Phases and progression of vulvar lichen sclerosus
VLS is a chronic disease that can progress. Understanding how it evolves—with and without treatment—helps make clinical decisions at the right time.
How vulvar lichen sclerosus progresses
Vulvar lichen sclerosus does not have a universally accepted staging classification like other oncological processes, but it does evolve characteristically over time. In general terms, we distinguish three clinical stages:
Initial phase
Symptoms are mild or moderate. There may be intermittent itching, mild localized hypopigmentation, and minimal atrophy. At this stage, diagnosis is more difficult because the signs are subtle—and early treatment has greater capacity to halt progression.
Established phase
Symptoms are more intense and clinical signs more evident: well-defined whitish plaques, notable atrophy, possible active fissures, and dyspareunia. The disease is clearly active. Proper treatment can control symptoms and halt progression, but some changes may already be difficult to reverse.
Phase with anatomical sequelae
Chronic inflammation has produced structural changes: fusion of labia minora, clitoral phimosis, narrowing of the introitus. These changes are partially or totally irreversible with conventional medical treatment. In some cases, reconstructive surgery may be indicated.
The difference treatment makes
The progression of VLS is radically different with appropriate treatment than without it:
> Without treatment, the disease tends to progress slowly but steadily. Symptoms intensify, lesions spread, and anatomical changes accumulate. The risk of irreversible sequelae increases over time. The risk of associated malignancy also increases with active and prolonged disease.
> With appropriate treatment—primarily ultrapotent topical corticosteroids in the correct regimen—the vast majority of patients experience significant symptom improvement and disease stabilization. Treatment does not eliminate the autoimmune predisposition, but it controls the inflammatory response that produces the damage.
The key is to maintain treatment continuously, even during symptom-free periods. VLS tends to reactivate when treatment is discontinued.
Reversible and irreversible changes
This is one of the most frequent questions in consultation. The honest answer:
Reversible with medical treatment
- Pruritus, burning, and vulvar pain respond well to proper corticosteroid treatment
- Active erosions and fissures heal with inflammation control
- Hypopigmentation may improve partially, although it rarely disappears completely
- Mild atrophy may improve, especially in early phases
Partially reversible or irreversible
- Advanced fusion of labia minora
- Established clitoral phimosis
- Severe narrowing of the introitus
For established anatomical changes, medical treatment can halt progression but rarely reverses them completely. In these cases, vulvar reconstructive surgery may be indicated.
The timing of diagnosis changes the prognosis
Early diagnosis of VLS is not just good clinical practice—it is decisive for prognosis. A patient diagnosed in the initial phase, with proper treatment from the beginning, has a much greater chance of maintaining vulvar anatomical integrity than a patient diagnosed years later, when structural changes are already significant.
This is why diagnostic delay has real consequences. And this is why in our practice we emphasize the importance of consulting at the first symptoms, without waiting for the disease to progress.