A 67-year-old woman comes to the office with severe vulvar itching and burning for the past 6 months. The patient has tried over-the-counter, topical lubricants for her symptoms without relief. She is no longer sexually active because vaginal penetration is not possible due to pain. Medical history includes type 1 diabetes mellitus that is well controlled with insulin. The patient had a total vaginal hysterectomy at age 48 for adenomyosis. She previously had no abnormal Pap tests and has not had cervical cancer screening since the hysterectomy. Vital signs are normal. Physical examination shows thin, dry, white, plaque-like vulvar skin with loss of the labia minora. There is clitoral hood retraction. Excoriations are present bilaterally on the vulva.
Which of the following is the best next step in evaluation of this patient?

Question

A 67-year-old woman comes to the office with severe vulvar itching and burning for the past 6 months.  The patient has tried over-the-counter, topical lubricants for her symptoms without relief.  She is no longer sexually active because vaginal penetration is not possible due to pain.  Medical history includes type 1 diabetes mellitus that is well controlled with insulin.  The patient had a total vaginal hysterectomy at age 48 for adenomyosis.  She previously had no abnormal Pap tests and has not had cervical cancer screening since the hysterectomy.  Vital signs are normal.  Physical examination shows thin, dry, white, plaque-like vulvar skin with loss of the labia minora.  There is clitoral hood retraction.  Excoriations are present bilaterally on the vulva. 
Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

11ec25c8_d9f4_ab32_bc81_87d5ae3d5313_MD0003_00 This patient has vulvar lichen sclerosus, a chronic inflammatory disease common in postmenopausal women, particularly in those with an autoimmune disease (eg, type 1 diabetes mellitus). In early stages of the disease, the vulva thins, causing hypopigmented (white) areas and increasing skin sensitivity that results in intense vulvar itching and burning (and associated erosions and excoriations). Chronic irritation and scratching transform the thinned skin to thickened, white vulvar plaques (ie, lichenification), often with perianal skin thickening in a classic figure-eight pattern. In severe cases, normal anatomic structures may be obliterated or atrophied, leading to loss of the labia minora and clitoral hood retraction, which can result in dyspareunia (as in this patient) and urinary symptoms (eg, dysuria, nocturia). Although lichen sclerosus can be clinically diagnosed, a vulvar punch biopsy is recommended to confirm the diagnosis and rule out vulvar cancer (which can occur in patients with prolonged or persistent lichen sclerosus). (Choices A and E) A potassium hydroxide preparation and yeast culture of skin scrapings are performed in patients with candida intertrigo. Candida intertrigo is more common in patients with diabetes mellitus and causes vulvar pruritus; however, patients typically have red, erythematous lesions with associated satellite lesions that can extend to the inner thighs and groin, which are not seen in this patient. (Choice B) The genitourinary syndrome of menopause (also known as vulvovaginal atrophy) is caused by low estrogen levels; however, this condition is diagnosed clinically rather than by serum estrogen level measurement. Vulvovaginal atrophy can cause vulvar pruritus and dyspareunia but does not cause white plaques or involve the perianal region. (Choice C) Pap testing assesses for cervical and vaginal malignancies, which can occur secondary to chronic inflammation. Although lichen sclerosus causes chronic inflammation, it spares the vagina and does not increase the risk of these malignancies. In addition, Pap testing is not recommended in women age >65 or in those who have had a hysterectomy and no prior abnormal Pap tests. Educational objective: Vulvar lichen sclerosus is a chronic inflammatory condition that can present with vulvar pruritus, white vulvar plaques, and loss of normal architecture (eg, loss of labia minora). A vulvar punch biopsy is recommended to confirm the diagnosis and rule out vulvar cancer. References: Lichen sclerosus in women: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28661705)

A 67-Year-Old Woman Comes to the Office with Severe Vulvar