Differential Diagnosis for Chronic Vulvar Symptoms

Primary Differential Diagnoses

The American Urological Association and British Association of Dermatologists suggest that lichen sclerosus is the most likely diagnosis, given the constellation of chronic vulvar itching, burning, fissuring with bleeding, and dyspareunia in a postmenopausal-age woman 1, 2
Lichen sclerosus occurs most commonly in postmenopausal women, affecting 85-98% in the anogenital area, and is characterized by intractable pruritus, vulvar soreness, dyspareunia, and characteristic fissures/tears with bleeding 1, 2
The British Association of Dermatologists recommends that physical examination typically reveals porcelain-white plaques, fragile atrophic skin, and fissures in a figure-eight pattern around vulva and anus, which is pathognomonic for lichen sclerosus 1, 2
Lichen planus presents with vulvar burning, soreness, and dyspareunia similar to lichen sclerosus, but is distinguished by erosive lesions, potential vaginal involvement, and possible introital stenosis, according to the British Association of Dermatologists 2
Vulvovaginal candidiasis is characterized by intense pruritus and external dysuria, but typically presents with thick white discharge, and normal vaginal pH (≤4.5) helps distinguish from other causes, as recommended by the Centers for Disease Control and Prevention 3, 5

The American College of Obstetricians and Gynecologists and British Association of Dermatologists recommend a thorough physical examination to assess for porcelain-white plaques, fissures, ecchymosis, and architectural changes, including labial fusion, buried clitoris, or introital narrowing 1, 2
Biopsy is mandatory if diagnosis is uncertain, disease fails to respond to treatment, or there is suspicion of neoplastic change, according to the British Association of Dermatologists 2

The American Urological Association and British Association of Dermatologists recommend ultrapotent topical corticosteroids (clobetasol propionate 0.05%) as first-line treatment for lichen sclerosus, with long-term maintenance therapy typically required to prevent progression and scarring 1, 2
The Centers for Disease Control and Prevention recommend single-dose fluconazole 150 mg orally or topical azoles for 3-7 days for uncomplicated vulvovaginal candidiasis, and extended therapy with topical azoles for 7-14 days, followed by maintenance fluconazole 150 mg weekly for 6 months for complicated or recurrent cases 3, 5