What's behind the white areas?
The term leukoplakia describes the pattern, not the cause. Modern classifications divide these changes into several groups. The most common is lichen sclerosus, a chronic inflammatory disease with an autoimmune mechanism in which the skin thins, loses elasticity, becomes white and parchment-like. Another group is squamous cell hyperplasia, a response to prolonged scratching and irritation when the epithelium thickens. Separately, there are precancerous changes - intraepithelial neoplasia of the vulva, associated with the human papillomavirus or with long-term lichen sclerosus.
- Lichen sclerosus of the vulva
- Squamous epithelial hyperplasia
- Mixed form
- Atrophic changes due to estrogen deficiency
- Vulvar intraepithelial neoplasia
- Vitiligo and other skin diseases that give a similar picture
Causes and risk factors
The exact cause of lichen sclerosus is unknown, but there is a connection with autoimmune diseases: in some women, thyroid disease, vitiligo, and alopecia areata are diagnosed. Hereditary predisposition and hormonal background play a role: the peak incidence occurs in the period after menopause and, less often, in childhood. Squamous cell hyperplasia develops where there is constant irritation: scratching during candidiasis, allergies to pads and soap, wearing tight synthetic underwear. A separate risk factor for precancerous changes is the human papilloma virus and smoking.
- Postmenopausal estrogen deficiency
- Autoimmune diseases and heredity
- Chronic scratching and irritation
- Allergies to hygiene products and linen
- Recurrent candidiasis
- High-risk HPV infection
- Smoking
- Diabetes mellitus
Symptoms
The leading complaint is itching, which intensifies in the evening and at night and interferes with sleep. The skin becomes dry, thin, and cracks easily, causing burning and pain, especially during urination and sexual intercourse. Externally, the areas look whitish, shiny, sometimes reminiscent of thin paper; over a long period of time, the labia minora become smooth and the entrance to the vagina narrows. Often there are cracks and minor hemorrhages from scratching. It is important that some women do not experience itching at all, and changes are found during a preventive examination.
- Persistent itching that gets worse at night
- White dense or shiny areas
- Dryness, burning, cracks
- Pain during intercourse
- Discomfort when urinating
- Changing the shape of the labia and narrowing the entrance
- Hemorrhages and abrasions from scratching
Diagnostics
The examination begins with a detailed examination of the vulva, if necessary, with magnification - vulvoscopy. The doctor excludes infectious causes of itching: takes smears for fungi and microflora, assesses the condition of the vagina. The key study is a biopsy of the altered area with histology: it is this that distinguishes lichen sclerosus from hyperplasia and precancerous changes. A biopsy is required for ulcers, indurations, bleeding and in the absence of treatment effect. Additionally, glucose levels, thyroid function and human papillomavirus status are checked.
- Gynecological examination and vulvoscopy
- Smears for fungi, microflora and infections
- Vulvar biopsy with histological examination
- High-risk HPV testing
- Blood glucose, thyroid assessment
- Cervical cytology
- Repeat biopsy if treatment fails
Treatment and care
For lichen sclerosis, the basis of treatment is considered to be strong local hormonal drugs, which are prescribed by the doctor according to a scheme with a gradual decrease in the frequency of use; when used correctly, they are safe and significantly reduce itching and progression. Additionally, daily moisturizing with emollients, gentle hygiene without soap and antiseptics, cotton underwear, and avoidance of panty liners with fragrance are also important. Postmenopausal women may require topical estrogen therapy. Treatment is long-term, and observation is lifelong, because there remains a small risk of malignant changes.
- Local hormonal preparations according to the doctor’s regimen
- Regular moisturizing and protecting the skin
- Soft hygiene without soap, gels and antiseptics
- Cotton loose underwear
- Elimination of allergens and irritants
- Treatment of candidiasis and blood sugar control
- Local estrogens after menopause as prescribed by a doctor
- Surgical treatment only for complications and precancerous changes
- Examination by a gynecologist at least once a year
