Lichen planus Lichen planus is characterized by its erosive appearance, just as it is on other surfaces. 
Typical nonspecific erosions of vulvar lichen planus with surrounding white epithelium. (Photos: Libby Edwards, M.D.)
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"It's diagnosed by knowing that, statistically, the most common cause of erosion on the mouth and on the vulva is lichen planus,"
Dr. Edwards says.
"You may find white lesions, as you would with lichen planus in the mouth. The biopsy usually comes back as lichenoid dermatitis
and is, therefore, not conclusive," she says. Therefore, the dermatologist should go by what is seen. Chronic, nonspecific erosions on the vulva should be treated as lichen
planus with topical steroids, as it would be if the lesions were in the mouth. Lichen planus is also treated with topical corticosteroids. If the vagina is also affected, the dermatologist can prescribe
hydrocortisone rectal steroids, but instruct the patient to insert the suppositories into the vagina. In such cases, it may be prudent to prescribe an antifungal preventively, such as fluconazole (Diflucan, Pfizer).
Topical or vaginal applications of estrogen, or systemic estrogen, can also help, Dr. Edwards says. "Lichen planus is chronic and much more difficult to control than is lichen sclerosis in the average woman," she says. Therefore, when women with lichen planus have an inadequate response to topical steroids, dermatologists can then use
medications that are also used for oral lichen planus, such as methotrexate and etanercept (Enbrel, Amgen and Wyeth).
Vulvodynia Vulvodynia is a pain syndrome that is a combination of neuropathy and pelvic floor muscle abnormalities that can be exacerbated
by depression and anxiety from having this condition, Dr. Edwards says. The diagnosis of vulvodynia is made by exclusion, she says. "If a patient reports chronic vulvar pain, burning and rawness, but the exam shows completely normal tissues with normal secretions,
the dermatologist can make a diagnosis of vulvodynia, Dr. Edwards says. The most effective treatments are those used for postherpetic neuralgia. Amitriptyline and gabapentin are often prescribed,
she says. Although the diagnosis for vulvodynia is time-consuming, effectively treating it can profoundly benefit the patients. DIV Desquamative inflammatory vaginitis (DIV) may be either one disease or a group of diseases. It is characterized by noninfectious
vaginal inflammation that causes a purulent vaginal discharge that burns the introitus. "Dermatologists need to look at (the discharge) under a microscope," Dr. Edwards says. "If the culture shows abundant white cells but no infection, the patient has either DIV or an estrogen deficiency," she says.
DIV is treated either by rectal hydrocortisone suppositories that are inserted instead into the vagina or clindamycin. When
the patient is sufficiently healed, the dermatologist can taper to the lowest possible doses to control the DIV. Clindamycin is used for its anti-inflammatory properties. Particularly at the start of treatment, Dr. Edwards also prescribes fluconazole as prophylaxis against yeast infections.
If the patient has an estrogen deficiency, she can be treated with either oral or topical estrogen. Disclosure: Dr. Edwards reports no relevant financial interests.
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