Clinical Signs of Vulvar Lichen Sclerosus
Symptoms are what the patient feels. Signs are what the specialist observes. In VLS, clinical examination is the fundamental diagnostic tool—and knowing the signs helps understand what is occurring in the tissue.
Primary Signs of VLS
Primary signs are the classic findings that the specialist looks for when examining a patient with suspected VLS:
Hypopigmentation—the whitish plaques
The most characteristic finding of VLS is the presence of whitish areas on the vulvar skin. This hypopigmentation is due to the loss of melanocytes and thinning of the epithelium. The plaques may be localized or extend throughout the vulva, including the perineum and perianal area. Their appearance is matte, sometimes compared to cigarette paper or parchment-like skin.
Atrophy and tissue thinning
The vulvar epithelium progressively thins. The skin loses its normal structure, becomes fragile, and tears easily with minimal trauma. Histologically, this corresponds to the loss of normal epithelial architecture and the presence of fibrosis in the dermis.
Loss of elasticity
Vulvar tissue affected by VLS loses elasticity. Skin that is normally soft and flexible becomes rigid and poorly distensible. This contributes to dyspareunia and the appearance of fissures with movement or distension.
Secondary signs and structural changes
As the disease progresses without adequate treatment, structural changes appear that may be irreversible:
Fusion of labia minora
The labia minora may adhere to each other or to the body of the clitoris, reducing their size or causing them to progressively disappear. This fusion is an anatomical sequela of chronic inflammation.
Clitoral phimosis
The clitoral prepuce may adhere and partially or completely cover the clitoral glans. This reduces clitoral sensitivity and may cause retention of secretions under the hood.
Narrowing of the introitus
Progressive fibrosis can reduce the diameter of the vaginal opening, producing a narrowing that makes sexual intercourse difficult or impossible and, in severe cases, gynecological examination.
Active fissures and erosions
During active phases of the disease, linear fissures in the vulvar folds and posterior commissure are common, as well as superficial erosions that may bleed with friction.
Lichenification
In patients with intense pruritus and chronic scratching, lichenification may appear—thickening of the skin from continued scratching. It is a sign secondary to pruritus, not to VLS itself, but common in patients with uncontrolled VLS.
The characteristic pattern of VLS
When involvement is extensive, VLS produces a characteristic distribution pattern that specialists call “hourglass” or “figure-of-8”: involvement of the vulva and perineum, surrounding the anal opening, with an area of healthy skin between both areas. This pattern is practically diagnostic of VLS when present.
It is one of the findings that allows the experienced specialist to make the clinical diagnosis without the need for biopsy in many cases.
Why examination is irreplaceable
Symptoms—what the patient feels—are subjective and variable. Signs—what the specialist observes—are objective and comparable between reviews. That is why regular clinical examination is essential in VLS follow-up: it allows documentation of whether the disease is active, whether it is responding to treatment, and whether new anatomical changes are appearing.
A follow-up consultation without direct examination of the vulvar area is an incomplete consultation in the context of VLS.