4. A 73-year-old patient has longstanding introital itching and rawness, with dyspareunia. Topical estradiol cream intravaginally three times weekly with weekly fluconazole has not helped. The physical reveals deep red patches and erosions of the vestibule and anterior mucosal membranes, with loss of the labia minora. An oral exam shows deep redness of the gingivae and erosions of the buccal mucosae, with surrounding white, lacy papules.
Diagnosis: After correlating the vulvar and oral findings, you make a diagnosis of lichen planus. Erosive multimucosal lichen planus is a disease of cell-mediated immunity that overwhelmingly affects menopausal women. The most common surfaces involved are the mouth, vagina, rectal mucosa, and vulva; usually, at least two surfaces are affected. The esophagus, extra-auditory canals, nasal mucosa, and eyes also can be involved. Dry, extragenital skin usually is not affected in the setting of erosive vulvovaginal lichen planus.
For more information on this case, see “Chronic vulvar symptoms and dermatologic disruptions: How to make the correct diagnosis.” OBG Manag. 2014;26(5):30-49.