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BackTable / OBGYN / Article
Vulvar Lichen Sclerosus: Diagnosis, Treatment & What to Avoid
Audrey Qian • Updated Aug 25, 2025 • 116 hits
Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects the anogenital region, often presenting with patchy, discolored, thin skin. While its etiology remains unclear, postmenopausal women are disproportionately affected, and the condition carries a known risk of complications, including scarring and narrowing of the anogenital area and an estimated 5% risk of progression to squamous cell carcinoma.
OBGYN Dr. Hope Haefner outlines an evidence-based approach to the diagnosis and management of vulvar lichen sclerosus, including biopsy considerations, therapeutic strategies, and maintenance regimens. She also addresses common misconceptions around vaginal care products and procedures, emphasizing the importance of patient education in improving outcomes.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• Classic presentations of lichen sclerosus without signs of erosion or thickened tissue may not require biopsy, but persistent pain, firm nodules, or suspicion for malignancy warrants tissue sampling to rule out differentiated vulvar intraepithelial neoplasia or squamous cell carcinoma. Palpation remains an essential part of vulvar examination to detect abnormalities not visible to the eye.
• High-potency topical steroids like clobetasol ointment remain a first-line treatment for lichen sclerosus. Because vulvar thinning results from the underlying condition rather than steroid use, mid-potency topical steroids can be safely continued for long-term maintenance.
• For persistent itching or pain despite steroid treatment, adjunct therapies such as tacrolimus, extended oral prednisone tapers, intramuscular triamcinolone, or neuromodulators may be effective. Dermatology referral may be considered when immunosuppressants are used but do not improve symptoms.
• Vaginal steaming, laser rejuvenation, and over-the-counter products containing benzocaine or plant-derived irritants may worsen vulvar health, causing contact dermatitis, mimicking lichen conditions, and delaying appropriate treatment. A detailed history of all topical product use is essential during evaluation to address patient misinformation.
Table of Contents
(1) Assessing Symptoms in Lichen Sclerosus: Examination & Biopsy
(2) Treating Lichen Sclerosus: Topical Steroids, Immunotherapies & Other Treatments
(3) Treatment Strategies to Avoid in Vulvovaginal Care
Assessing Symptoms in Lichen Sclerosus: Examination & Biopsy
Lichen sclerosus can often be clinically diagnosed without a biopsy, particularly for patients who show classic symptoms and no signs that indicate cancer, such as erosion or tissue thickening. However, if patients present with worsening pain or there is palpable firmness of the vulvar tissue, then biopsies are needed to assess for differentiated vulvar intraepithelial neoplasia or squamous cell carcinoma, which develops in approximately 5% of lichen sclerosus cases.
In addition to biopsies, a hands-on, tactile examination as part of the routine vulvar exam is crucial – palpation can assess for firmness or nodularity not visible to the eye. To optimize patient comfort during a biopsy, clinicians may use topical lidocaine covered with saran wrap before injecting lidocaine with epinephrine.
[Dr. Jessica Ritch]
Moving on from the vulvodynia side of things, you mentioned that a lot of the patients that you're seeing now have lichen sclerosus, and I think this is an area where a lot of gynecologists can struggle, too, is making that diagnosis and treating the lichen sclerosus. Tell me a little bit more about what features, what signs and symptoms you're looking for here, when you would get a biopsy, and how you start that process.
[Dr. Hope Haefner]
When we first started our center for vulvar diseases, we were taught from the experts that you should biopsy to prove it's lichen sclerosus, but that's really gone by the wayside. If they have the classic appearance of lichen sclerosus, they don't have erosions, they don't have any tissue that's thickened, anything concerning for pre-cancer or cancer, then you don't need to biopsy it to prove it. If you place them on treatment and they're not feeling any better, then, yes, go ahead and think about doing a biopsy. Maybe you have the wrong diagnosis.
We do biopsy those that we're at all concerned about differentiated vulvar intrapithelial neoplasia or cancer. I have found a classic presentation of the lichen sclerosus cancer patient, though. We've had three or four patients that you walk in the room, they're standing up, and you say, would you like to sit down, and they say, I can't sit down, it hurts too much. They've had multiple biopsies. They don't show anything but lichen sclerosus, or–
One patient, actually, they thought she had Crohn's disease. When they finally were able to lie down and be examined, and we touch the vulva, we feel hardness and firmness. You biopsy that area, and they have cancer. If someone's got excruciating pain and something hard and firm, obviously, you've got to biopsy to see if it's a cancer. Up to 5% of patients with lichen sclerosus develop a squamous cell carcinoma.
[Dr. Jessica Ritch]
Definitely, the pain is a good tip-off, but just like you've noticed, I feel like the couple of patients that I've had where the biopsy has come back cancer when we've been watching their lichen sclerosus is when they have that area that's a little bit firmer, maybe a little bit thicker, instead of that thin area. Really important that they're getting examined on a regular basis and being followed up in biopsying for any newer abnormal areas.
[Dr. Hope Haefner]
Put touch into the examination when you're seeing them. Touch the area, make sure that you are biopsying the area that is firm and painful. I don't want to sound mean. Obviously, it's painful to do the biopsy. We'll put some topical lidocaine on first, and we'll cover it with some saran wrap, and then we'll inject it with a lidocaine with epinephrine dependent on the area it is in the vulva.
[Dr. Jessica Ritch]
Trying to make it as comfortable as possible. It's so easy to be persuaded, I think, from patients who are in a lot of pain to avoid the exam. I know many times they don't want, but I do think it's important that we convince people to be examined and biopsied if needed, and give them as many comfort measures as we can to make that process a little bit easier.
[Dr. Hope Haefner]
There are times we've had to take them into the operating room to do the biopsies because they're so uncomfortable. We certainly don't want to torture the patient, but if you can do it in the clinic with the measures I spoke, it's much better because you get a faster diagnosis and can get them in with a gynecologic oncology surgery division.
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Treating Lichen Sclerosus: Topical Steroids, Immunotherapies & Other Treatments
Once lichen sclerosus is diagnosed, effective treatment may first include high-potency topical steroids, most commonly clobetasol ointment, as standard first-line therapy. Typical regiment includes nightly application for three months, or twice daily for one month followed by nightly for two months if lichen simplex chronicus is present. Subsequently, maintenance regimen options include clobetasol 2-3 times per week or transition to nightly mid-potency steroids, such as triamcinolone 0.1% ointment.
While steroid overuse can lead to complications, it is the underlying disease rather than the steroid that is responsible for vulvar skin thinning and scarring. Thus, maintenance with steroids is generally safe for long-term use. Patients with persistent symptoms despite using clobetasol may use topical tacrolimus or be referred to dermatology for immunosuppressive therapy.
If itching still persists after using steroids and immunosuppressant therapies, an extended oral prednisone taper or intramuscular triamcinolone may provide symptom control, often with amitriptyline, gabapentin, or hydroxyzine. Currently, clinical interest in the vulvovaginal microbiome is growing, though more data are needed to inform practice. Dr. Haefner explains that providers must stay informed to counter harmful misinformation patients may encounter about vaginal health practices.
[Dr. Jessica Ritch]
On the other side of that, where most lichen sclerosus are not going to turn into cancer, even though, of course, cancer is more common when somebody has lichen sclerosus. How do you set about treating lichen sclerosus? What do you start with?
[Dr. Hope Haefner]
I generally look at the vulva, and if it's fairly advanced, I will go with a class 1 steroid ointment. I prefer ointments. They have less additives. They are tolerated better than the creams by most patients. We'll use clobetasol ointment nightly for three months. Sometimes if it's really got some thickening like lichen simplex chronicus along with the lichen sclerosus, I'll use it twice a day for a month and nightly for two months. Then you have the option. You can either go to three times a week with the clobetasol ointment versus going to a nightly mid-dose steroid ointment, and we use triamcinolone acetonide 0.1% ointment.
There's a list of the classes with class 1 being the strongest, class 7 the weakest. You can use any of the ones in class 4 on a nightly basis. Sometimes I'll try to get to a class 5, but we just picked triamcinolone 0.1%. There's any one that you can use. Actually, some patients have a reaction to various topical steroids. It's hard to imagine that they're actually allergic to a steroid. I usually thought it was a base, but I learned from an allergist years ago, there's different types of steroid allergies. Say someone can't tolerate the triamcinolone, you can look at the steroid allergy list and pick one from a different category that they might be able to tolerate.
[Dr. Jessica Ritch]
You're saying with the lower-class steroids, you can use them nightly. Then with those higher ones, you said up to three times a week. Of course, this is always the question is, how long can we use steroids? In general, for somebody who needs a long-term maintenance or care with the lichen sclerosus, how long are you comfortable with using something like clobetasol if you're spacing it out by the two or three times a week?
[Dr. Hope Haefner]
For the rest of their life, it's very safe. A lot of people say, oh, I was told it's going to thin my skin out. That's the disease. It's the lichen sclerosus that's doing it. It's not the steroid. Have I seen complications from steroids? Yes. I've seen steroid overuse, but that's a bright red vulva, not loss of the labia minora and clitoral scarring. We actually teach our lichen sclerosus patients to lift back on the hood of the clitoris on a daily basis to prevent scarring. We've never proven it, but I do see patients come in with complete scarring, and whereas ones we found early enough aren't getting the scarring. I do think it's helpful.
[Dr. Jessica Ritch]
For the patients who aren't really responding to the clobetasol, of course you mentioned that maybe that would be a time that you would biopsy so that you can confirm that it is the diagnosis. If that's happened, if you've confirmed it's lichen sclerosus and they're not responding to clobetasol, what's your next step?
[Dr. Hope Haefner]
You can use tacrolimus, but it can be irritating on the vulva. Then there's other things you can use, and that's where we send them to the dermatologists. For the lichens, particularly, we haven't talked about lichen planus, but they use methotrexate sometimes for that. Some of the other immunosuppressants that you can use that as a gynecologist, we tend to not use. We let the dermatologists manage that.
[Dr. Jessica Ritch]
Using some of these other immunosuppressant therapies. Every now and then I get one of those patients that's like, I've tried everything. We try clobetasol. We try tacrolimus. We try some over-the-counter moisturizers and vaginal estrogens. They're still not quite feeling their best. Do you have any tips for those people?
[Dr. Hope Haefner]
Sure. Often what's bothering them is that they're itching. If they're itching, we have other regimens we use. We have a whole itch, scratch, itch regimen. It's at least eight steps, but we start them on either oral prednisone or any other oral steroid you'd want to use, but we use prednisone, 40 milligrams a day for five days. They take it in the morning. Then 20 milligrams for 10 days. Sometimes we go even longer. Occasionally, that's enough to just get it so that they are under better control, and now the topical steroid is where they want to be.
Other patients that are miserable, itching, scratching, fail the prednisone, then we'll go with an injection of triamcinolone into the gluteus muscle. We use a milligram per kilogram, up to a maximum of 80 milligrams into the gluteus muscle. It works very well. It is given monthly for up to three times. On occasion, I'll give it four times, but you don't want to use it more than four times in a year usually. We give it monthly, three times frequently, we'll do that. Those patients will also get on gabapentin, amitriptyline. Amitriptyline works great for itching. Hydroxyzine, we'll use at times. Gabapentin works great for itching. We have this whole itch, scratch regimen that works well.
[Dr. Jessica Ritch]
In terms of some of these newer things that are under study, of course there's studies coming out about lasers and the lichen sclerosus and other potential immunologic treatments. Are there any things that you've seen that you think look promising?
[Dr. Hope Haefner]
There's been a lot of things in the literature that have come up recently. When I think about it, some of the interventions that I find most fascinating are the studies on the vaginal microbiome and the microenvironment. Those, not my area of expertise, but they are fascinating. I think that we're moving ahead in that. The ISSVD's secretary general has a particular interest in the microbiome. At the next meeting, we're going to have several lectures on microbiology, microbiome, and the various vulvovaginal diseases. Other things I've found interesting are what's out there on vulvar and vaginal health. Some of it is totally wrong. Some of the things that are being proposed for women to do are incredibly wrong and are harming patients.
Treatment Strategies to Avoid in Vulvovaginal Care
With the growing trend of self-directed “vaginal wellness” interventions, Dr. Haefner explains several procedures and products to avoid due to the potential harm they may cause. In particular, vaginal laser rejuvenation, often promoted for lichen sclerosus, produces only temporary benefits and requires repeated treatments without proven long-term outcomes. Additionally, vaginal steaming and insertion of foreign materials have no therapeutic value and instead carry the risk of injury or burns.
Several products to avoid include over-the-counter feminine hygiene products that often contain benzocaine, plant extracts, and other ingredients, which may provoke contact dermatitis, mimic inflammatory dermatoses, or worsen chronic vulvar irritation. Benzocaine especially has been associated with raised, erosive lesions that may resemble molluscum or lichen simplex chronicus histologically. Careful history-taking that includes product use becomes essential when evaluating vulvar irritation, and providers may proactively recognize patterns of product misuse and address misinformation.
[Dr. Jessica Ritch]
What are the things that you think are wrong? Things that you see most commonly out there that you just wish nobody would ever do or that you could just put a big X over that piece of advice.
[Dr. Hope Haefner]
Offhand, I'm not a big fan of using laser vaginal rejuvenation. Having read all the information and debated this in detail before, I realized once tissue is lasered, yes, you do get some nice glycogenated epithelium, but that's not going to last. It's going to slough off. You're not going to be lasering multiple times every year for the rest of their life. There are indications for it. I can understand it. It's being used for lichen sclerosus. I'm not convinced it's a good means for lichen sclerosus. That's one of the things for vaginal health I've looked at and haven't really thought was the way to go.
[Dr. Jessica Ritch]
Anything else that you would recommend avoiding altogether? I know there's, of course, a lot of crazy stuff out there on social media. You see stuff about steaming. Of course, douching has been the long-term enemy of all gynecologists. Are there any new trends that you've noticed that you'd really wish people would avoid?
[Dr. Hope Haefner]
I'm not at all supportive of steaming. I think there's absolutely no place for that. Some of the foreign bodies that are placed into it, I'm not really thinking that's good either. I think that over the counter, when you go to a pharmacy and you look at the various things for the vagina to make it smell good, and they're cold, they're not supposed to be put in the vagina, but often patients think it's for the vagina, and they're causing a lot of contact dermatitis. A lot of these over-the-counter products, when you look at them, they have plant products in them, they have 20 ingredients, and people are getting contact dermatitis from them.
[Dr. Jessica Ritch]
Always important to get a good sense of what people have been using so that you can see and when you see that really inflamed, uncomfortable looking area to the vulva and the vagina, it may just be a contact dermatitis from these products that people think are safe, because they're over the counter, right?
[Dr. Hope Haefner]
Correct. There's one in particular that has benzocaine in it. We've seen several patients that are using multiple applications of the product that would has benzocaine in it. They're getting raised areas with central erosions. At first, I thought it looked like molluscum contagiosum when I saw my first patient with it, but it is more compatible with lichen simplex chronicus where you biopsy it.
They are thinking that is what's going to cure their vulvovaginal irritation, and it's actually making it a lot worse. I've had to admit one patient in to get off of those products. She was using seven tubes a day of a product with benzocaine in it. We had to actually get her on a psych ward because she was suicidal, and work with her getting her on other appropriate medications to get off of that.
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Cite This Podcast
BackTable, LLC (Producer). (2024, September 3). Ep. 64 – Vulvovaginal Disorders: Diagnosis & Treatment Approaches [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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