Diagnosing and Treating Vulvar Disease in Women of Color and Hypoestrogenic Women

Conclusions

• Women of color with vulvar depigmentation are at risk of misdiagnosis, so clinicians should distinguish vitiligo from lichen sclerosus by clinical features and biopsy the correct site.
• For vitiligo, biopsy should target the border of depigmentation, whereas for lichen sclerosus biopsy should sample active diseased areas such as pallor, atrophy, erythema, or purpura and avoid low-yield erosions or lichenified skin.
• Vulvar vitiligo and lichen sclerosus can coexist, and the presence of itch, fissures, texture change, erosions, or purpura should prompt evaluation for a second dermatosis.
• Vulvar vitiligo may be treated with topical or oral JAK inhibitors, often in combination with UVB phototherapy, though genital treatment data remain limited.
• Menopause is a normal life stage, but genitourinary syndrome of menopause is a common and chronic symptomatic condition that affects a substantial minority of patients.
• When postmenopausal patients have dryness or itch without an obvious dermatosis, topical vaginal estrogen is a safe and effective first-line option for many patients.
• Clinicians should remain alert that findings such as pallor, scarring, fusion, erosions, or architectural change are more suggestive of lichen sclerosus or another dermatosis than uncomplicated GSM.
• Patient selection matters for estrogen use, especially in those with hormone-sensitive cancers, where coordination with oncology may be appropriate.