Article by Dr. Patricia Gutiérrez Ontalvilla, MD, PhD. Plastic surgeon, doctor of medicine, specialist in vulvar lichen sclerosus, and creator of the Liquenia® Protocol.
When a mother comes to the office asking about her daughter, she almost always brings the same prepared phrase: “she itches down there and we’ve been using creams for months that do nothing.” And she almost always brings something else she hasn’t mentioned in any previous consultation, because no one has asked her: that the girl holds her urine, or that she has been constipated for some time. Lichen sclerosus in girls exists, is more common than believed, and is diagnosed late for reasons that can be corrected.
Lichen sclerosus is not a disease exclusive to adult women. It also appears in girls before puberty, with an average age at diagnosis around 6 years. Its most visible signs for a mother are not always itching: frequently they are urinary symptoms or constipation. It is a chronic, treatable disease, and with appropriate treatment most girls improve. What is not true is that it disappears on its own when puberty arrives.
What signs of lichen sclerosus in girls does a mother actually see?
Here is the main reason for diagnostic delay. Vulvar itching is sought, and what the girl manifests many times is something else.
A study published in Journal of Lower Genital Tract Disease (Wang, Arlen, and Vash-Margita, 2021) reviewed 19 premenarchal girls diagnosed with vulvar lichen sclerosus. The average age at diagnosis was 6.2 years, with a range of 3.3 to 13.3 years. And the finding that interests me most from that work: 63.2% presented lower urinary tract symptoms and 57.9% had constipation.
Average age at diagnosis in premenarchal girls, with cases from 3.3 years (Wang et al., 2021)
Presented urinary symptoms at the time of diagnosis, and 57.9% constipation (Wang et al., 2021)
Proportion of girls with complete resolution of signs at 4 years or at puberty, despite correct treatment (Casey et al., 2014)
Translated to what is seen at home: a girl who starts holding her urine, who says it stings when urinating, who is constipated without clear cause, or who touches herself and complains when sitting. The itching is there, but it is not always the first or most noticeable thing.
That study has 19 patients from a single center, and it should be said: it is a small series and does not allow calculation of population frequencies. But it coincides with what I see in the office and with what is described in pediatric literature, and it is enough to justify a specific recommendation: when faced with urinary symptoms or persistent constipation in a girl, examine the vulva.
At what age can lichen sclerosus appear in girls?
Earlier than most imagine. A review published in Pediatric Annals (Poindexter and Morrell, 2007) describes cases from 6 months of age, with an average around 5 years. Lichen sclerosus follows a bimodal age distribution: one peak in prepubertal childhood and another after menopause.
This means that age does not rule out anything. A four-year-old girl with persistent vulvar symptoms may have lichen sclerosus, and ruling it out because of her age is precisely what lengthens the diagnosis. The signs to look for are the same as in adults: whitish plaques, thin and shiny skin, loss of pigment around the vulva and anus. I develop them on the page about clinical signs of vulvar lichen sclerosus.
Lichen sclerosus in girls and the diagnosis that is confused with something else
This point is delicate and I prefer to address it head-on, because no one explained it in time to the families who have experienced it.
The anogenital lesions of a girl, with thinned skin, fissures, and small bleeding, can resemble the signs of sexual abuse. The review by Poindexter and Morrell addresses this explicitly. Lichen sclerosus in girls has frequently been confused with sexual abuse, and that confusion delays the correct diagnosis. It also subjects families to an unnecessarily difficult situation.
Saying this does not diminish the importance of child protection, which is a priority and must follow its proper channels. It is pointing out that there is a well-described dermatological entity that produces similar findings. Knowing it avoids two opposite errors: the unnecessary suffering of a family, and attributing to a skin disease what is not. The assessment always corresponds to a professional with experience.
Is it true that lichen sclerosus in girls disappears with puberty?
Not reliably, and this is probably the mistaken idea that does the most harm. For years it was taught that lichen sclerosus in girls resolved on its own with the hormonal changes of puberty. That belief still circulates.
The data do not support it. The largest published study in girls, in Clinical and Experimental Dermatology (Casey, Cooper, and Powell, 2014), followed 72 prepubertal girls for 4 to 8 years. With correct treatment, clinical signs improved in 90.3% at three months. But complete resolution of signs was achieved in only 29.2% at four years of follow-up or upon reaching puberty.
That is: seven out of ten girls still had signs of the disease. Poindexter and Morrell formulate it just as clearly: some patients have spontaneous resolution at puberty, but many do not.
The practical consequence is direct. Lichen sclerosus in girls requires follow-up, even when the girl is well and even after puberty. Discharge is not given for reaching a certain age.
Is it safe to use corticosteroid on a girl?
Yes, and here I want to be especially clear, because fear of corticosteroids does as much harm as their abuse.
In the study by Casey and colleagues, 62 of the 72 girls were treated with clobetasol propionate 0.05%, an ultrapotent topical corticosteroid, applied daily for three months. 72.6% achieved disappearance of symptoms, compared to 32.2% of those treated with medium or low potency corticosteroids. And the data every mother asks about: no serious adverse effects were recorded with the ultrapotent corticosteroid.
Both errors have consequences. Applying too much, for months and without control, thins the skin. But applying too little, or not applying anything out of fear, leaves the inflammation working silently, and that is what produces the scars. In a girl, the goal is not to use the minimum possible amount: it is to use the prescribed amount until the skin returns to its normal appearance, and then maintain.
Dr. Patricia Gutiérrez Ontalvilla
It is worth reading these figures with their scope: it is a prospective study compared with a retrospective series, not a randomized trial, and describes the experience of one center with long follow-up. But it is the best available evidence on lichen sclerosus in girls and points in only one direction. If fear of corticosteroids is what holds you back, I address it separately in the article on corticophobia in vulvar lichen sclerosus. The drug information sheet is in clobetasol for vulvar lichen sclerosus.
Is it inherited? The question every mother asks
It is the second question that appears in the office, almost always accompanied by guilt. The short answer is that a described familial aggregation exists, but that having lichen sclerosus does not mean you have transmitted it, nor that your daughter will have it because you do. I develop this in the article on whether lichen sclerosus is inherited from mother to daughter.
What to do if you suspect lichen sclerosus in girls
- Request a directed vulvar examination. Describing symptoms is not enough: it must be examined. You can request it in pediatrics, in pediatric and adolescent gynecology, or in dermatology.
- Also mention urinary and digestive issues. If your daughter holds her urine, it stings when urinating, or she is constipated, mention it even if it seems to belong to another consultation. According to available data, this is what most girls with lichen sclerosus present.
- Bring photos if the lesions appear and disappear. With good lighting, taken by you, saved with the date. They save months.
- Do not apply creams from other people or treatments on your own. An antifungal or mild corticosteroid applied randomly can mask the condition and complicate the diagnosis.
- If there is already a diagnosis, do not suspend treatment on your own when the girl stops complaining. Symptom improvement comes before skin improvement.
- Maintain follow-up. Pediatric literature recommends reviews every 6 to 12 months even in asymptomatic girls.
If you want to understand how the diagnosis is reached and what tests are involved, I explain it step by step in diagnosis of vulvar lichen sclerosus.
Signs that should not wait for the next review
Consult without waiting if fissures that do not close appear, bleeding without apparent cause, sustained pain when urinating or defecating, changes in the shape of the vulva, or a thickened or hardened area. None of these findings by itself means that something serious is occurring. But all justify an in-person and early assessment.
References
- Casey GA, Cooper SM, Powell JJ. Treatment of vulvar lichen sclerosus with topical corticosteroids in children: a study of 72 children. Clin Exp Dermatol. 2015;40(3):289-292. doi:10.1111/ced.12519
- Wang M, Arlen AM, Vash-Margita A. Characteristics Among Premenarchal Girls With Lichen Sclerosus. J Low Genit Tract Dis. 2021;25(2):152-157. doi:10.1097/LGT.0000000000000584
- Poindexter G, Morrell DS. Anogenital pruritus: lichen sclerosus in children. Pediatr Ann. 2007;36(12):785-791. doi:10.3928/0090-4481-20071201-07
Frequently asked questions about lichen sclerosus in girls
At what age can lichen sclerosus appear in girls?
Lichen sclerosus in girls can appear in early childhood. The review by Poindexter and Morrell published in Pediatric Annals in 2007 describes cases from 6 months of age, with an average around 5 years. In the series by Wang and colleagues from 2021, the average age at diagnosis was 6.2 years, with cases from 3.3 years. Age does not rule out the diagnosis.
Will my daughter’s lichen sclerosus disappear at puberty?
Not reliably. In the study by Casey and colleagues on 72 prepubertal girls, with follow-up of 4 to 8 years, only 29.2% achieved complete resolution of signs. The belief that lichen sclerosus in girls cures itself with puberty is not supported by the data. Follow-up must be maintained.
Is it dangerous to use corticosteroid on a girl’s vulva?
In the study by Casey and colleagues, 62 girls were treated with clobetasol 0.05% daily for three months and no serious adverse effects were recorded. 72.6% achieved disappearance of symptoms, compared to 32.2% with medium or low potency corticosteroids. The risk of applying too little, or not applying out of fear, is leaving the inflammation active. The regimen is always set by the professional doing the follow-up.
Why does my daughter have urinary symptoms or constipation?
It is more common than it seems. In the series by Wang and colleagues from 2021, 63.2% of girls presented lower urinary tract symptoms and 57.9% constipation at the time of lichen sclerosus diagnosis. Discomfort when urinating or defecating can lead the girl to hold it in, and that perpetuates the problem. It is worth mentioning in the consultation even if it seems to belong to another specialist.
Can it be confused with signs of sexual abuse?
Yes, and it is described in the literature. The anogenital lesions of childhood lichen sclerosus, with thinned skin, fissures, and small bleeding, can resemble findings of abuse. Poindexter and Morrell note that this confusion has delayed diagnoses and has generated very difficult situations for families. Knowing the disease does not replace professional assessment, which must always be performed.
Has your daughter had vulvar symptoms for months without diagnosis?
If itching, discomfort when urinating, or skin changes recur and no cream resolves them, the next step is a directed vulvar examination. It must be performed by a professional with experience in vulvar pathology.
Dr. Patricia Gutiérrez Ontalvilla is a doctor of medicine, surgeon, and scientific researcher specialized in lichen sclerosus and regenerative cells. President of the Nixarian Foundation and creator of the Liquenia® Protocol. View professional profile and publications.
Content for informational and educational purposes. Vulvar lichen sclerosus is a chronic disease that can be controlled with appropriate treatment and follow-up. This article does not replace diagnosis or individualized medical advice. When faced with persistent vulvar symptoms in a girl, consult with pediatrics, pediatric and adolescent gynecology, or dermatology.
