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Vulvar Lichen Sclerosus and Vulvar Psoriasis

Vulvar Lichen Sclerosus and Vulvar Psoriasis

Introduction

Misdiagnoses are, unfortunately, a common part of many of our journeys to getting a proper diagnosis. Some common misdiagnoses that people with lichen sclerosus get are yeast infections, herpes, menopause/GSM, psoriasis, and vitiligo. Part of our strategy in creating a world where folks with vulvar lichen sclerosus (VLS) get diagnosed sooner involves raising awareness about VLS and vulvar health in general. With that, today we will be discussing VLS and vulvar psoriasis. In particular, we will discuss the differences between the two regarding signs, symptoms, diagnosis, and treatment.

Disclaimers

*This post is evidence-based; I draw on the medical literature to share what you need to know about lichen sclerosus as well as vulvar psoriasis. Importantly, what I share is my interpretation of the science and data.

**If this post is helpful to you, we’d love your support so we can continue providing important education like this. Make a donation today, volunteer with us, or share our posts in your support groups.

Lichen Sclerosus Signs and Symptoms

Before we dive into vulvar psoriasis, let us briefly review what vulvar lichen sclerosus (VLS) is. Lichen sclerosus is a chronic, inflammatory skin condition considered an autoimmune condition by most of the medical community. It causes symptoms like pain (stinging, burning, rawness, irritation) and itching (mild to severe). Signs of lichen sclerosus involve hypopigmentation (where the skin loses its pigment and becomes lighter in color), scarring and architectural changes, as well as thickening of the skin/ skin that resembles wax or cigarette paper. The gold standard treatment for LS is ultrapotent topical corticosteroids, with more frequent application in the beginning and maintenance treatment for life.

If you are new here and want to learn more about LS, check out this video I made on the topic. Conversely, If reading is your preferred medium, grab my FREE LS eBook (over 100+ pages of LS information and support resources).

What is Vulvar Psoriasis?

Psoriasis is a chronic, inflammatory skin condition that affects the epidermis (the top layer of skin). It affects approximately 2% of the general population (Myers, Gottlieb, and Mease, 2006). Like many skin conditions, there are different subtypes of psoriasis, but a common form involves silver-colored plaques of skin on the elbows and knees (and sometimes the scalp and nails). People with generalized plaque psoriasis may also have plaque psoriasis on the vulva. While rare, some people will only have vulvar psoriasis without affecting any other body part (Meeuwis et al., 2011).

Signs

Clinical signs–aka what can be seen when looking at the vulva–of plaque-type vulvar psoriasis include thin plaques of skin that can look bright pink, red, greyish, or silvery, depending on the color of your skin color. When the patches are whiteish-grey-silvery, they tend to appear scaly, whereas reddish skin plaques may not appear scaly (Manani, 2023). The patches are often symmetrical–two different plaques with the same shape and outline (Meeuwis et al., 2011). Sometimes, there are fissures–small cracks/tears in the skin–on the plaques. These fissures can get infected, requiring antibiotic treatment (ibid).

Most cases of vulvar psoriasis are of the plaque-type variant. However, there are cases of pustular vulvar psoriasis involving blister-like pustules on a reddish-rash-like skin patch.

Symptoms

Symptoms of plaque-type vulvar psoriasis include itch (which can be severe), soreness, burning, and pain with sex (ibid). It’s not uncommon for patients with vulvar psoriasis to experience irritation and discomfort with clothes and have difficulties with daily activities like walking, doing chores, and exercising. 

If you’re thinking, “Hm, burning, soreness, itch, silvery-grey patches of skin on the vulva, this sounds an awful lot like lichen sclerosus,” I’m with you! There is a lot of overlap, especially with the symptoms. We will talk about the differences later on in this post.

How is Vulvar Psoriasis Diagnosed?

Vulvar psoriasis is based on a clinical diagnosis. This involves the doctor listening to the patient’s symptoms and examining the vulvar skin. If the patient has psoriasis elsewhere on the body (such as the knees, scalp, or nails), this is often a helpful clue to providing a diagnosis (Madanini, 2023; Simonetta, Burns, and Guo, 2015). A biopsy is typically unnecessary for a diagnosis.

Image of a doctor with black skin and a long, white labcoat and black glasses reviewing a chart with a patient.

However, if you get a diagnosis of vulvar psoriasis that is unresponsive to treatment or if the clinical presentation is not obvious (e.g., it could also be lichen simplex chronicus or extramammary Paget’s disease), the clinician may perform a biopsy (Madanini, 2023; Simonetta, Burns, and Guo, 2015). If your doctor has a dermascope in the clinic, they may examine the skin with this tool. A dermascope is a handheld device that helps give your dermatologist a better, more details view of the skin. Dermoscopy allows the clinician to examine the skin using a skin surface microscope. Dermoscopy may reveal regularly arranged scales and dotted vessels along a pink-colored background (Madnani, 2023). 

Treatment for Vulvar Psoriasis?

Let’s talk treatment for a minute. Unfortunately, like vulvar lichen sclerosus, there is no cure for vulvar psoriasis. Instead, the focus is on treating and managing the condition. First-line treatment includes topical corticosteroids. However, the steroids tend to be weaker than those prescribed for vulvar lichen sclerosus. The potency and dosing schedules vary depending on the severity of the psoriasis and how the patient responds to treatment. Second-line treatments include vitamin D topical creams or calcineurin inhibitors (Simonetta, Burns, and Guo, 2015). Sometimes, patients are prescribed a combination of weak topical steroids and vitamin D creams (Meeuwis et al., 2011). If infection is present, antibiotics and/or anti-fungal medications may be prescribed temporarily until the infection clears (Meeuwis et al., 2011; Pincus, 1992). Some doctors will advise emollients and topical tar-based products, although these are not always well-tolerated on the vulva (Simonetta, Burns, and Guo, 2015). 

Image of different colored antibiotic and anti-fungal pills with a hand, wearing a blue latex glove holding a syringe and big block letters spelling out antibiotics next to it. Sometimes when vulvar psoriasis skin gets fissured and cracked, it can lead to infection, requiring anti-fungals or antibiotics.

In severe cases, vulvar psoriasis may require oral, systematic treatments, such as methotrexate, oral retinoids, or biologics (Kalb et al., 2009; Meeuwis et al., 2011; Salim and Wojnarowska, 2002; Simonetta, Burns, and Guo, 2015. Biologics are medications derived from natural sources such as humans or animals and may be produced with biotechnology.

Other helpful tips involve avoiding scratching the area, which can cause a psoriasis flare or break the skin, potentially causing an infection. 

What are the Differences between Lichen Sclerosus and Vulvar Psoriasis?

Symptoms of vulvar psoriasis are incredibly similar to lichen sclerosus. Both can cause soreness, itching, burning, pain, and pain with sex. Therefore, when it comes to differentiating the two, it often comes down to clinical signs.

Perhaps the biggest difference in signs is that vulvar psoriasis does not cause any architectural changes. Architectural changes include fusing of the labia, narrowing of the vaginal opening due to scar tissue build-up, and fusing of the clitoral hood over the glans clitoris. Learn more about lichen sclerosus and architectural changes here.

Both vulvar psoriasis and vulvar lichen sclerosus can cause white, grey, or silvery skin plaques, which may or may not also have fissures. One difference, however, is the plaques of skin with psoriasis tend to be symmetrical, while lichen sclerosus plaques are not necessarily symmetrical. For example, with VLS, many patients will only have a plaque/patch of white/grey/silvery skin on one side of the vulva (e.g., the left labia minora). This is why having a knowledgeable gynecologist, dermatologist, or vulvar specialist make the diagnosis is crucial, as differentiating the two can be challenging, even to a trained clinician. 

What to Do If You Believe You’ve Been Misdiagnosed?

If you got a vulvar psoriasis diagnosis, but you think it was a misdiagnosis and that you have vulvar lichen sclerosus instead, the best course of action would be to get a second opinion. Check out our lichen sclerosus provider directory to find a lichen sclerosus doctor near you. You may also want to look for a vulvar specialist or expert dermatologist with a special focus on genital conditions. Note that this second opinion may require a biopsy to confirm the diagnosis. Also, you may have both conditions–again, having a good dermatologist or vulvar specialist would be important here.

Conclusion on Lichen Sclerosus or Vulvar Psoriasis

In sum, vulvar lichen sclerosus and vulvar psoriasis share similar symptoms–vulvar itch, burning, soreness, pain, and pain with sex. Clinically, plaque-type psoriasis can present as whiteish, greyish, or silvery plaques of skin or pink or red patches or rash. However, unlike vulvar lichen sclerosus, vulvar psoriasis typically does not cause architectural change. Vulvar psoriasis is diagnosed clinically and treated with weak topical steroids, vitamin D creams, or calcineurin inhibitors. If you aren't sure if you have vulvar psoriasis or think you have been misdiagnosed, be sure to see a specialized dermatologist, vulvar specialist, or gynecologist.

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References

1.Kalb RE, Bagel J, Korman NJ, et al. Treatment of intertriginous psoriasis: From the Medical Board of the National Psoriasis Foundation. Journal of the American Academy of Dermatology. 2009;60(1):120-124. doi:https://doi.org/10.1016/j.jaad.2008.06.041

2.Simonetta C, Burns EK, Guo MA. Vulvar Dermatoses: A Review and Update. Missouri medicine. 2015;112(4):301-307. Accessed October 28, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170060/#b5-ms112_p0301

3.Meeuwis K, Hullu J, Massuger L, Kerkhof P, Rossum M. Genital Psoriasis: A Systematic Literature Review on this Hidden Skin Disease. Acta Dermato Venereologica. 2011;91(1):5-11. doi:https://doi.org/10.2340/00015555-0988

4.Myers WA, Gottlieb AB, Mease P. Psoriasis and psoriatic arthritis: clinical features and disease mechanisms. Clinics in Dermatology. 2006;24(5):438-447. doi:https://doi.org/10.1016/j.clindermatol.2006.07.006

5.Pincus SH. Vulvar Dermatoses and Pruritus Vulvae. Dermatologic Clinics. 1992;10(2):297-308. doi:https://doi.org/10.1016/s0733-8635(18)30336-x

6.Salim A, Fenella Wojnarowska. Skin diseases affecting the vulva. 2002;12(2):81-89. doi:https://doi.org/10.1054/cuog.2001.0239

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