A 51-year-old woman comes to the office for a routine health maintenance examination. She has no concerns today. The patient recently had a normal screening mammogram. She has type 1 diabetes mellitus and her last hemoglobin A1c level was 7.6%. The patient had an abnormal Pap test at age 35 that required cervical conization, but all subsequent Pap tests have been normal. She is currently sexually active and has had no pain with intercourse. Her last menstrual period was 2 weeks ago. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 26 kg/m². Pelvic examination is shown below. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_daa0_f0f3_bc81_f7611a1dc9cf_MD0003_00 This patient most likely has vitiligo, an acquired depigmentation disorder that occurs due to melanocyte destruction. Although vitiligo typically has a more generalized distribution, a subset of patients have lesions that affect only the genital or oral mucosa. Patients with vitiligo develop flat, hypopigmented macules with distinct borders that can expand and coalesce. These lesions do not have overlying scaling or inflammation; therefore, patients are often asymptomatic (eg, normal vulvar architecture) and the vitiligo may be an incidental finding (as in this patient). Although the etiology of vitiligo is unknown, it is likely partially immune-mediated, as it often occurs in those with a concomitant autoimmune disease (eg, type 1 diabetes mellitus, thyroid disorder). Diagnosis is clinical, and treatment is dependent on disease severity and includes corticosteroids (which can stabilize disease progression) and phototherapy (which may help with repigmentation). (Choice A) Discoid lupus erythematosus can cause areas of hypopigmentation; however, patients typically have associated well-circumscribed erythematous plaques with an overlying scale and surrounding inflammation (not seen in this patient). (Choice B) Patients with lichen planus have bright, glazed, red-purple plaques and papules with an overlying white, lacy pattern (ie, Wickham striae). Individuals with lichen planus often have significant symptoms (eg, pruritus, pain, dyspareunia) but no associated hypopigmentation, making this diagnosis unlikely in this patient. (Choice C) Vulvar lichen sclerosus appears as hypopigmented skin with a thin, wrinkled appearance. Patients are often symptomatic with associated pruritus. In addition, lichenification and plaque formation obliterate the vulvar architecture and can cause vaginal introitus stenosis (not seen in this patient). (Choice D) Tinea versicolor is due to a fungal (eg, Malassezia) infection that can cause hypopigmented, coalescing, scaled macules. Although these lesions are usually asymptomatic, they preferentially involve the trunk and upper extremities (rarely the vulva). (Choice F) Vulvar intraepithelial neoplasia is due to chronic human papillomavirus infection and presents as either asymptomatic or pruritic lesions. However, these lesions are typically raised and multifocal (not seen in this patient). In addition, this diagnosis is unlikely in this patient with normal Pap testing since undergoing cervical conization (ie, no chronic human papillomavirus infection). Educational objective: Vitiligo creates flat, white macules with distinct borders due to melanocyte destruction, and is often associated with autoimmune disease (eg, type 1 diabetes mellitus). Patients are typically asymptomatic. Treatment includes corticosteroids and phototherapy. References: Vitiligo. (http://www.ncbi.nlm.nih.gov/pubmed/25596811) Vitiligo as a systemic disease. (http://www.ncbi.nlm.nih.gov/pubmed/24767192) Comorbidities in vitiligo: comprehensive review. (http://www.ncbi.nlm.nih.gov/pubmed/29808541)

A 51-Year-Old Woman Comes to the Office for a Routine