ACOG
PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN–GYNECOLOGISTS
This Practice Bulletin was devel-
oped by the ACOG Committee on
Practice Bulletins—Gynecology
with the assistance of Lori A.
Boardman, MD, ScM, and Colleen
M. Kennedy, MD, MS. The infor-
mation is designed to aid practition-
ers in making decisions about
appropriate obstetric and gyneco-
logic care. These guidelines should
not be construed as dictating an
exclusive course of treatment or
procedure. Variations in practice
may be warranted based on the
needs of the individual patient,
resources, and limitations unique to
the institution or type of practice.
THE AMERICAN COLLEGE OF
OBSTETRICIANS AND
GYNECOLOGISTS
WOMEN’S HEALTH CARE PHYSICIANS
VOL. 111, NO. 5, MAY 2008
NUMBER 93, MAY 2008
Diagnosis and
Management of Vulvar
Skin Disorders
Symptoms of vulvovaginal disorders are common, often chronic, and can sig-
nificantly interfere with women’s sexual function and sense of well-being. In the
evaluation of women who report symptoms of vulvar disorders, the most com-
mon diagnoses are dermatologic conditions and vulvodynia (both generalized
and localized forms) (1). The purpose of this document is to review diagnostic
approaches and provide a structured framework for the management of vulvar
disorders.
Background
Definition
Pruritus and pain are two of the most common presenting symptoms of vulvar
disorders in women treated in clinics that provide specialized care for vulvar
conditions (1–3). Pruritus and vulvar pain may occur in the presence of obvi-
ous dermatologic disease or in conditions with few visible skin changes. In
evaluating vulvar pruritus, it can be helpful to group women into those with
acute symptoms and those with chronic symptoms (see box, “Conditions
Commonly Associated With Vulvar Pruritus”). Vulvodynia, defined as burning,
stinging, rawness, or soreness, with or without pruritus, can be further charac-
terized by the site of the pain, whether it is generalized or localized, and
whether it is provoked, spontaneous, or both (4).
Examination and Evaluation
In cases of acute vulvar pruritus, common etiologies include vulvovaginal can-
didiasis and contact dermatitis. Chronic vulvar pruritus should prompt a search
OBSTETRICS & GYNECOLOGY 1243
for underlying dermatoses, such as lichen sclerosus, lichen
simplex chronicus, or psoriasis; neoplasia, including vul-
var intraepithelial neoplasia, squamous cell carcinoma,
and Paget disease of the vulva; or vulvar manifestations of
systemic diseases, such as Crohn disease.
Patients presenting with pain should first be evaluat-
ed to rule out underlying organic causes, including
inflammatory conditions, neoplasias, infections, or neu-
rologic disorders. When organic causes are ruled out, the
diagnosis of vulvodynia can be made, and attention
should then be paid to more fully elucidating the nature
of the pain disorder.
Chronic or recurrent forms of vulvovaginal disease
can be difficult to diagnose and treat. When taking a
medical history, it is important to ask about the onset,
duration, location, and nature of vulvar symptoms
(including the relationship of symptoms to the patient’s
menstrual cycle), as well as any possible precipitating or
known risk factors. In the evaluation of infectious caus-
es of vulvovaginal symptoms, microscopy using both
Conditions Commonly Associated
With Vulvar Pruritus
Acute
Infections
• Fungal, including candidiasis and tinea cruris
• Trichomoniasis
• Vulvovaginal candidiasis
• Molluscum contagiosum
• Infestations, including scabies and pediculosis
Contact dermatitis (allergic or irritant)
Chronic
Dermatoses
• Atopic and contact dermatitis
• Lichen sclerosus, lichen planus, lichen simplex
chronicus
• Psoriasis
• Genital atrophy
Neoplasia
• Vulvar intraepithelial neoplasia, vulvar cancer
• Paget disease
Infection
• Human papillomavirus infection
Vulvar manifestations of systemic disease
• Crohn disease
1244 ACOG Practice Bulletin Vulvar Skin Disorders
saline and potassium hydroxide preparations, in con-
junction with vaginal pH determination, will help to
guide the use of subsequent diagnostic tools. These addi-
tional diagnostic approaches include vaginal yeast cul-
ture, a variety of point-of-care tests approved by the U.S.
Food and Drug Administration, culture or polymerase
chain reaction for confirmation of herpes simplex virus,
and specific serologic tests (5). For autoimmune disor-
ders and suspected cases of neoplasia, biopsy is the pre-
ferred approach.
Vulvar Dermatoses
Dermatitis (or eczema), a poorly demarcated, erythema-
tous, and usually itchy rash, has been reported to occur in
20–60% of patients with chronic vulvar symptoms (6).
Contact dermatitis is one of the most frequently encoun-
tered and often avoidable problems seen in clinics that
provide specialized care for vulvar disorders. Many
seemingly innocuous behaviors, such as bathing, the use
of sanitary or incontinence pads, or exposure to known
irritants or allergens in numerous topical medications
(see box, “Common Vulvar Irritants and Allergens”),
have the potential to initiate contact dermatitis (7, 8).
Avoiding allergens can reduce the occurrence of both
contact dermatitis and lichen simplex chronicus. On
examination, clinical signs can range from mild erythe-
ma, swelling, and scaling to marked erythema, fissures,
skin thickening, erosions, and ulcers (8). The evaluation
of dermatoses also should include assessment to rule out
candidiasis.
Vulvar lichen simplex chronicus is a chronic eczema-
tous disease characterized by scaling and lichenified
plaque with intense and unrelenting itching, which may
result in sleep disruption. Although lichen simplex chron-
icus occurs primarily in mid- to late-adult life, it can occur
in children. From 65% to 75% of patients will report a
history of atopic disease, and lichen simplex chronicus
can be seen as a localized variant of atopic dermatitis.
Lichen simplex chronicus represents an end-stage
response to a wide variety of possible initiating process-
es, including environmental factors (eg, heat, excessive
sweating, and irritation from clothing or topically applied
products) and dermatologic disease (eg, candidiasis,
lichen sclerosus) (9). In long-standing disease, the skin
appears thickened and leathery, and areas of hyper-
pigmentation and hypopigmentation may be present.
Erosions and ulcers also can develop, most commonly
from chronic scratching. Vaginal yeast cultures are help-
ful in identifying the presence of an underlying condition
on which lichen simplex chronicus is superimposed.
Lichen sclerosus, a chronic disorder of the skin, is
most commonly seen on the vulva, with extragenital
lesions reported in up to 13% of women with vulvar dis-
OBSTETRICS & GYNECOLOGY

Common Vulvar Irritants and Allergens
Adult or baby wipes
Antiseptics (eg, povidine iodine, hexachlorophene)
Body fluids (eg, semen or saliva)
Colored or scented toilet paper
Condoms (lubricant or spermicide containing)
Contraceptive creams, jellies, foams, nonoxynol-9,
lubricants
Dyes
Emollients (eg, lanolin, jojoba oil, glycerin)
Laundry detergents, fabric softeners, and dryer sheets
Rubber products (including latex)
Sanitary products, including tampons, pads
Soaps, bubble bath and salts, shampoos, conditioners
Tea tree oil
Topical anesthetics (eg, benzocaine, lidocaine, dibu-
caine)
Topical antibacterials (eg, neomycin, bacitracin,
polymyxin)
Topical antimycotics (eg, imidazoles, nystatin)
Topical corticosteroids
Topical medications, including trichloroacetic acid, 5-flu-
orouracil, podofilox or podophyllin
Vaginal hygiene products, including perfumes and
deodorants
ease (10). The mean age of onset is in the fifth to sixth
decade, but it may occur at any age, including prepuberty
(11). The exact etiology of this condition is unclear,
although an autoimmune process or possible genetic link
is likely (12, 13). Patients presenting with lichen sclero-
sus most commonly report pruritus, followed by irrita-
tion, burning, dyspareunia, and tearing. The prevalence
of this condition remains unknown because lichen scle-
rosus may be asymptomatic.
On examination, typical lesions of lichen sclerosus
are porcelain-white papules and plaques, often with areas
of ecchymosis or purpura. The skin commonly appears
thinned, whitened, and crinkling (leading to the descrip-
tion “cigarette paper”). Although the vaginal epithelium
is largely spared from lichen sclerosus, involvement of
the mucocutaneous junctions may lead to introital nar-
rowing. Perianal involvement can create the classic “fig-
ure of eight” or hourglass shape. Other findings include
fusion of the labia minora, phimosis of the clitoral hood,
and fissures (14). Because other vulvar diseases can
VOL. 111, NO. 5, MAY 2008
mimic lichen sclerosus, a biopsy is necessary to confirm
the diagnosis, except in a prepubertal child (15, 16).
Lichen planus, an inflammatory disorder of the gen-
ital mucosa most likely related to cell-mediated immuni-
ty, exhibits a wide range of morphologies. The most
common form and the most difficult to treat is the ero-
sive form, which can lead to significant scarring and
pain. Most commonly recognized on the skin or oral
mucosa, this condition may affect the lower genital tract.
Approximately 1% of the population has oral lichen
planus, and of women with oral disease (17), approxi-
mately 20–25% have genital vulvovaginal disease (18).
The classic presentation of lichen planus on mucous
membranes, including the buccal mucosa, is that of
white, reticulate, lacy, or fernlike striae (Wickham stri-
ae). On occasion, the skin may appear uniformly white,
and thus lichen planus can be confused with lichen scle-
rosus. Pruritic, purple, shiny papules are typically asso-
ciated with lichen planus. However, if papules are found
on the genital skin, they appear dusky pink in color,
without an apparent scale, and less well demarcated.
In erosive lichen planus, deep, painful, erythema-
tous erosions appear in the posterior vestibule and often
extend to the labia minora, resulting in agglutination and
resorption of the labial architecture. The vaginal epi-
thelium can become erythematous, eroded, acutely
inflamed, and denuded of epithelium. Erosive patches, if
present, are extremely friable. Over time, these eroded
surfaces may adhere, resulting in synechiae and, eventu-
ally, complete obliteration of the vaginal space (19, 20).
Symptoms commonly reported by patients with erosive
vulvar lichen planus include dyspareunia, burning, and
increased vaginal discharge (21).
Erosive lichen planus often is labeled as desquama-
tive inflammatory vaginitis when vaginal discharge
reveals predominance of inflammatory cells and imma-
ture parabasal and basal epithelial cells (these will
appear small and round, with relatively large nuclei).
The vaginal pH is increased, usually in the range of 5–6.
Whether desquamative inflammatory vaginitis is a type
of erosive lichen planus or a distinct type of vaginitis is
controversial (19, 20). Biopsy of the affected area, which
reveals a bandlike infiltrate of lymphocytes and colloid
bodies in the basal layers of the epidermis, may be rela-
tively nonspecific because of the complete loss of the
epithelium. However, a histologic specimen can help
rule out immunobullous diseases, such as cicatricial
pemphigoid, bullous pemphigoid, and pemphigus vul-
garis, which may mimic lichen planus (22).
Vulvar Atrophy
Estimates indicate that up to 50% of all postmenopausal
women will experience vulvovaginal irritation, soreness,
ACOG Practice Bulletin Vulvar Skin Disorders 1245
and dryness, lower urinary tract problems, and dyspare-
unia (23, 24). The onset of symptoms can occur long
after other menopausal symptoms (eg, hot flushes)
resolve. However, perimenopausal women who do not
have visible signs of vulvovaginal atrophy also can expe-
rience symptoms of vulvar irritation and dryness (25).
Finally, despite the use of systemic hormone therapy,
approximately 10–25% of users will continue to experi-
ence symptoms of urogenital atrophy despite improve-
ment in other symptoms associated with estrogen
deficiency (26).
As women approach menopause, vulvar tissue
becomes increasingly sensitive to irritants (27), and in
the absence of estrogen, the vaginal mucosa becomes
pale, thin, and often dry. Vaginal secretions are reduced,
the vaginal pH becomes more alkaline, and the vaginal
flora is altered (28, 29). Activities that once were not
associated with discomfort may become so. The genital
area becomes increasingly susceptible to trauma, chemi-
cal irritants, and bacterial overgrowth. In severe atrophic
vaginitis, a purulent, noninfectious discharge may devel-
op, along with fissuring of the vestibule. The diagnosis
is based on an elevated vaginal pH (range of 6.0–7.5)
and the presence of parabasal or intermediate cells on
microscopy. An amine test result will be negative in this
setting (although bacterial vaginosis continues to be a
problem in this population as well) (30).
Other Considerations
In assessing vulvar pruritus and pain, the common caus-
es of vulvovaginitis (candidiasis, bacterial vaginosis, and
trichomoniasis), particularly in their more complicated
forms, must be included in the differential diagnosis. For
example, non-albicans candidal infections typically
present with burning, not itching, and minimal evidence
of inflammation. Because most atypical species do not
form hyphae or pseudohyphae, microscopy is not helpful
and, therefore, culture is warranted (31, 32). Negative
yeast cultures, in the setting of persistent vulvar burning
with no other identifiable organic cause, also will help
establish a diagnosis of vulvodynia (33, 34).
Genital human papillomavirus (HPV), the most
common sexually transmitted viral infection, is associat-
ed with a number of vulvar epithelial disorders, includ-
ing genital warts, vulvar intraepithelial neoplasia (VIN),
and some vulvar carcinomas. Distinguishing warts from
vulvar neoplasia on the basis of appearance alone is not
always possible because VIN can present as red, white,
dark, raised, or eroded lesions. In general, a biopsy
should be performed on hyperpigmented, indurated,
fixed, or ulcerative lesions, or lesions that do not respond
to treatment or worsen during treatment.
1246 ACOG Practice Bulletin Vulvar Skin Disorders
If the patient is immunocompromised or the diagno-
sis is uncertain (eg, Paget disease can present as multiple
bright red, scaly, eczematoid plaques [35], whereas mela-
noma can range in color from brown to bluish-black [36]),
biopsy should be undertaken. Because multicentric dis-
ease is commonly encountered, particularly in younger
women, a complete examination should include the
cervix, vagina, and perianal area. Up to 50% of women
with VIN will have antecedent or concomitant lower gen-
ital tract neoplasia, usually cervical or vaginal intraepithe-
lial neoplasia (5).
In addition to contact irritation from the array of
treatments used to alleviate vulvar symptoms, many
patients with underlying chronic vulvar skin disorders,
including lichen sclerosus, lichen planus, and psoriasis,
are also at risk of developing steroid rebound dermatitis,
also called steroid rosacea. Withdrawing from use of
a moderate- to high-potency topical steroid can result
in rebound vasodilation, accompanied by burning and
irritation.
Clinical Considerations and
Recommendations
When and how should a vulvar biopsy be
performed?
The threshold for biopsy of the vulva should be low
except in the pediatric population. Changes on the vulva
often are subtle and can be overlooked. Findings such as
thickening, pebbling, hypopigmentation, or thinning of
the epithelium indicate a possible dermatologic process,
and biopsy will aid in diagnosis and management.
Biopsy of hyperpigmented or exophytic lesions, lesions
with changes in vascular patterns, or unresolving lesions
is particularly important and should be performed in
order to rule out carcinoma. Diagnostic delays in identi-
fying vulvar cancer are exceedingly common and have
been linked to failures or procrastination in the perform-
ance of biopsies of abnormal-appearing vulvar skin (37).
Anesthesia is recommended for vulvar biopsy; com-
bination lidocaine and prilocaine cream or 4% liposomal
lidocaine cream can be placed on the proposed biopsy
site before inserting the anesthesia needle (38). A sys-
tematic review of topical anesthetics for dermatologic
procedures found both medications to be effective, but
liposomal lidocaine had a more rapid onset (30 minutes
versus 60 minutes with combination lidocaine and prilo-
caine cream) and lower cost (39). To minimize discom-
fort, a solution of 8.4% sodium bicarbonate can be added
to the lidocaine (1:10 ratio). Onset of action occurs with-
OBSTETRICS & GYNECOLOGY
in 2–5 minutes; if epinephrine is used with either of
these anesthetics, the onset of action will be delayed, but
the duration of effect will be increased (40).
Choice of biopsy instrument depends on the loca-
tion and nature of the lesions. For most inflammatory
diseases, ulcers, pigmented lesions, or suspected tumors,
a punch biopsy is the preferred method because estab-
lishing the depth of such lesions is critical (41). Small
lesions often can be completely excised, and lesions
involving the submucosal or subcutaneous tissue should
be adequately sampled. When sampling ulcerative areas,
a biopsy of the edge of the ulcer is preferred; when sam-
pling hyperpigmented areas, a biopsy of the thickest
region is recommended (42).
One of the most common methods of biopsy
involves the use of a 3–5-mm Keyes punch. A shave or
snip biopsy works best for sampling more superficial
disorders, such as lichen sclerosus or lichen planus, or
for sampling bullous lesions. Although both shave and
snip samples will extend into the dermis, they should not
go through the dermis. A stitch or topical solution can be
used to control bleeding (43).
How should labial adhesions be treated?
Labial adhesions are not uncommon in prepubertal girls
and typically resolve spontaneously by menarche. Labial
adhesions should be observed unless they are sympto-
matic (eg, urinary obstructive symptom). Topical estro-
gen cream is considered first-line medical treatment for
the separation of labial adhesions (44). Girls should be
monitored for side effects of estrogen therapy, including
breast budding and vaginal bleeding. To decrease the risk
of recurrence and to prevent reagglutination of raw
opposing skin surfaces, an emollient can be applied
nightly for at least 1 month. Manual separation in the
office setting should only be performed with adequate
anesthesia, and surgical excision should be reserved for
acute urinary obstruction (45). One small trial showed
success with topical steroids as a potential alternative to
the use of estrogen (46).
In what circumstances is estrogen or testos-
terone cream an appropriate treatment?
The use of estrogen treatment for vaginal atrophy has
been well documented and can be accomplished with a
variety of locally applied estrogen preparations (24).
However, some differences have been demonstrated
between forms of local therapies. When compared in
randomized controlled trials with either estrogen tablets
or with the estrogen ring, conjugated equine estrogen
cream was found to be significantly associated with
adverse effects, including bleeding, breast pain, and per-
VOL. 111, NO. 5, MAY 2008
ineal pain (47–49). All forms of topical estrogen therapy
increase the possibility of endometrial hyperplasia and
overstimulation. However, it is currently unknown whether
women receiving long-term therapy with topical estro-
gen require prophylactic therapy with progesterone (24).
It should be noted that systemic estrogen therapy,
although efficacious, raises concerns for many women
and may still not be sufficient to relieve the symptoms of
urogenital atrophy (50).
Whether or not estrogen use improves the function
of vulvar epithelium in vulvar atrophy (including clitoral
circulation and fibrosis) remains controversial. Small
studies have demonstrated improvement in circulation
and sexual function in women following localized or
systemic estrogen use (51, 52).
Topical estrogen therapy also has been reported for
the treatment of symptomatic labial adhesions (53, 54).
The use of estrogen for other vaginal disorders is less
well documented, and includes treatment for radiation
injury (55) and treatment of vaginal mucosa burn injury
following misapplication of 100% acetic acid (56).
Indications for the use of testosterone cream in the
treatment of vulvar or vaginal disorders remain contro-
versial. Historically, testosterone cream was used in the
treatment of lichen sclerosus. Subsequently, studies were
undertaken comparing testosterone with topical steroids
in the treatment of vulvar lichen sclerosus and resulted in
two findings, a lack of clear effect with testosterone and
the superiority of topical steroids (12, 57–59). Thus,
given the undesirable side effects of masculinization and
virilization associated with the use of testosterone, and
unproven therapeutic benefit, it should not be used in the
primary treatment of lichen sclerosus.
How should vulvar atrophy be treated?
As noted previously, the data specifically addressing vul-
var atrophy are limited. Studies assessing the benefits of
a variety of therapies, including hormones, focus on
patient symptoms such as vulvovaginal dryness, burning,
pruritus, and dyspareunia, with the distinction between
vulvar and vaginal symptoms not clearly made.
Management options for urogenital atrophy in adult
women include lifestyle modification strategies, the use of
vaginal moisturizers, and low-dose topical estradiol
preparations. Maintaining regular vaginal intercourse pro-
vides protection from urogenital atrophy by increasing
blood flow to the pelvic organs (60), an effect that also
may occur through masturbation (61). The use of a non-
hormonal vaginal moisturizer has been shown through
prospective randomized studies to exert a beneficial effect
similar to that of local hormone therapy (49, 62), although
the same cannot be said of vaginal lubricants (25).
ACOG Practice Bulletin Vulvar Skin Disorders 1247
 What is the appropriate treatment for lichen
sclerosus?
The recommended treatment for lichen sclerosus is use
of a high-potency topical steroid, the most studied of
which is clobetasol propionate (59, 63, 64). In one
prospective cohort study of patients with lichen scle-
rosus treated with ultrapotent topical steroids, 96%
experienced complete or partial relief of their vulvar
symptoms, 23% demonstrated complete resolution of the
vulvar skin to normal texture and color, and 68% showed
partial resolution of the hyperkeratosis, purpura, fissur-
ing, and erosions associated with this disorder (65).
Although no randomized controlled trials provide evi-
dence of the most effective steroid regimen, a reasonable
approach is to begin with once-daily application of ultra-
potent topical steroids for 4 weeks, tapering to alternate
days for 4 weeks, followed by 4 weeks of twice weekly
application (16). Although some practitioners recom-
mend twice-daily application, pharmacodynamic studies
have clearly demonstrated that once-daily application of
an ultrapotent steroid is sufficient (66). Topical steroid
therapy is not without complications, including the pos-
sibility of contact sensitization, skin changes, and sec-
ondary infection. However, studies have shown that
long-term maintenance therapy with either a moderate or
ultrapotent topical steroid did not lead to steroid-induced
atrophy, telangiectasia, striae, or secondary infection
(67). In general, a 30-g tube of an ultrapotent topical
steroid should last approximately 3–6 months (16).
There is conflicting evidence on the need for ongo-
ing maintenance therapy. Some experts recommend dis-
continuation of therapy following the initial regimen
described previously and reuse of therapy for flares or
recurrent symptoms (16). However, others recommend
an ongoing maintenance regimen of twice-weekly appli-
cation of either an ultrapotent or moderate strength
steroid (68). Monitoring at 3 months and 6 months fol-
lowing initial therapy is recommended to assess the
patient’s response to therapy and to ensure proper appli-
cation of the medication. Annual examinations are
suggested for patients whose lichen sclerosus is well
controlled, and more frequent visits for those with poor-
ly controlled disease (for whom intralesional steroid
injections also may be beneficial) (69). Patients should
be advised to return for visits if persistent ulcerations or
new growths appear. Biopsy of such lesions, as well as
of erosions, hyperkeratotic, or hyperpigmented areas, is
important to exclude intraepithelial neoplasia or invasive
squamous cell cancer. Whether long-term topical treat-
ment with a potent steroid cream can reduce the risk of
malignant evolution (68) remains unclear pending
results from larger follow-up studies.
1248 ACOG Practice Bulletin Vulvar Skin Disorders
In small, uncontrolled studies, other therapies
found to be of use in the treatment of complicated lichen
sclerosus (eg, unresponsive to topical steroids) include
retinoids (70, 71), potassium para-aminobenzoate (72),
cryotherapy (73), and photodynamic therapy with topi-
cal 5-aminolaevulinic acid (74). Topical cyclosporine
failed to show benefit in the treatment of five cases of
vulvar lichen sclerosus (75). Management with hormon-
al topical therapies, including estrogen, testosterone
(57, 61, 63, 76), and progesterone (63, 77), has incon-
sistently resulted in improvement in lichen sclerosus
and has been associated with significant side effects (eg,
hyperandrogenism). The use of the topical macrolide
immunosuppressants (eg, pimecrolimus, tacrolimus)
was proposed initially as a therapeutic option for lichen
sclerosus, given that these medications do not cause der-
mal atrophy. Although promising in the treatment of
lichen sclerosus (78–80), these immunosuppressants are
considered by most experts to be second-line agents for
treatment of patients unresponsive to or intolerant of
other treatment. Surgery, although not curative, is
reserved for the treatment of malignancy and postin-
flammatory sequelae (eg, release of labial adhesions or
introital stenosis) (81).
What is the appropriate treatment for lichen
planus?
The prognosis for spontaneous remission of vulvovaginal
lichen planus is poor. As with vulvovaginal atrophy and
lichen sclerosus, lifestyle modifications are important in
maintaining function as well as providing comfort.
Treatment options are numerous and include topical and
systemic corticosteroids, topical and oral cyclosporine,
topical tacrolimus, hydroxychloroquine, oral retinoids,
methotrexate, azathioprine, and cyclophosphamide. Al-
though symptomatic improvement is possible (21),
patients should be advised that complete control is not the
norm (20). Rather, vulvovaginal lichen planus is a frus-
trating, chronic, and recurring disease that requires long-
term maintenance.
Evidence supporting treatment options for vulvo-
vaginal lichen planus have come largely from retro-
spective case reports and case series (82–85). The most
frequently recommended treatment for vulvovaginal
lichen planus is the use of high-potency topical steroids,
with the evidence for this recommendation based on
small studies of oral rather than genital disease (84).
Given the potential for significant side effects with the
use of systemic immunosuppressants, methotrexate,
cyclosporine, azathioprine, and hydroxychloroquine sul-
fate should be used only after local treatments have
failed. Furthermore, study results of systemic therapies
OBSTETRICS & GYNECOLOGY
have been inconsistent, likely related to selection of
those patients with more severe disease (85).
As with lichen sclerosus, surgery is reserved for the
treatment of postinflammatory sequelae, including vagi-
nal coaptation and release of labial adhesions. Finally,
although squamous cell carcinomas are rarely encoun-
tered, women with lichen planus should be routinely
monitored (85, 86).
What other conditions should be investigated
in women presenting with vulvar disease (eg,
lichen planus, lichen sclerosus, or Paget
disease)?
Diseases with vulvar and perianal involvement include
not only dermatologic processes (eg, lichen sclerosus
and psoriasis) but also systemic diseases such as Crohn
disease. Approximately one third of women with Crohn
disease present with gynecologic complications, includ-
ing enteric fistulas to both the upper and lower genital
tract, granulomatous salpingitis and oophoritis, and vul-
var inflammation, edema, granulomas, abscesses, and
ulcerations (87).
Numerous studies have now demonstrated a strong
association, particularly in women, between lichen scle-
rosus and a variety of autoimmune-related disorders,
including alopecia, vitiligo, thyrotoxicosis, hypothy-
roidism, and pernicious anemia (12). In a recent case
series of women with vulvovaginal lichen planus, 55%
had a personal or family history of an autoimmune dis-
order (88). Despite the strong association between lichen
sclerosus and autoimmune-related disorders, there are no
recommendations regarding evaluation for coexisting
autoimmune-related disorders in women with lichen
sclerosus beyond a brief examination for alopecia areata
and vitiligo and consideration of thyroid function tests
(89). In women, there is also an association of vulvar
lichen sclerosus with squamous cell carcinoma, with up
to a 5% incidence of malignancy (12). Therefore, close
follow-up is recommended with biopsy of any concern-
ing lesions, although the recommended follow-up inter-
val has not been determined (eg, 6 months, 12 months, or
other). Additionally, although the concern of malignancy
is greater in poorly controlled lichen sclerosus, there is
no clear evidence that optimal control of lichen sclerosus
symptoms reduces the risk of malignancy.
Paget disease of the vulva is a rare form of intra-
epithelial neoplasia characterized by adenocarcinoma-
tous cells and accounts for approximately 2% of vulvar
neoplasms. Although most cases of extramammary vul-
var Paget disease are primary rather than associated with
underlying adenocarcinoma, approximately 25% of
cases are associated with neoplastic disease (90). When
VOL. 111, NO. 5, MAY 2008
associated disease is present, it is typically local (adeno-
carcinoma in the skin adnexa or Bartholin gland) but also
may be distant (most commonly, of the breast, but also
of the genital, urinary, or intestinal tract). In contrast,
perianal extramammary Paget disease is associated with
underlying colorectal adenocarcinoma in up to 80% of
cases (90). Thus, when Paget disease is confirmed by
biopsy, evaluation including breast, genitourinary tract,
and gastrointestinal tract should be undertaken.
Summary of
Recommendations
The following recommendation is based on limit-
ed or inconsistent scientific evidence (Level B):
The recommended treatment for lichen sclerosus is
an ultrapotent topical corticosteroid, such as clo-
betasol propionate.
The following recommendations are based prima-
rily on consensus and expert opinion (Level C):
Biopsy of hyperpigmented or exophytic lesions,
lesions with changes in vascular patterns, or unre-
solving lesions is particularly important and should
be performed to rule out carcinoma.
For patients with biopsy-confirmed Paget disease,
further evaluation of the breast, genitourinary tract,
and gastrointestinal tract should be undertaken.
Proposed Performance
Measure
The percentage of women with lichen sclerosus who are
offered high-potency topical corticosteroids as first-line
treatment
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OBSTETRICS & GYNECOLOGY
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ACOG’s own internal resources and documents were used publication may be reproduced, stored in a retrieval system,
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of Health and the American College of Obstetricians and Diagnosis and management of vulvar skin disorders. ACOG Practice
Gynecologists were reviewed, and additional studies were Bulletin No. 93. American College of Obstetricians and Gynecologists.
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When reliable research was not available, expert opinions
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Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services
Task Force:
I Evidence obtained from at least one properly
designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
case–control analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncon-
trolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level A—Recommendations are based on good and con-
sistent scientific evidence.
Level B—Recommendations are based on limited or incon-
sistent scientific evidence.
Level C—Recommendations are based primarily on con-
sensus and expert opinion.

VOL. 111, NO. 5, MAY 2008 ACOG Practice Bulletin Vulvar Skin Disorders 1253