A 58-year-old, postmenopausal woman comes to the office due to increasing vulvar pain. The pain was initially mild and intermittent when it began several months ago but has worsened over the past few weeks. In addition, the patient has now developed odorless, pink-tinged vaginal discharge with pruritus. She also has had a few painful oral lesions in the past several months that she treated with topical anesthetics with minimal improvement. Review of systems is otherwise negative. The patient is not sexually active. On examination, the gingivae have a lacelike, reticular appearance, and there are multiple white plaques on the tongue and palate. The vulva is diffusely erythematous, and the labia minora have multiple glazed, brightly erythematous erosions bordered by white striae. The vaginal introitus is stenotic, and a limited speculum examination reveals a friable, erythematous vaginal epithelium with a serosanguinous discharge. The remainder of the physical examination is normal. Which of the following is the most likely diagnosis in this patient?

Question

A 58-year-old, postmenopausal woman comes to the office due to increasing vulvar pain.  The pain was initially mild and intermittent when it began several months ago but has worsened over the past few weeks.  In addition, the patient has now developed odorless, pink-tinged vaginal discharge with pruritus.  She also has had a few painful oral lesions in the past several months that she treated with topical anesthetics with minimal improvement.  Review of systems is otherwise negative.  The patient is not sexually active.  On examination, the gingivae have a lacelike, reticular appearance, and there are multiple white plaques on the tongue and palate.  The vulva is diffusely erythematous, and the labia minora have multiple glazed, brightly erythematous erosions bordered by white striae.  The vaginal introitus is stenotic, and a limited speculum examination reveals a friable, erythematous vaginal epithelium with a serosanguinous discharge.  The remainder of the physical examination is normal.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9f7_6a57_bc81_cd80d6cabdce_MD0003_00 This patient has vulvar lichen planus, a chronic inflammatory condition that typically occurs in postmenopausal women. The most common type of vulvar lichen planus is the erosive variant, in which chronic inflammation causes desquamation and erosion of mucosal surfaces, including the vulva, vagina, and oral cavity (as seen in this patient). Clinical features of erosive lichen planus include: Glazed, brightly erythematous vulvar erosions with a border of serpentine-appearing, white striae (ie, Wickham striae) that typically cause vulvar pain, pruritus, and dyspareunia. Acute vaginal inflammation that causes friable vaginal mucosa and a serosanguinous vaginal discharge; chronic inflammation can eventually result in stenosis of the vaginal introitus. Lacelike, reticular erosions on the gingivae and palate that cause painful oral ulcers and plaque formations on the tongue. Diagnosis may be made clinically but should be confirmed with a vulvar punch biopsy because the clinical features of lichen planus may overlap with those of vulvar cancer. Patients with lichen planus require evaluation of all mucosal surfaces because erosions may occur in the absence of other symptoms. First-line treatment is with high-potency topical corticosteroids. (Choice A) Desquamative inflammatory vaginitis can cause vulvar pain and abnormal vaginal discharge. However, vulvar architecture is maintained (eg, no erosive vulvar lesions), and concomitant oral lesions would not be expected. (Choice C) Lichen sclerosus can present with vulvar pruritus and white vulvar plaques with associated erosions. However, patients with lichen sclerosus typically have no vaginal involvement, making the diagnosis unlikely in this patient with an erythematous vaginal epithelium and serosanguinous vaginal discharge. Lichen sclerosus (Choice D) Vulvovaginal atrophy may present with vulvar pain and serosanguinous discharge; however, there is no association with either oral lesions or erosive vulvar lesions. (Choice E) Vulvovaginal candidiasis can present with vulvovaginal pruritis and erythema; however, these patients typically have a thick, white vaginal discharge rather than serosanguinous discharge and erosive lesions. Some patients (eg, immunosuppressed) can have accompanying oropharyngeal candidiasis; however, the associated white oral plaques do not typically have a lacelike, reticular appearance (ie, Wickham striae). oropharyngeal candidiasis Educational objective: Vulvar lichen planus is a chronic inflammatory disorder that can present with multiple glazed, erythematous vulvar erosions bordered by white striae (ie, Wickham striae). Patients often have associated vaginal and oral lesions. Treatment is with topical corticosteroids. References: Genital lichen planus: update on diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26650696) Erosive vulvar lichen planus-a diagnosis not to be missed: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/24183096) Erosive lichen planus. (http://www.ncbi.nlm.nih.gov/pubmed/28778640) Lichen sclerosus and lichen planus in women and girls. (http://www.ncbi.nlm.nih.gov/pubmed/25608255)

A 58-Year-Old, Postmenopausal Woman Comes to the Office Due to Increasing