Authors: Colleen M. Kennedy, MD; MS, Lori A. Boardman, MD, ScM; and, Debra Heller, MD

Case:

A 54 year-old post-menopausal teacher presents with a history of worsening vulvar pruritus over the past 18 months. She takes no medications except levothyroxine for hypothyroidism and notes her TSH was tested 3 months ago and was normal. She has tried numerous over-the-counter agents including antifungals and Replens® without improvement. 

On examination, the vulva (figure 1), while structurally intact, is remarkable for a well-demarcated white plaque with fine crinkling and fragility as evidenced by purpura (arrow) and extending throughout the perineum in a figure-of-eight distribution. Additionally, there is hyperkeratosis at the labia majora bilaterally. The vagina appears slightly atrophic (consistent with the patient's age) and is otherwise normal, without lesions or abnormal discharge. Microscopy is normal, without yeast, clue cells, trichomonads or white blood cells. A vaginal fungal culture is negative.

1.	What is the most likely diagnosis? a. Vitiligo b. Lichen simplex chronicus c. Lichen sclerosus d. None of the above	(Figure 1) Click on image to enlarge.
2.	The diagnosis of lichen sclerosus is typically made by: a. Biopsy of the involved area b. Clinical exam with classical findings c. Fungal and bacterial cultures d. Both a and b are correct
3.	What is the most likely course for this patient (regarding the lichen sclerosus): a. Complete resolution with treatment b. Waxing and waning of symptoms c. Progression of disease including scarring despite treatment d. High likelihood of developing vulvar squamous cell cancer
4.	Initial therapy for lichen sclerosus consists of: a. Oral corticosteroid b. Topical corticosteroid c. Topical testosterone d. Topical progesterone e. None of the above
	Note: Additional educational references and lichen sclerosus images are included in the Answers section! Email