Persistent Vulvar Pain

Reading: Committee Opinion No. 673 - Persistent Vulvar Pain 

What is persistent vulvar pain? 

• Persistent vulvar pain is a complex disorder and often very frustrating to both the patient and the provider 

• Because it is difficult to treat and even with appropriate treatment, pain may not resolve completely 

• Terminology and Classification - from 2015 Consensus Terminology and Classification of Persistent Vulvar Pain 

• From the International Society for Study of Vulvovaginal Disease: 

• Can be caused by a specific disorder or it can be idiopathic 

• Idiopathic vulvar pain = vulvodynia

• Vulvar pain caused by specific disorder: 

• Infectious (ie. recurrent candidiasis, herpes) 

• Inflammatory (lichen sclerosus, lichen planus, etc.) 

• Neoplastic (ie. Paget disease, SCC) 

• Neurologic (postherpetic neuralgia, nerve compress or injury) 

• Trauma

• Iatrogenic (postoperative, chemotherapy, radiation) 

• Hormonal deficiencies (ie. genitourinary syndrome of menopause, lactational amenorrhea) 

• Vulvodynia = vulvar discomfort, most often reported as burning pain, which occurs in the absence of relevant visible findings or a specific, clinically identifiable neurological disorder for at least 3 months 

• Descriptors 

• Localized (ie. vestibulodynia, clitorodynia), general, or mixed (can be localized or generalized) 

• Provoked (ie. insertional, contact), spontaneous, or mixed (provoked and spontaneous) 

• Onset (primary or secondary) 

• Temporal pattern (intermittent, persistent, constant, immediate, delay) 

How do we evaluate what the cause of vulvar pain is? 

• Exclude other causes before assigning vulvodynia 

• Vulvodynia = diagnosis of exclusion 

• History

• Do your normal OPQRS – how long has the patient been having pain? Where is it? 

• Also obtain medical and surgical history

• Sexual history - make sure to ask permission 

• Allergies 

• Previous treatment 

• Physical exam 

• Know your anatomy!  

View fullsize

UPTODATE

• Cotton swab test

  • Using a cotton swab and moving across the labia → start on thighs → labia majora → interlabial sulci. Then test vestibule in the 2, 4, 6, 8, 10 o’clock position 

• R/o infection  

• Wet mount, vaginal pH, fungal culture, and gram stain 

• Vulvoscopy - usually not needed 

• If there is concern, you can also biopsy an area - can find dermatoses 

• Musculoskeletal evaluation 

• Palpation of the different muscles within the pelvis to see if there is referred pain

• Palpation of the pubovaginalis portion of the levator ani, obturator internus, and urethrovaginal sphincter 

Treatment 

• Unfortunately, the evidence for treating vulvodynia is based on clinical experience and observational studies - few randomized studies exist 

• If there is obvious cutaneous or mucosal disease present 

• Treat the disease! Ie. infections, dermatoses 

• We talk about this here on previous podcasts: 

• Vulvar itching

• Benign vulvar dermatoses

• If there is not, do the cotton swab test 

• If no areas of tenderness then consider alternative diagnosis 

• If there is tenderness or burning with cotton swab test, do a yeast culture 

• Positive yeast culture: antifungal 

• If negative, or if antifungal does not provide adequate relief, move to:

• Vulvar care measures

• Cotton underwear and no underwear at night 

• Avoid vulvar irritants and douching 

• Mild soaps for bathing, or anti-allergenic soaps, do not apply directly to vulva 

• Apply preservative free emollient (ie. coconut oil) 

• Switch to 100% cotton menstrual pads 

• Use water based lube for intercourse 

• Cool gel to vulvar area for relief 

• Topical medications - ie. estrogen cream, tricyclic antidepressants can be compounded 

• Oral medications - TCAs and anticonvulsants; use one drug at a time 

• TCAs should be used for up to 3 weeks to assess adequate pain control 

• Injections (ie. botox for trigger point injections, can also use steroids for trigger point injections ) 

• Biofeedback/physical therapy - assess for pelvic floor dysfunction 

• Dietary modification 

• CBT 

• Sexual counseling 

• If still no adequate relief and localized pain → can consider surgery with vestibulectomy 

• Should only be done if other treatments have failed 

• Success rate is 60-90% compared to 40-80% for nonsurgical interventions 

• If generalized pain - consider increasing the dose of medication, combining meds, etc. 

Vulvar Intraepithelial Neoplasia (VIN)

Here’s the RoshReview Question of the Week!

A 41-year-old woman, G2P2, presents to your office for postcoital bleeding. She has a history of laparoscopic hysterectomy for persistent cervical intraepithelial neoplasia 3. A vaginoscopy is performed and shows multiple lesions in the upper third of the vagina. One lesion located within a suture recess near the vaginal cuff is not able to be visualized in its entirety. Biopsy reveals a high-grade squamous epithelial lesion. Her social history is significant for smoking. Which of the following is the best therapy?

• CO2 laser ablation

• Human papillomavirus vaccination

• Imiquimod

• Surgical excision

Check your answer at the links above and check out RoshReview’s CREOG question bank!

---

Follow along with ACOG CO 675!

What is Vulvar Squamous Intraepithelial Lesions (SIL) and why do we care? - previously called VIN 

• VIN is increasingly common - esp in women in their 40s 

  • VIN has increased more than 4x from 1973 to 2000! 

  • VIN should be considered a premalignant condition

• How do we classify?

  • Has changed a lot over time, but most recently we have used:

    • LSIL of the vulva - used for low grade changes that come from HPV infections (usually present as genital warts) 

    • HSIL of the vulva - used for high grade changes that comes from HPV infections (precancerous lesions) - used to be called “usual type” 

      • VIN, warty type 

      • VIN, basaloid type 

      • VIN, mixed (warty or basaloid) type 

    • Differentiated type - from things like lichen sclerosus 

  • The International Society for the Study of Vulvovaginal Disease ISSVD recommends these terms to unify the nomenclature of HPV-associated squamous lesions of the lower genital tract - all of these are based on histopathologic findings:

View fullsize

ACOG CO 675

How do we diagnose VIN? 

• Unfortunately, no good screening strategies

  • Detection usually limited to visual inspection 

  • What does it look like?

    • Can vary. Most will be raised, but some can be flat 

    • Discoloration of the skin - white, gray, red, brown, or even black 

  •  Should biopsy to make definitive diagnosis if not sure of diagnosis of something else (ie. LS) 

    • Biopsy should be performed in postmenopausal women with apparent genital warts and in women of all ages with genital warts where topical therapies have failed 

    • Colpo can also be useful - just remember that you need to soak the vulva in acetic acid with a gauze pad for several minutes 

What do we do to treat? 

• Treat all vulvar HSIL (VIN usual type) 

  • Surgery 

    • Wide local excision should be done if there is suspected to be cancer 

    • Can be occult invasion even if initial biopsy is vulvar HSIL 

    • Should include gross margin of 0.5-1 cm around tissue with visible disease 

    • May be altered to avoid injury to critical structures like clitoris, urethra, anus, or other structures 

    • However, if lesions in critical areas, should be referred to specialist to avoid impaired psychosexual function (ie. if extensive around the perineum, reaching back to anus or around the clitoris 

    • If clear margins in excised tissue, much lower risk of recurrence 

  • Laser Ablation Therapy 

    • Should be done if occult invasion is not a concern

    • Can be used for single, multifocal, or confluent lesions, although risk of recurrence may be higher than with excision 

    • Colpo can help delineate lesions of margins 

    • As with excision, 0.5-1cm margin to be treated 

    • Remember than unlike genital warts, the entire thickness of the epithelium must be treated

  • Medical Therapy 

    • Topical imiquimod 5% 

    • Regimens that have been published include 3x/week to affected area for 12-20 weeks 

    • Colpo assessment at 4-6 weeks 

    • Residual lesions require surgical treatment 

• Surveillance

  • Recurrence rate is as high as 9-50% with all treatment regimens

    • Higher with positive margins

    • Lower in surgically treated patients 

  •  Follow up has been limited in most studies 

  • However, women with Vulvar HSIL are at high risk of recurrence during their life time 

  • If complete response to therapy and no new lesions at follow-up visits, scheduled 6 and 12 months after initial treatment should be monitored by visual inspection 

Pediatric Vulvovaginitis

Infrequently in the general gynecologist’s office, you may be asked to evaluate a child for concern of vulvovaginitis. Today’s episode will review some common questions regarding approach in pediatric gynecology, and be specific to a pre-pubertal population.

Many times this is the first time that the young patient has seen a gynecologist! It’s going to be a scary and unfamiliar environment, as the only context for physicians for many children at this point are their pediatrician or family physician. You’ll likely have to lean in to the parent/close relative/guardian for history and more information regarding chronicity, anxieties, and specific complaints.

Common complaints can include:

• Itching or discharge.

• Pain or irritation.

• Issues with going to the bathroom (ie. some children may have issues of leaking urine, seemingly losing the developmental milestone of urinary continence).

The approach in pediatrics is somewhat different:

• Getting the trust of the patient - this may be harder for us as Ob/Gyns, since we are not always used to dealing with a pediatric population.

  1. Stickers, coloring books, asking about school and friends etc.

• If they are old enough to speak for themselves, always ask them what’s going on!

• Then ask/tell them that you are going to talk to their parent/guardian who is with them that you’d like to ask them as well what is going on — this is respectful of the child and keeps them involved.

• For adolescent patients, usually have the parents/guardian step out of the room for some time for sensitive questions 

  1. Assess risk: safety at school, home, people they don’t get along with or who may be hurting them 

  2. Drug/alcohol/tobacco use - kids may feel guilty about using. Ask if friends/family use, then can broach the subject with them.

  3. Sexual activity (usually approached with “Do you have anyone at school that you might like? Have you held hands or kissed them?).

Specific questions related to the complaint:

• Assessment of vulvar hygiene

  1. Showering/bathing habits - bubble baths? What types of soaps? 

  2. Toileting - how do they wipe? Have them demonstrate 

  3. Choice of clothing/clothing due to hobbies/activities - leotards, tights, swimsuits, etc - how long are they wearing them during the day? What kind of underwear? What about pajamas? 

• The exam

  1. Most children will not have had a pelvic exam, and most (read: almost all) do not require a speculum exam!

  2. Check for abnormal breast development (ie. early breast development) in younger children.

  3. Check for abdominal masses.

  4. Pelvic exam:

     1. Child can be laid back on the table in frog leg position, can also have parent sitting on exam table and holding child on lap in this position.

     2. Careful external examination, also can spread labia from lower legs/bottom and look at urethra/hymenal ring.

        1. Look for skin changes on the labia - red? White? Thin? 

        2. Also, see if there is labial adhesions.

        3. Purulent discharge/other types of discharge can be seen on underwear as well 

     3. Q-tip test to evaluate for vaginal potency.

     4. Foreign objects that cannot be easily removed should not be done in the office with smaller children, may require vaginoscopy  

Now let’s review some differential diagnoses that may present in young children.

Infectious 

1. Candida 

   1. Possible to have yeast infection in children who have had recent antibiotic treatment or if they wear diapers.

   2. Usually uncommon in normal prepubertal girls, unlike in women.

   3. If mostly on the outside, or diaper dermatitis, can use topical antifungal agents like nystatin, clotrimazole, miconazole, etc.

2. Gardnerella - also possible, but it is not common. Treat like BV. 

3. STI - suspect if purulent discharge with evidence of sexual abuse on interview/exam

   1.  Evidence includes anal or genital tears, evidence of ejaculation.

   2. Laceration to lower half of the hymenal ring, usually 3-9 o’clock is consistent with penetrating injury.

   3. Suspicion of child abuse is something that requires mandatory reporting to authorities.

   4. Things to test for include gonorrhea, chlamydia, trichomonas.

   5. Genital warts: can be diagnosed clinically and usually with biopsy.

Noninfectious 

• Foreign body

  1. Can cause acute and chronic vulvovaginitis with purulent discharge, foul smell, and even bleeding.

  2. Most common things are toilet paper, small toys, etc → can usually be removed with warm vaginal lavage (ie. obtaining thin catheter and attach to 60cc syringe). Place the tip of catheter into the vaginal canal, and can lavage several times 

  3. Can treat introitus with small amount of Xylocaine jelly if needed for pain / local anesthetic.

  4. If large object or not easily removed, may need sedation/anesthesia for extraction.

  5. If there is suspicion for battery within the vagina, this is a reason for anesthesia, vaginoscopy for possible burns 

• Trauma 

  1. Vulvar trauma can cause significant bleeding - area is highly vascular 

  2. Interview is important - was there recent straddle injuring/skating injury?

     1. History should correlate with physical finding - otherwise suspect abuse.

  3. Straddle injury: injury usually anterior area of the vulva, including mons, clitoral hood, and anterior aspect of the labial 

     1. Should not have injury to the posterior fourchette and hymenal areas - this would suggest sexual abuse.

     2. Assess ability to urinate and presence of hematoma; if unable to urinate,, need to drain bladder, ice, and give pain medication if large hematoma.

        1. If not obstructive, can ice and give pain medication. Most hematomas will resolve spontaneously 

     3. Surgery is rarely needed and can result in introduction of skin → infection 

Skin issues 

• Lichen sclerosus 

  1. We talked about lichen sclerosus in postmenopausal women previously!

  2. It can cause itching, discomfort, even discharge.

  3. Usually appears white, thin skin (onion skin, cigarette-paper), and usually around the vulva and perianal regions.

     1. Can usually diagnose with visual inspection, and biopsy is rarely needed, though in adults you should biopsy (can be associated with malignancies in adulthood).

  4. Treatment: superpotent topical steroids → first start with more frequent treatment, then maintenance therapy.

• Labial adhesions

  1. Most frequently in infants and young children, peak incidence up to 3% in second year of life in girls.

  2. Usually due to inflammation + low estrogen.

  3. Can lead to discomfort and possible issues with urination, recurrent urinary tract infection.

  4. If asymptomatic, no treatment is necessary especially if it only involves a small portion of the labia.

  5. If symptomatic - initial treatment with topical estrogen/estradiol cream twice a day with fingertip or Q-tip, sometimes with a little pressure, but do not try to manually separate the adhesion as this can cause tearing/pain/bleeding.

     1. Usually can see a thin, translucent raphe in the middle (location of placing estrogen) 

     2. Another option is topical betamethasone as alternative or adjunctive topical treatment  

  6. Surgical separation - rarely indicated. Usually only for those with severe obstruction to urinary flow or who have urinary retention. 

• Vulvar ulcers 

  1. Can be non-sexually transmitted ulcers and can present with systemic symptoms like fatigue, malaise, fever, etc.

  2. Etiology may not always be determined, but viruses can sometimes cause them (ie. flu A, EBV, mycoplasma, CMV).

     1. Take a careful sexual history to rule out other STDs, HSV - but perform these tests as well just in case.

  3. Can also test with CBC and monospot test.

  4. If continues to be painful, unable to urinate, some girls may need to be admitted for pain control and foley placement.

  5. Other things to rule out: Behcet’s syndrome (if chronic ulcers), Crohn’s disease.

Nonvaginal issues 

• Urethral prolapse

  1. Distal end of the urethra can prolapse either partially or in a complete circumferential fashion (“donut-like”).

  2. Tissue can be friable and can become infected.

  3. Usually will have pain with urination, bleeding, etc. 

  4. May need to differentiate from other things like sarcoma botryoides or prolapsed ureterocele (may need a urologist!).

  5. If symptomatic, can be treated with topical estrogen 2x/day for two weeks, and then reassess.

• Pinworm 

  1. Can cause vulvar symptoms as well, like itching, but usually is perianal itching.

  2. Caused by the worm enterobiasis.

  3. Can be diagnosed with visual inspection or “paddle test” where there is a plastic paddle sometimes with adhesion pressed to perianal area → then place on glass slide to see worms.

  4. Treatment is with albendazole or mebendazole, and should think about treating the entire household.

  5. Wash all bedding and clothes!

Benign Vulvar Dermatoses

So back in December 2019 (episode 66), we talked about vulvovaginal itching and gave a broad differential for workup of this very common symptom. Today, we thought we might focus on a few of the commonly tested and supremely confusing vulvar dermatoses, based on the new ACOG PB 224.

A quick refresher on diagnosis and workup: 

• History and physical are supreme in helping you establish acute vs. chronic and narrowing down most likely suspects.

• Labs beyond a wet mount are usually not needed, unless suspecting immunocompromise or needing a genital culture for persistent vaginitis symptoms.

• Biopsies in general are reserved for ruling out possible premalignant or malignant areas.

Lichen Simplex Chronicus (LSC)

• Chronic, nonscarring, inflammatory condition characterized by intense itch-scratch.

  • Most commonly reported symptom is chronic or intermittent intense itch, most commonly in the evening or night.

• Very common - accounting for up to a third of vulvar clinic visits, and often is a secondary condition of other “itchy” vulvar disease like contact dermatitis. 

• Most commonly encountered in middle aged women or elderly, and in women with a history of environmental allergies, asthma, or childhood eczema.

• On exam, appearance is often erythematous, scaling, and/or lichenified (thickened/leathery) plaques, with variable degrees of excoriation due to the intense itching associated with the condition. 

  • The skin with longstanding disease is often described as “bark-like” it’s so thick! 

• Consideration can be given to identifying other diseases that may be contributing to itching, such as candidiasis, but biopsy is not generally indicated.

• Treatment is multipronged:

  • Education on stopping the itch-scratch cycle.

  • Removal of offending/worsening factors, such as contact dermatitis, excessive heat/moisture, or treatment of infection.

  • Medium or high-potency topical corticosteroid, applied once or twice daily. If started on steroid, should be seen again within 4 weeks to assess response and adjust course. 

  • Oral anti-pruritic medications.

Lichen Sclerosus

• Chronic, scarring disorder that is bimodal in age distribution -- affects most commonly the anogential skin of prepubertal girls and postmenopausal women. 

• Often asymptomatic and goes unrecognized by many clinicians.

• If symptomatic, most common presenting symptoms include itching/irritation/burning, dyspareunia, and tearing.

• On exam, the skin often has the classic “cigarette paper” appearance - thin, whitened, and crinkled. 

  • Extensive involvement from the superior vulva to the perianal tissue may create an “hourglass shape” of involvement which is classic for this disease.

  • Due to the scarring nature of the condition, the introitus may be narrowed, there may be phimosis (inability to retract skin around) of the clitoral hood, and presence of fissures. 

• Biopsy is generally warranted in postmenopausal patients - patients with LS have increased risk of vulvar squamous cell carcinoma, ranging from 2-5%. 

  • Biopsy should be undertaken in areas which appear to be high risk -- i.e., if presence of any ulcers/erosions, or hyperpigmented or hyperkeratotic areas.

• Treatment of LS is important in order to halt and prevent further scarring. Initially, a high potency corticosteroid should be used, generally clobetasol propionate 0.05% or mometasone furoate 0.1%. 

  • Dosing / application schedule is not well studied, but the PB recommends nightly for 4 weeks, every other night for 4 weeks, and then twice weekly for 4 weeks.

  • Maintenance therapy is generally needed until puberty in girls, or lifelong in older patients, and should be the most infrequent dosing that maintains resolution. 

  • For disease not responding to steroids, it is most important to ensure the diagnosis is correct! You don’t want to treat VIN/ vulvar SCC with steroids. 

    • Intralesional steroid injections or topical calcineurin inhibitors such as tacrolimus can be used for particularly resistant disease, but consider vulvar specialist referral before you are doing these.

Lichen Planus

• Multisystem scarring dermatosis affecting the skin, oral mucosa, and vulvovaginal area, likely as a consequence of a dysfunctional cell-mediated immune system. 

  • Autoimmune disorders have been seen in up to a third of patients with LP.

• Rare, with incidence in general population less than 1%. 

• Most common in perimenopausal and menopausal women. 

• Common presenting symptoms are dyspareunia, burning, soreness, itching, and vaginal discharge.

• Diagnosis is complicated as there are multiple potential presentations; However, over 70% with vulvovaginal disease will also have oral involvement, so if suspected an oral exam should also be performed. 

  • Classic (papulosquamous): white, reticular, lacy, fernlike striae.

    • Dusty pink, poorly demarcated papules may also be present.

    • Occasionally with extensive involvement can “white out” vulvar skin and make picture confusing versus lichen sclerosus.

  • Erosive deep, painful, and erythematous lesions appear in posterior vestibule extending to labia minora. Architecture is often distorted and vaginal epithelium may be completely denuded. Lesions are extremely friable. 

  • Hypertrophic is the least common presentation, though with white, thick, warty plaques. 

• Wet mount performed for diagnosis will often demonstrate an abundance of immune cells in addition to parabasal and basal epithelium, as well as increased pH (5-6)

• Biopsy may be indicated based on the presentation, and may be helpful for distinguishing from rarer diagnosis like bullous pemphigoid / pemphigus vulgaris (ask your derm friends).

• Treatment is based on expert opinion but is high-potency topical corticosteroids, generally twice daily and tapered back over time. 

  • For erosive disease, also should be treated with intravaginal steroid therapy, such as hydrocortisone suppositories, and followed by vulvar specialist. 

  • Often will also need dilator therapy along with steroids due to scarring nature of disease. 

A quick word on topical corticosteroids

• So medium and high-potency corticosteroids feature heavily in the treatment of benign vulvar dermatoses… so review PB 224 for a list of them! 

  • Ointments are the preferred treatment compared to creams, lotions, or gels, as the ointments have the least additional additives that can make skin more sensitive and also allow for highest effective dose to penetrate the skin. 

View fullsize

ACOG PB 224

Vulvovaginal Itching

Today we’re working up the classic GYN sick visit in vulvovaginal itching. We recommend The V Book by Elizabeth Stewart, MD, and though we haven’t read Dr. Jen Gunter’s The Vagina Bible yet, we’ve heard great things!

We start off the episode with a review of things that can cause itching, stratifying from benign to more worrisome. For benign causes, the primary culprit is vaginitis. Think yeast (Candida), bacterial vaginosis, or less commonly gonorrhea/chlamydia or trichomoniasis. Another benign cause is desquamative inflammatory vaginitis, that can be associated with large amounts of discharge. Genitourinary syndrome of menopause, or atrophic vagnitis, is another common cause in postmenopausal women.

Benign dermatoses of the vulva can include lichen planus, which manifests as a red or purplish raised rash, that can present as hypertrophic or ulcerative. It can further lead to lichen simplex chronicus, which is an area of thickened skin due to repeated excoriation. Lichen planus can also involve other areas of the body. Finally, benign dermatoses like eczema, contact dermatitis, or psoriasis can also affect the vulva.

More worrisome dermatoses can include lichen sclerosus. Generally benign, this is a chronic, progressive inflammatory mucocutaneous disease that peaks in prepubertal and in menopausal women. The skin becomes thin and parchment-paper or “cigarette paper”-like in consistency, whitening, and destruction of the architecture and narrowing of the vaginal introits. It can be worrisome, particularly in older women, because it can harbor vulvar intraepithelial neoplasia (VIN) or squamous vulvar cancer. Of course, both of those can also occur on their own, often in the context of HPV infection.

Another malignant dermatosis is extramammary Paget’s disease. In this case, the vulva have an eczematous appearance with slightly raised edges and a red background. This is rare, with the malignancy originating in the vulvar apocrine-gland-bearing skin cells.

Ok, so lots of things can cause this itching, but what should we do? Always start with a complete history and physical. Histories should have special focus on vulvar hygiene, as this is often the culprit. A physical exam should include all skin including the vulva, to rule out more significant dermatoses. With the vulva, we advise a “top down” systematic approach before proceeding with the speculum exam.

The gynecologists handy tool will be the wet mount. Vaginal pH should be < 4.5, and basic pHs may suggest infection or poor lactobacillus presence. Dropping 20% KOH solution on the slide will allow for better visualization of yeast, as well as allow for the performance of the whiff test. On microscopy, you should see plenty of squamous cells (large, squarish cells with small nucleus or no nucleus), compared to paranasal cells (small round cells with prominent nuclei). Sheets of squamous cells with paranasal cells suggests desquamative inflammatory vaginitis. Clue cells have stippled or fuzzy borders along squamous cells. Yeast often has the classic ‘budding pseudohyphae’ or ‘spaghetti and meatballs’ appearance.

Genital cultures may be helpful in identifying resistant or unusual organisms, such as Candida glabratta. If allergies are suspected, referral for patch testing may be worthwhile if avoidance isn’t feasible. Biopsy should be performed to rule out malignancy at ulcerating areas, with lichen sclerosus, or with other areas of concern.

With vulvar hygiene, go as simple as possible. As our mentor Dr. Crichton always says: if you wouldn’t put it in your eye, don’t put it on the vulva. Recommend cotton underwear during the day, no underwear at night; unscented detergents and soaps; only water on vulva; latex condoms and provide own lube with silicone lube; avoid panty liners every day, only during periods . Coconut oil makes for excellent personal moisturizer and lubricant.

If something is present, you should treat the condition. Infections should be treated with appropriate antimicrobials. Lichen planus should be given symptomatic treatment to stop itching. Lichen sclerosus often will need high potency steroids (i.e., clobetasol) to resolve. Malignancies will require excision with referral to oncology for true invasive cancers.