Diagnosis and Management of Common Vulvar Disorders

Conclusions

• Normal vulvar pigment changes, sebaceous glands, and vestibular papillomatosis are common benign findings that should not be mistaken for disease.
• Genital dermatoses often look subtler and more atypical than similar diseases elsewhere on the body, so diagnosis requires careful examination of the vulva and other mucosal sites.
• When vulvar disease is unclear or unresponsive, biopsy is feasible and should be used early to confirm the diagnosis and rule out malignancy.
• Irritant contact dermatitis is a common vulvar problem driven by urine, pads, wipes, soaps, discharge, and other exposures, and management centers on removing irritants and using topical anti-inflammatory therapy.
• Allergic contact dermatitis is also common on the vulva, often triggered by topical anesthetics, antibiotics, preservatives, lanolin, fragrances, or steroids, and patch testing can identify relevant allergens.
• Patients with severe vulvar dermatitis often need potent topical steroids, sometimes systemic steroids, and treatment of secondary infection or yeast when present.
• Topical steroid use on the vulva can be effective and safe when correctly targeted and monitored, but misuse on hair-bearing skin can cause steroid dermatitis and striae.
• Persistent vulvar itching should prompt evaluation for infection, eczema, psoriasis, lichen simplex chronicus, or medication-related causes rather than assuming yeast alone.
• Lichen simplex chronicus is an itch-scratch cycle that can be broken with strong topical anti-inflammatory treatment, itch control, and sometimes gabapentin or intralesional corticosteroids.
• Vulvar psoriasis often appears subtle and pink rather than classically scaly, and many patients improve only after treatment is escalated beyond topicals, including biologics when needed.
• Lichen sclerosus is a chronic autoimmune-leaning vulvar disease that causes white atrophic plaques, pruritus, fissuring, scarring, and often requires long-term maintenance therapy.
• Maintenance treatment in lichen sclerosus appears important not only for symptom control but also for reducing the risk of vulvar squamous cell carcinoma.
• Lichen planus typically causes erosive vulvar disease with oral and vaginal involvement, can scar, and often requires aggressive initial treatment followed by maintenance.
• For lichen planus and resistant lichen sclerosus, systemic options such as hydroxychloroquine or other immunomodulators may help when topical therapy is insufficient.
• Persistent or changing vulvar lesions, especially in lichen sclerosus or lichen planus, should trigger repeat biopsy and ongoing surveillance for squamous cell carcinoma or dVIN.