaginitis)
  1. Choice of strength depends on severity
    1. Level 1: Clobetasol Propionate 0.05% ointment (ultra-potent bid in severe cases)
    2. Level 2: Betamethasone dipropionate 0.05% ointment
    3. Level 3: Betamethasone dipropionate 0.05% cream
    4. Level 4: Triamcinolone acetonide 0.1% ointment (medium potency qhs in mild cases)
  2. Taper steroid on resolution of active lesions
3. Systemic Corticosteroids
  1. Indicated in cases refractory to Topical Corticosteroids
  2. Prednisone 40 to 60 mg orally daily for 2-4 weeks
References
1. Goldstein (2005) Clin Obstet Gynecol 48:818
2. O'Connell (2008) Am Fam Physician 77:321

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This page was written by Scott Moses, MD. This page was last revised on 3/31/2008 9:36:11 PM. This page was last published on 6/1/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.