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# Vulvar lichen sclerosus and vulvar cancer

Lichen sclerosus is a chronic itchy whitening of vulvar [skin](https://durgical.com/en/anatomy/skin/). Untreated, it raises the risk of vulvar cancer, a skin cancer of the outer genitals.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Labia majora](https://durgical.com/en/anatomy/labium-majus-of-vulva/)
- [Labia minora](https://durgical.com/en/anatomy/labium-minus-of-vulva/)
- [Clitoris](https://durgical.com/en/anatomy/clitoris/)
- [Perineal body](https://durgical.com/en/anatomy/perineal-body/)
- [Urethra (female)](https://durgical.com/en/anatomy/female-urethra/)
- [Vagina](https://durgical.com/en/anatomy/vagina/)
- [Bartholin glands](https://durgical.com/en/anatomy/greater-vestibular-gland/)

## Why it happens

- [Dysplasia and carcinoma in situ](https://durgical.com/en/general-pathology/dysplasia-and-carcinoma-in-situ/)
- [Oncogenic viruses and H. pylori: the table to know](https://durgical.com/en/general-pathology/oncogenic-viruses-and-h-pylori-the-table-to-know/)
- [Precancerous conditions: when chronic inflammation, metaplasia or hyperplasia raise the risk](https://durgical.com/en/general-pathology/precancerous-conditions-when-chronic-inflammation-metaplasia-or-hyperplasia-rais/)
- [Skin: epidermis layers, dermis, hypodermis](https://durgical.com/en/histology/skin-epidermis-layers-dermis-hypodermis/)

## What it is

Lichen sclerosus is a chronic inflammatory, likely autoimmune, skin disease of the anogenital area causing white, thin, scarring plaques. Vulvar cancer, most often squamous cell carcinoma, arises through two pathways: one linked to lichen sclerosus in older women and one linked to high-risk HPV in younger women.

## Who gets it

Lichen sclerosus is most common in postmenopausal women and also affects prepubertal girls. Vulvar cancer is uncommon, mainly affecting women over 60, although HPV-related cases occur at younger ages. Delayed diagnosis is frequent because itching is often treated as infection.

## Causes

- Lichen sclerosus: autoimmune inflammation, with genetic predisposition and low-oestrogen states
- HPV-independent vulvar cancer: arises in chronic lichen sclerosus via differentiated vulvar intraepithelial neoplasia (p53 mutation)
- HPV-associated vulvar cancer: persistent high-risk HPV infection (types 16 and 18) via high-grade squamous intraepithelial lesion
- Other vulvar cancers: melanoma, Bartholin gland carcinoma, basal cell carcinoma, Paget disease of the vulva

## Risk factors

- Age over 60 and postmenopausal status
- Untreated or poorly controlled lichen sclerosus
- Persistent high-risk HPV infection and genital warts
- Cervical or vaginal intraepithelial neoplasia
- Smoking
- Immunosuppression, including HIV infection
- Other autoimmune diseases (thyroid disease, vitiligo) for lichen sclerosus

## Pathophysiology

In lichen sclerosus, T-cell mediated inflammation thins the epidermis and replaces the upper dermis with homogenised collagen, producing fragile white skin, fissures and scarring that can bury the [clitoris](https://durgical.com/en/anatomy/clitoris/), fuse the [labia minora](https://durgical.com/en/anatomy/labium-minus-of-vulva/) and narrow the introitus. Chronic inflammation and scratching drive keratinocyte mutations (notably TP53), leading to differentiated VIN and keratinising squamous cell carcinoma. Separately, high-risk HPV oncoproteins E6 and E7 inactivate p53 and Rb, producing high-grade lesions that progress to basaloid or warty carcinoma. Vulvar cancer spreads first to the inguinofemoral lymph nodes.

## Classification

- Lichen sclerosus (benign, chronic, premalignant risk)
- Differentiated VIN (HPV-independent, high progression risk)
- Vulvar high-grade squamous intraepithelial lesion (HPV-associated)
- Invasive vulvar cancer, staged by FIGO system (size, depth, nodes, spread)

## Symptoms and signs

- Intense chronic vulvar itching, often worse at night
- White, shiny, crinkled plaques, often in a figure-of-eight around vulva and anus
- Fissures, bruising, pain and dyspareunia
- Loss of labia minora, buried clitoris and narrowed introitus
- A lump, ulcer or thickened area that does not heal (suspected cancer)
- Bleeding or discharge not related to menses

## Red flags

- Persistent ulcer, nodule or thickened plaque on the vulva
- New lesion despite treatment of lichen sclerosus
- Pigmented vulvar lesion that changes
- Palpable groin lymph nodes
- Postmenopausal vulvar bleeding

## Diagnosis

**Clinical**
Lichen sclerosus is often diagnosed by its typical appearance; any atypical or persistent lesion needs biopsy. Inspection of the whole anogenital area, [cervix](https://durgical.com/en/anatomy/cervix-of-uterus/) and groin.

**Tests**
Biopsy of the vulva (punch biopsy) to confirm lichen sclerosus when uncertain, and always for suspected cancer or VIN; HPV testing and cervical screening; thyroid tests when autoimmune disease is suspected.

**Imaging**
For cancer: groin ultrasound, CT, MRI or PET-CT for staging; sentinel lymph node mapping at surgery.

## Differential diagnosis

- Genitourinary syndrome of menopause
- Lichen planus and lichen simplex chronicus
- Vulvovaginal candidiasis
- Vitiligo
- Contact dermatitis and psoriasis
- Genital warts and herpes ulcers

## Goal of treatment

Control itching and inflammation of lichen sclerosus to prevent scarring and cancer, and treat vulvar cancer with the least mutilating surgery that achieves cure.

## Treatment

**Medical**
Lichen sclerosus: ultrapotent topical corticosteroids are first-line, with a tapering then long-term maintenance schedule; emollients as soap substitutes.

**Medical**
Second-line for lichen sclerosus: topical calcineurin inhibitors; HPV-related high-grade lesions may be treated with topical imiquimod.

**Surgical**
Vulvar intraepithelial neoplasia: wide local excision or laser ablation. Invasive cancer: radical local excision or vulvectomy with sentinel node biopsy or inguinofemoral lymphadenectomy.

**Medical**
Locally advanced cancer: chemoradiation, with surgery in selected cases.

**Follow-up**
Lifelong follow-up of lichen sclerosus with examination at least yearly and biopsy of any new or persistent lesion; wound care and lymphoedema monitoring after cancer surgery.

## Complications

- Scarring, labial fusion and introital stenosis
- Sexual dysfunction and urinary difficulty
- Squamous cell carcinoma of the vulva
- After cancer surgery: wound breakdown, lymphoedema and altered body image

## Prognosis

Lichen sclerosus cannot be cured but is well controlled with topical steroids, which lower the cancer risk. Vulvar cancer detected early, without nodal spread, has a good survival rate; nodal involvement is the main prognostic factor.

## Prevention

- HPV vaccination and smoking cessation
- Regular self-examination and follow-up for women with lichen sclerosus
- Prompt biopsy of persistent lesions

## Test yourself

Think of the answer, then tap the question to see it.

## An older woman has intense vulvar itching and white, shiny, crinkled plaques around the vulva and anus. Diagnosis and first-line treatment?

Lichen sclerosus; ultrapotent topical corticosteroid.

## What is the most common histological type of vulvar cancer?

Squamous cell carcinoma.

## What are the two pathways to vulvar squamous cell carcinoma?

HPV-associated (younger women, high-grade squamous lesion) and HPV-independent (older women, lichen sclerosus, differentiated VIN with p53 mutation).

## To which lymph nodes does vulvar cancer spread first?

The inguinofemoral (groin) lymph nodes.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/conditions/vulvar-lichen-sclerosus-and-vulvar-cancer/)

## Related conditions

- [Human papillomavirus (HPV) infection](https://durgical.com/en/conditions/human-papillomavirus-infection/)
- [Cervical intraepithelial neoplasia (cervical dysplasia)](https://durgical.com/en/conditions/cervical-intraepithelial-neoplasia/)
- [Cervical cancer](https://durgical.com/en/conditions/cervical-cancer/)
- [Lichen planus](https://durgical.com/en/conditions/lichen-planus/)
- [Vulvovaginal candidiasis](https://durgical.com/en/conditions/vulvovaginal-candidiasis/)
- [Contact dermatitis (irritant and allergic)](https://durgical.com/en/conditions/contact-dermatitis/)
- [Psoriasis](https://durgical.com/en/conditions/psoriasis/)
- [Cutaneous squamous cell carcinoma](https://durgical.com/en/conditions/cutaneous-squamous-cell-carcinoma/)
- [Melanoma](https://durgical.com/en/conditions/melanoma/)
- [Genitourinary syndrome of menopause (atrophic vaginitis)](https://durgical.com/en/conditions/genitourinary-syndrome-of-menopause/)
- [Bartholin gland cyst and abscess](https://durgical.com/en/conditions/bartholin-gland-cyst-and-abscess/)
- [Viral warts (verruca)](https://durgical.com/en/conditions/viral-warts/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Lichen sclerosus: Causes, Diagnosis, and Images - DermNet](https://dermnetnz.org/topics/lichen-sclerosus) (DermNet, 2024); [Vulvar Cancer](https://medlineplus.gov/vulvarcancer.html) (MedlinePlus (U.S. National Library of Medicine), 2024); [Vulvar Cancer Treatment](https://www.cancer.gov/types/vulvar/patient/vulvar-treatment-pdq) (National Cancer Institute, 2024).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/conditions/vulvar-lichen-sclerosus-and-vulvar-cancer/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/vulvar-lichen-sclerosus-and-vulvar-cancer/