Question:

A 9-year old girl complained of an itchy hypopigmented patch around her vulva for about a year. There was no history of local application of medication or sexual abuse. On physical examination, there was a mildly atrophic hypopigmented patch around her vulva and anus with some telangiectasia on the inner sides of her labia majora.

Answer: B. Lichen sclerosus et atrophicus

Lichen sclerosus et atrophicus may present in children and adult as an itchy ivory-white atrophic macule or patch. It rarely presents as vesicles or bullae with haemorrhage and erosions which may be mistaken as child sexual abuse. Microscopic examination shows mild orthokeratosis and atrophy in the epidermis. There is focal separation of the epidermis from the dermis. The upper dermis shows edema, a mild superficial perivascular inflammatory cell infiltrate composed of eosinophils, neutrophils, lymphocytes, histiocytes and dilated blood vessels. The prognosis for the children is better than that of adult because spontaneous resolution may occur before puberty while those lesions in the adult may develop into leucoplakia or even squamous cell carcinoma. Management includes symptomatic relief of itchiness with potent topical steroid and continuous surveillance of malignant change.