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Background
Lichen planus is a multisystem disease and so can present to a variety of specialists-dermatologists, rheumatologists, general practitioners, and sexual health clinicians.
The vulvovaginal component can lead to distressing symptoms, distortion of anatomy with vaginal stenosis or obliteration, resulting in loss of sexual function and deterioration in quality of life for the patient.
The disease is chronic in nature so patients require dedicated follow-up, counselling and support.
Unfortunately an accurate diagnosis is often missed or delayed. Increased awareness of the genital aspect of lichen planus is needed and patients with lichen planus should always be questioned about genital symptoms.
Treatment options are limited, but this case highlights the benefit of a combined approach and the success of a novel treatment.
Case presentation
A 60-year-old Caucasian teacher was referred with a 2 year history of vulval and vaginal soreness. A prior diagnosis of lichen sclerosis had been made, but vulval steroid ointment and vaginal oestrogen had failed to alleviate symptoms.
On further questioning the main problem was rapidly progressing dyspareunia, both superficial and deep. Other complaints were excess lacrimation, constipation, dysuria and oral inflammation and ulceration, described as "it feels as if the lining of my mouth is peeling off".
The patient was on no medication and there was no relevant personal or family history. Sexually transmitted disease and autoimmune screens were negative. The examination revealed no obvious oral ulceration or cutaneous lesions and a normal vulva. The vagina was very erythematous with a narrowed introitus and thin filmy adhesions to the mid third. The examination was extremely painful. A diagnosis of lichen planus was made and the patient scheduled for an examination under anaesthesia, division of vaginal adhesions and biopsies.
At surgery, 2 months later, the vagina had completely occluded secondary to filmy adhesions. The adhesions were digitally divided and biopsies taken. These subsequently confirmed lichen planus. The patient was discharged on 30 mg oral prednisone daily and nightly intravaginal Colifoam (Stafford-Miller Ltd, Welwyn Garden City, Herts, UK) enemas. With support from a dedicated nurse specialist she was able to commence vaginal dilator use in 5-7 days and attempt intercourse in 2-3 weeks.
At review, 4 weeks later in the multidisciplinary gynaecology skin clinic, she was well and able to have full penetrative...