An 11-year-old girl is brought to the office due to vulvar itching. The patient first had the pruritus intermittently, but her symptoms have worsened over the past several months despite nightly application of a moisturizing ointment. She now has trouble sleeping due to the constant itching. The patient has no known medical conditions and has had no surgeries. She has not reached menarche and is not sexually active. The patient is on a community swim team and has swim practice multiple times a week and uses the same bathing suit. Vital signs are normal. Examination of the vulva reveals thin, white skin with excoriations extending to the perianal area. The superior portions of the labia minora are adherent at the midline. A small anal fissure is also noted. Which of the following is the most likely diagnosis in this patient?

Question

An 11-year-old girl is brought to the office due to vulvar itching.  The patient first had the pruritus intermittently, but her symptoms have worsened over the past several months despite nightly application of a moisturizing ointment.  She now has trouble sleeping due to the constant itching.  The patient has no known medical conditions and has had no surgeries.  She has not reached menarche and is not sexually active.  The patient is on a community swim team and has swim practice multiple times a week and uses the same bathing suit.  Vital signs are normal.  Examination of the vulva reveals thin, white skin with excoriations extending to the perianal area.  The superior portions of the labia minora are adherent at the midline.  A small anal fissure is also noted.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d9f8_2da8_bc81_1711573741f9_MD0003_00 This patient has vulvar lichen sclerosus, a chronic inflammatory condition that causes thinning of the vulvar skin in hypoestrogenic populations, such as premenarchal girls and postmenopausal women. In lichen sclerosus, white, atrophic papules form and eventually merge into plaques, leading to thin, white vulvar lesions and changes in vulvar architecture (eg, adherence of the labia at the midline). These lesions are chronically inflamed and can result in perianal and vulvar pruritus, at times so severe that it awakens affected individuals from sleep. Excessive scratching can result in excoriations, lichenification (ie, thickened skin), and edema of the labia. Lichenification of the perianal region can result in anal fissures and constipation. lichen sclerosus Although biopsy is recommended in adults to exclude an underlying malignancy (eg, vulvar cancer), children have no associated malignancy risk and can be diagnosed clinically. First-line treatment is the same for adults and children: superpotent topical corticosteroids (eg, clobetasol). (Choice A) Vulvovaginal candidiasis can cause vulvar pruritus; however, this rarely occurs in prepubertal girls without underlying immunosuppression (eg, type 1 diabetes mellitus, HIV) or recent antibiotic use. The vulva is erythematous but has no architectural changes. (Choice B) Patients with condyloma acuminata are typically asymptomatic but may have vulvar pruritus. Patients typically have small, flesh-colored lesions that can coalesce into verrucous plaques rather than thinning of the vulvar skin. (Choice C) Labial adhesions can cause vulvar pruritus due to fusion of the labia at the midline, which results in a small vaginal opening and difficulty voiding. However, labial adhesions are more common in girls age <2, are not associated with lichenification, and have no perianal involvement. (Choice E) Streptococcal dermatitis typically occurs as a superinfection in patients with a constant irritant (eg, bathing suit) and can cause perianal pruritis and anal fissures. However, patients have a bright, erythematous perianal rash with sharply demarcated borders rather than thin, white skin. Streptococcal dermatitis (Choice F) Vaginal foreign bodies cause vulvovaginal pruritus and a malodorous vaginal discharge rather than vulvar skin changes. Educational objective: Vulvar lichen sclerosus commonly presents in prepubertal girls with pruritus and thin, white lesions of the vulva and perianal region. Treatment is with superpotent topical corticosteroids. References: Clinical recommendation: pediatric lichen sclerosus. (http://www.ncbi.nlm.nih.gov/pubmed/24602304) Lichen sclerosus in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/23812382) Lichen sclerosus and lichen planus in women and girls. (http://www.ncbi.nlm.nih.gov/pubmed/25608255)

An 11-Year-Old Girl Is Brought to the Office Due to Vulvar