A 70-year-old woman comes to the office due to vulvar pruritus. The patient has had increasing pruritus over the past 4 months that has not improved with topical emollients. She has no pelvic pain, vaginal bleeding, or abnormal vaginal discharge. The patient had similar symptoms 20 years ago, for which she was prescribed a corticosteroid cream that resolved the symptoms. She has not been sexually active for the last 10 years. The patient has hypercholesterolemia and type 2 diabetes mellitus. Her last Pap test with HPV cotesting was normal 5 years ago. Blood pressure is 132/78 mm Hg and pulse is 84/min. BMI is 32 kg/m². On pelvic examination, there is a firm, white plaque with overlying excoriations on the left labium majus. Mild atrophy of the bilateral labia minora is noted, and the vagina has minimal rugation but no lesions. Which of the following is the best next step in management of this patient?

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11ec25c8_d9f6_a706_bc81_f58c2786798f_MD0003_00 This patient's unifocal, firm, white vulvar plaque is concerning for vulvar squamous cell cancer. A risk factor for vulvar cancer is lichen sclerosus, as seen in this patient's prior symptoms that resolved with corticosteroid cream. Patients with chronic lichen sclerosus have continued inflammation and hyperplasia of the vulvar epithelium that can result in malignant transformation and development of a neoplastic lesion. This lesion typically develops over the labia majora and can become pruritic, friable, and ulcerated. In patients with lesions concerning for malignancy, the best next step in management is vulvar biopsy, which distinguishes between benign (eg, lichen sclerosus) and neoplastic disease. In those with neoplastic changes, biopsy further determines the depth of invasion and differentiates between noninvasive (ie, vulvar intraepithelial neoplasia) or invasive (ie, vulvar cancer) disease. If this patient's lesion is benign on biopsy and is a recurrence of lichen sclerosus, she can be retreated with high-dose corticosteroids (Choice A). However, if the lesion is neoplastic, additional management is indicated. Patients with noninvasive disease can be treated with either medical therapy (eg, imiquimod) or laser ablative therapy (Choice B). Those with invasive disease require surgery (eg, wide local excision ± lymph node dissection) and possible chemoradiation. (Choice C) Antifungals are used in the treatment of candidal intertrigo or vulvovaginitis. Patients typically have symmetric, erythematous plaques with an overlying scale. Those with vaginitis have an accompanying thick, white vaginal discharge. candidal intertrigo (Choice D) Topical estrogen cream is indicated in patients with symptomatic vulvovaginal atrophy (ie, genitourinary syndrome of menopause). Patients have vulvar pruritus and labial atrophy, as seen in this patient; however, a focal, firm plaque is unlikely due to atrophy alone. Therefore, this patient requires further evaluation with biopsy. (Choice E) Trichloroacetic acid is a treatment option for condylomata acuminata, which typically presents with multiple fungating or dome-shaped lesions. condylomata acuminata Educational objective: Vulvar lichen sclerosus is a risk factor for the development of vulvar cancer. Therefore, patients with a history of lichen sclerosus and a new unifocal vulvar lesion (eg, firm, white plaque) require vulvar biopsy to evaluate for vulvar cancer. References: Differentiated vulvar intraepithelial neoplasia is often found in lesions, previously diagnosed as lichen sclerosus, which have progressed to vulvar squamous cell carcinoma. (http://www.ncbi.nlm.nih.gov/pubmed/21057461) Squamous precursor lesions of the vulva: current classification and diagnostic challenges. (http://www.ncbi.nlm.nih.gov/pubmed/27113549) Differentiated vulvar intraepithelial neoplasia-like and lichen sclerosus-like lesions in HPV-associated squamous cell carcinomas of the vulva. (http://www.ncbi.nlm.nih.gov/pubmed/29505429)

A 70-Year-Old Woman Comes to the Office Due to Vulvar