Obgyn · Year 3 · from Obgyn

Case 2: Vulvar Lichen Sclerosus with Vulvar Intraepithelial Neoplasia

Patient Demographics

  • Age: 67 years
  • Sex: Female
  • Occupation: Retired librarian

Chief Complaint

"I've had terrible vulvar itching for years that won't go away, and now I noticed a new raised area."

History of Present Illness

The patient has a 10-year history of vulvar itching and discomfort. She was diagnosed with lichen sclerosus 8 years ago and was prescribed topical clobetasol, which she used intermittently with partial relief. Over the past 6 months, she noticed a new raised, firm area on her right labia majora that is occasionally tender. The lesion has slowly increased in size. She also reports dyspareunia and has avoided intercourse for the past year.

Gynecologic History

  • Menarche: Age 13
  • Menopause: Age 52
  • No hormone replacement therapy
  • Prior pregnancies: G2P2
  • Last Pap smear: 5 years ago (discontinued per guidelines after age 65)
  • No history of abnormal Pap smears
  • Prior vulvar biopsy 8 years ago: Lichen sclerosus

Past Medical History

  • Lichen sclerosus (diagnosed 8 years ago)
  • Hypertension
  • Osteoporosis
  • Autoimmune thyroiditis

Social History

  • Non-smoker
  • Married, lives with husband
  • No history of sexually transmitted infections

Physical Examination

Vulvar Inspection:

  • Diffuse white, thin, atrophic skin affecting bilateral labia majora, minora, clitoral hood, and perineum
  • "Cigarette paper" wrinkling of skin
  • Loss of normal vulvar architecture:
  • Resorption of labia minora
  • Clitoral phimosis (clitoral hood adherent)
  • Introital narrowing
  • New finding: 1.5 cm raised, hyperkeratotic, slightly erythematous plaque on right labia majora
  • No ulceration or obvious necrosis

Vaginal Examination:

  • Vaginal mucosa atrophic
  • Cervix appears normal
  • Uterus small, atrophic
  • No adnexal masses

Clinical Assessment

Lichen sclerosus with new suspicious lesion

Concern: New raised lesion in the setting of chronic lichen sclerosus requires biopsy to rule out:

  • Differentiated vulvar intraepithelial neoplasia (dVIN)
  • Vulvar squamous cell carcinoma

Vulvar Biopsy

Procedure:

  • Local anesthesia with 1% lidocaine
  • 4 mm punch biopsy of raised lesion (right labia majora)
  • Additional biopsy from adjacent lichen sclerosus area
  • Hemostasis with silver nitrate

Pathology Results:

Biopsy 1 (raised lesion):

  • Differentiated vulvar intraepithelial neoplasia (dVIN)
  • Background lichen sclerosus
  • No invasion identified

Biopsy 2 (adjacent area):

  • Lichen sclerosus
  • No dysplasia

Diagnosis

Differentiated VIN (dVIN) arising in lichen sclerosus

Understanding the Pathology

Differentiated VIN (dVIN):

  • Non-HPV-related vulvar precancer
  • Arises in background of chronic vulvar dermatoses (especially lichen sclerosus)
  • Associated with keratinizing squamous cell carcinoma
  • Higher risk of progression than usual-type VIN
  • Often unifocal and subtle

Compared to Usual-type VIN (uVIN):

  • HPV-related
  • Occurs in younger women
  • Often multifocal
  • Classic warty or basaloid appearance

Risk Discussion

  • dVIN has 33-86% risk of progression to invasive SCC
  • Higher malignant potential than uVIN
  • Requires complete excision

Treatment Plan

Surgical Excision:

  • Wide local excision of dVIN lesion
  • Goal: 5-10 mm margins
  • Primary closure anticipated

Procedure Performed:

  • Local anesthesia
  • Elliptical excision of lesion with 1 cm margins
  • Primary closure with absorbable sutures
  • Specimen sent for permanent pathology

Final Pathology:

  • Differentiated VIN
  • Margins clear (closest margin 6 mm)
  • No invasive carcinoma
  • Adjacent lichen sclerosus

Postoperative Care

  • Wound care instructions
  • Sitz baths
  • Activity restrictions for 2 weeks
  • Pain management with acetaminophen/NSAIDs

Long-term Management of Lichen Sclerosus

Importance of Continued Treatment:

  • Lichen sclerosus is a chronic condition with 4-6% lifetime risk of vulvar SCC
  • Consistent treatment may reduce cancer risk

Optimized Treatment Regimen:

  • Clobetasol 0.05% ointment:
  • Daily x 4 weeks
  • Then every other day x 4 weeks
  • Then twice weekly for maintenance
  • Vaginal estrogen for atrophy and dyspareunia
  • Emollient (petroleum jelly) for barrier protection
  • Avoid irritants (scented products, tight clothing)

Surveillance Plan

  • Vulvar examination every 6 months given history of dVIN
  • Self-examination monthly with mirror
  • Biopsy any new lesions immediately
  • Continue topical corticosteroid maintenance
  • Patient education: Report any new bumps, color changes, or non-healing areas

Follow-up (3 months)

  • Surgical site well-healed
  • Using clobetasol as directed
  • Pruritus improved
  • No new lesions

Follow-up (1 year)

  • No recurrence of dVIN
  • Lichen sclerosus stable on maintenance therapy
  • Vulvar architecture unchanged
  • Will continue every 6-month surveillance

Teaching Points

  • Lichen sclerosus has 4-6% lifetime risk of vulvar SCC
  • Differentiated VIN arises in chronic vulvar dermatoses (lichen sclerosus, lichen planus)
  • dVIN has higher malignant potential than HPV-related usual-type VIN
  • Any new lesion in lichen sclerosus requires biopsy
  • Wide local excision with clear margins is treatment of choice for VIN
  • Long-term surveillance is essential - these patients remain at elevated risk
  • Consistent treatment of underlying dermatosis may reduce cancer risk

Clinical Image

Image Description: Clinical photograph of the vulva demonstrating lichen sclerosus with characteristic white, atrophic skin changes and loss of normal architecture including labial resorption and clitoral phimosis. A raised, hyperkeratotic lesion is visible on the labia, representing differentiated vulvar intraepithelial neoplasia requiring biopsy.

Attribution: Educational illustration. Used for medical education purposes.

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