Lichen planus (LP) is a chronic inflammatory condition that can affect the skin, hair, nails, and mucous membranes. Vulvar lichen planus (VLP) is a specific manifestation targeting the delicate tissues of the vulva and often the vagina. This condition is a T-cell mediated response where the immune system mistakenly attacks its own skin cells, leading to inflammation and tissue damage. VLP is frequently severe and significantly impacts quality of life, requiring specialized medical attention for proper diagnosis and management. It typically affects women between the ages of 30 and 60.
The Appearance of Vulvar Lichen Planus
Vulvar lichen planus presents in two main visual forms: the papular/reticular and the erosive variant. The erosive form is the most frequent in the genital area. The papular form is characterized by small, flat-topped, polygonal bumps called papules. These lesions often have a purplish or reddish-brown hue and can coalesce into larger plaques on the labia majora or mons pubis.
A distinguishing feature of the papular variant is the presence of fine, white, lace-like patterns known as Wickham’s striae. These striae may appear on the surface of the papules or in the surrounding tissue. This pattern is highly suggestive of lichen planus, especially when seen around the edges of lesions. This form is generally less destructive and less symptomatic than the erosive presentation.
The erosive variant is the most common and challenging form, involving non-keratinized mucous membranes like the labia minora and the vestibule. These lesions appear as bright red, raw, and well-demarcated patches with a shiny or glazed look. These areas represent superficial erosions where the top layer of skin has been shed due to intense inflammation.
Chronic inflammation and tissue damage can lead to permanent changes in the vulvar architecture. Scarring can cause the labia minora to shrink or disappear and may lead to adhesions, which narrow the vaginal opening. Severe cases can result in the clitoris becoming partially or completely buried beneath its hood due to tissue fusion.
Associated Physical Symptoms
The physical symptoms of VLP often focus on sensory discomfort and functional impairment. The most frequent complaints include intense burning, chronic soreness, and generalized irritation of the vulva and vagina. This discomfort is persistent and may not be fully alleviated by typical over-the-counter remedies.
Pain during sexual activity, known as dyspareunia, is a significant consequence, especially when erosions are present at the vaginal opening or within the vagina. The erosive form often extends into the vagina, a condition called desquamative vaginitis. This causes a painful, raw surface and a sticky, yellowish discharge. Vaginal involvement can make penetration painful and may lead to bleeding upon contact.
Urinary symptoms are frequently reported, including a burning sensation upon urination (dysuria). This is often due to urine contacting the raw, eroded tissue around the vaginal opening and urethra. While itching (pruritus) is a symptom, it is often less prominent in the erosive form compared to the intense pain and burning.
How Vulvar Lichen Planus Differs From Other Conditions
Accurate diagnosis is important because VLP can be mistaken for other vulvar conditions. Lichen sclerosus (LS) is one such condition that also involves chronic inflammation and can lead to scarring. However, LS typically presents with white, porcelain-like plaques and patches (hypopigmentation), which is distinct from the bright red erosions of VLP.
VLP has a strong tendency to involve the vagina and other mucous membranes, such as the mouth, which is rare in LS. LS lesions usually concentrate around the anus and vulva in a figure-of-eight pattern. VLP also needs to be differentiated from acute conditions like yeast infections or contact dermatitis.
Yeast infections and dermatitis are acute and respond well to specific treatments. VLP is a chronic, non-infectious, autoimmune disorder that does not resolve with antifungal or antibiotic medications. The presence of non-healing erosions, significant pain, and the characteristic white, lace-like striae help distinguish VLP from these more common, temporary issues.
Seeking Diagnosis and Managing the Condition
A definitive diagnosis requires consultation with a specialist, such as a dermatologist or gynecologist with expertise in vulvar disorders. While clinical appearance may suggest the condition, a biopsy is often necessary to confirm the diagnosis and rule out other possibilities, including rare malignancies. This procedure allows a pathologist to examine the tissue for the classic band-like pattern of inflammatory cells that characterizes LP.
Management of VLP focuses on controlling inflammation, reducing symptoms, and preventing scarring and tissue destruction. Treatment requires a long-term approach rather than a temporary cure. The first-line treatment involves high-potency topical corticosteroids, such as clobetasol, applied directly to the affected areas.
For cases that do not respond to steroid therapy, topical calcineurin inhibitors like tacrolimus may be used as a second-line option. These medications suppress the localized immune response, helping to relieve burning and pain and halt the destructive process. Regular follow-up is important to monitor disease activity and address potential complications promptly.