Detailed definition
Lichen sclerosus (LS) is a chronic, immune-mediated inflammatory dermatosis of unknown etiology, with peak incidence in postmenopausal women but also affecting prepubertal girls and, less commonly, men (where it presents on the foreskin/glans). Vulvar LS presents with intense pruritus, white porcelain-like atrophic patches with fine wrinkling ("cigarette paper" appearance), fissuring, ecchymoses, and architectural changes including labial fusion, clitoral burying, and introital narrowing. It can be exquisitely uncomfortable. LS is associated with a small but real (~5%) risk of vulvar squamous cell carcinoma over time. Diagnosis is clinical, supported by punch biopsy when the diagnosis is uncertain or to rule out malignancy. Treatment is high-potency topical corticosteroids — typically clobetasol propionate 0.05% — applied daily until clinical improvement and then maintenance dosing 1–3 times weekly indefinitely. Vaginal estrogen is appropriate for any concurrent GSM but does not treat LS itself.
Why it matters in menopause
LS is often misdiagnosed as menopausal vaginal atrophy because both produce thinning, pallor, and discomfort in the vulvovaginal area in postmenopausal women. Treating LS with only vaginal estrogen misses the diagnosis and the cancer-surveillance issue. Any postmenopausal woman with persistent vulvar itching, architectural changes, or white patches deserves a careful vulvar examination and consideration of biopsy.