VULVAR LICHEN SCLEROSUS DIAGNOSIS CHALLENGES

Abstract

Background: Vulvar lichen sclerosus (LSV) is a chronic inflammatory dermatosis that affects the vulva and anus. Vulvar lichen sclerosus is a multifactorial disease. Establishing a diagnosis of LSV requires challenges, because the course of the disease is very heterogeneous and the signs and symptoms of LSV are very diverse and non-specific, making diagnosis quite difficult.

Case: A 48-year-old woman presented with anogenital ulceration for 1 month. The complaint began with an itching feeling in the genital area. The wound was getting wider and accompanied by dysuria. The histopathological examination findings were consistent with vulvar lichen sclerosus. The immunohistochemistry examination revealed negative staining of p16 expression in the epidermal cell nuclei and cytoplasm and positive staining of p53 expression in the nuclei of some epidermal cells. The diagnosis was ulcerative vulvar lichen sclerosus. The patient was treated with NaCl 0.9% compress for 10 - 15 minutes, and mupirocin 2% cream, applied on the skin lesion area twice a day. After three months of therapy, the patient's lesions improved and the patient was given cetirisin 1 x 10 mg orally, zinc 1 x 1 tablet and vaseline album moisturizer to protect the skin.

Discussion: Vulvar ulcers are a non-specific finding with various etiologies, they can be caused by sexually and non-sexually transmitted infections, dermatoses, trauma, neoplasms, hormone-induced ulcers, and drug reactions. Several vulvovaginal conditions are more common in menopausal women, such as lichen sclerosis of the vulva, vulvar intraepithelial neoplasia (VIN), and squamous cell carcinoma. Confirming the diagnosis of LSV is still a challenge for clinicians because the signs and symptoms are non-specific so a biopsy needs to be performed especially if the patient has suspicious wounds (erosion or ulceration, pigmented areas or ecchymoses, popular or wart-like lesions). Typical histopathological examination of LSV is severe hyperkeratosis, basal cell vacuoles, fibrosis and inflammatory cells. Immunohistochemical examination was carried out to rule out the differential diagnosis of VIN and squamous cell carcinoma, namely p16 positive and p53 negative, whereas in the patient p16 was found negative and p53 was slightly stained positive in the nuclei of some of the basal cells of the epidermis.