Is Vulvovaginal Lichen Planus Associated With Squamous Cell Carcinoma?

Nonsclerotic Lichen Sclerosus: Definition of a Concept and Pathologic Description

OBJECTIVE

Nonsclerotic lichen sclerosus (NSLS) refers to the clinicopathologic situation of examination findings consistent with lichen sclerosus (LS) but without dermal sclerosis on microscopy. This review aims to describe the features of NSLS and provide a classification framework.

METHODS

The International Society of the Study of Vulvovaginal Diseases tasked the Difficult Pathologic Diagnoses Committee with development of consensus documents for conditions with problematic histopathology. The Difficult Pathologic Diagnoses Committee reviewed the literature on NSLS and formulated descriptions and diagnostic criteria, then approved by the International Society of the Study of Vulvovaginal Diseases membership.

RESULTS

Nonsclerotic LS may be categorized into 4 histopathologic subtypes: lichenoid dermatitis, hypertrophic lichenoid dermatitis, dermal fibrosis without acanthosis, and dermal fibrosis with acanthosis. Each has a pathologic differential diagnosis of 1 or more entities, so clinical correlation is required for final diagnosis of LS. There is no evidence to support a reliable association between absent sclerosis and clinical appearance, duration, or oncogenic potential of LS.

CONCLUSIONS

Pathologists and clinicians should be familiar with the concept of NSLS and its implications for patient management. Use of the term "early LS" to indicate a lack of sclerosis in presumed LS should be abandoned. Clinical correlation is required to confirm LS from among the differential diagnoses.

Vulvovaginal erosive lichen planus refractory to topical therapies: What's next? A case report

A 60-year-old woman was referred for progressive and severe vulvovaginal pain characterized by erosions and Wickham's stria for the past 7 months. Her condition had not responded to oral fluconazole, topical estrogen cream, and topical clobetasol cream. Vulvar and vaginal biopsies were obtained under general anesthesia to verify the diagnosis of erosive lichen planus given the failed response to ultrapotent topical steroids. Tacrolimus cream was added but not tolerated. Oral and cutaneous lesions of lichen planus also developed. In the absence of evidence-based guidelines, three different systemic treatments were administered sequentially (hydroxychloroquine, mycophenolate, and finally cyclosporin) before a satisfactory, well-tolerated, and sustained clinical response was obtained. Topical betamethasone ointment in a taper was continued to assist in sustaining a vulvovaginal response after cyclosporin was discontinued.

Molecular Features of Preinvasive and Invasive Vulvar Neoplasms

OBJECTIVES

Neoplasms arising from the vulva are uncommon and comprise various subtypes. Given the recent advancements in the molecular aspects of oncologic pathology and how they have impacted cancer treatment, an understanding of recent innovations in the molecular features of vulvar lesions is important.

MATERIALS AND METHODS

Systematic literature search was performed on PubMed, Google Scholar, and Scopus databases for molecular and genetic characteristics of vulvar neoplasms. Peer-reviewed literature published in English is included.

RESULTS

Squamous cell carcinoma (SCC) and its precursors are the predominant neoplasm at this site. Human papillomavirus (HPV) plays a crucial role in the pathogenesis of some of these lesions. Human papillomavirus-associated SCC follows the carcinogenic pathway driven by viral proteins E6 and E7 while HPV-independent SCC shows a high incidence of mutation of TP53 and CDKN2A genes. Mutations in the genes involving the PI3K-Akt pathway play an important role in the pathogenesis of both types of SCC. Among other vulvar malignancies, melanoma, and vulvar Paget disease (VPD) pose a significant clinical challenge and have unique molecular characteristics. Compared with dermal cutaneous melanoma, vulvar melanoma shows a higher rate of mutation of cKIT and NRAS genes and a lower rate of mutations in BRAF . Less than 20% of VPD shows amplification of ERBB2 and seldom shows mutation in genes involving the PI3K-Akt pathway.

CONCLUSIONS

Several potentially targetable molecular pathways have emerged as they have been shown to be involved in the tumorigenesis of SCC, melanoma, and VPD.

Retrospective analysis of the clinical characteristics and patient-reported outcomes in vulval lichen planus: Results from a single-center study

Vulval lichen planus (VLP) is a rare, but often chronic, inflammatory disease whose symptoms include genital pain, discomfort, and dyspareunia. The clinical manifestations include erythema, erosions, and scarring. The aim of this study was to longitudinally investigate patient-reported outcomes and clinical findings in patients with VLP. Patients (>18 years) with histologically confirmed VLP were included in the retrospective analysis. Patient demographics, clinical features, symptomatology, quality of life, management, clinical outcomes, and comorbidities associated with VLP were analyzed. Twenty-four patients were identified with a mean (standard deviation [SD]) follow-up time of 19.3 (13.8) months. Classical VLP with glazed erythema was found in seven (29.2%) patients, erosive VLP was present in 15 (62.5%) patients, and hypertrophic VLP in two (8.3%). Seven patients had additional cutaneous involvement, while six patients had both vulval and oral mucosal involvement. The labia minora was the most frequently affected anatomical site (83.3%), followed by the clitoris (58.3%). Scarring lesions were found in 62.5% (n = 15) of patients. All study participants received treatment with potent and/or superpotent topical corticosteroids but 50% required systemic therapy (acitretin, corticosteroids, or hydroxychloroquine). Five (20.8%) patients underwent surgery due to adhesions and scarring resulting from VLP. One patient was diagnosed with a vulval squamous cell carcinoma during long-term follow-up. The mean (SD) Dermatology Life Quality Index score was 8.4 (5.5) at presentation and 8.9 (6.8) at the end of follow-up. In conclusion, VLP was associated with moderate quality of life impairments which persisted despite treatment, suggesting that current treatments for VLP are inadequate.

Risk of Vulvar Squamous Cell Carcinoma in Lichen Sclerosus and Lichen Planus: A Systematic Review

OBJECTIVES

The objectives of this study were to determine: 1) the prevalence of lichen sclerosus (LS) and lichen planus (LP) present in association with vulvar squamous cell carcinoma (VSCC), and 2) the incidence and absolute risk of developing VSCC in LS and LP.

METHODS

A search was performed of MEDLINE, EMBASE and CINAHL databases. Three independent reviewers screened articles published before September 1, 2020, first on title/abstract and then on the full text. Women with a history of VSCC, human papillomavirus, smoking, or autoimmune disease were excluded. Newcastle-Ottawa observational study scales were used to assess the risk of bias and methodological quality of the included studies. Of the 3132 studies assessed, 31 were selected for analysis. Due to study heterogeneity, a qualitative synthesis was conducted.

RESULTS

The prevalence of LS and LP in association with VSCC ranged from 0% (95% CI 0-5) to 83% (95% CI 36-100) and 1% (95% CI 0-7) to 33% (95% CI 4-78), respectively. The incidence of VSCC ranged from 1.16 (95% CI 0.03-6.44) to 13.67 (95% CI 5.50-28.17) per 1000 person-years for LS. The absolute risk of developing VSCC in patients ranged from 0.0% (95% CI 0.0-5.52) to 21.88% (95% CI 9.28-39.97) with LS and was 1.16% (95% CI 0.1-4.1) with LP. Incidence was not calculable for LP owing to study characteristics.

CONCLUSIONS

This review provides evidence that there is an increased risk of developing VSCC in women with LS, while associations with LP are less clear. Early identification, treatment, and long-term follow-up are essential to prevent potential malignant progression of these vulvar dermatoses.

Clinicopathologic Diagnosis of Differentiated Vulvar Intraepithelial Neoplasia and Vulvar Aberrant Maturation

OBJECTIVE

The aim of the study was to describe the demographic, clinical, and histopathologic features of differentiated vulvar intraepithelial neoplasia (dVIN) and vulvar aberrant maturation (VAM).

METHODS

Specimens from 2010 to 2020 reported as dVIN or VAM were reviewed. Clinical data included age, rurality, symptoms, and evidence of lichen sclerosus (LS). Histopathologic data included epithelial thickness, keratinization, architectural and dyskeratotic features, stroma, p16, and p53. Differentiated vulvar intraepithelial neoplasia and VAM were distinguished by assessment of basal nuclear chromatin, enlargement, pleomorphism, and mitoses.

RESULTS

One hundred twenty women with a median age of 71 years had 179 examples of dVIN and VAM. Squamous cell carcinoma was concurrent in 66% and associated with rurality. Ten percent were asymptomatic, and all but 3 had evidence of LS. Differentiated vulvar intraepithelial neoplasia showed a range of thickness, architecture, and dyskeratosis; its unifying !feature was basal atypia. Differentiated vulvar intraepithelial neoplasia displayed hyperchromasia in 83% and easily observed mitoses in 70%. Nonkeratinizing morphology, subcategorized into basaloid and intermediate, occurred in 24% of women with dVIN. Traditional dVIN represented 62% of keratinizing cases; the remainder were atrophic (13%), hypertrophic (13%), acantholytic (8%), or subtle (5%). Vulvar aberrant maturation had abnormal stratum corneum, acanthosis, premature maturation, and enlarged vesicular nuclei. Null p53 helped distinguish dVIN from VAM and dermatoses.

CONCLUSIONS

The morphology of dVIN encompasses nonkeratinizing and keratinizing types, the latter subdivided into traditional, acantholytic, atrophic, hypertrophic, and subtle. Diagnosis relies on basal atypia with supportive p16 and p53. Atypia exists on a biologic spectrum with mild abnormalities of VAM and reactive change. Identification of dVIN and VAM requires collaboration between clinicians and pathologists experienced in vulvar disorders.

Superficially Invasive Vulvar Squamous Cell Carcinoma: A 37-Year-Long Experience of a Tertiary Referral Center

Superficially, invasive vulvar squamous cell carcinoma (SISCCA) (FIGO stage IA) is a rare subset of vulvar cancer defined as a single lesion measuring ≤2 cm with a depth of invasion of ≤1.0 mm. This is a retrospective study performed on 48 patients with SISCCA, surgically treated between 1981 and 2018 at the S. Anna Hospital, University of Turin, to evaluate pathological characteristics and prognosis of these tumors. Ten patients (21%) recurred: seven (14%) as SISCCA and three (7%) as deeply invasive carcinoma. One case with perineural invasion and groin node metastasis at recurrence. No patient had groin lymph node metastases at initial diagnosis. Site of SISCCA, type of surgery, status of surgical margins, and histopathological features did not differ between recurrent and non-recurrent patients. We observed a non-significant trend towards an increase of recurrences in younger women (median age: 63 years vs. 70 years, p = 0.09), while, surprisingly, smaller tumors (<12 mm) were significantly related to tumor relapse (p = 0.03). Overall, SISCCA has a good long-term prognosis, regardless of the pathological characteristics and the type of surgical treatment. We recommend close follow-up, especially for younger patients and for small tumors, due to the possibility of recurrence or re-occurrence even after years.

Lichen sclerosus of the vulva

Lichen sclerosus of the vulva (LSV) is seen frequently enough to warrant knowing how to diagnose it and institute appropriate treatment strategies. LSV is a chronic skin disorder, very likely of autoimmune origin, which may affect various areas of the perineum, although some women may be affected in extragenital areas. The disease has significant adverse impact on quality of life and sexual activity and may undergo malignant transformation. History of symptomatology and clinical examination is sufficient to make the diagnosis. Skin biopsy is only necessary in specific scenarios. Topical corticosteroids are still the mainstay of therapy, initially to institute remission and then for maintenance. Long-term therapy and surveillance are invariably necessary. Surgery does have a role, but only in specific associated conditions. A number of alternative treatment options have been mooted, especially if the disease is resistant to topical corticosteroids, but these options are still being assessed and studied.

Diagnosis and Management of Vulvovaginal Lichen Planus

Importance

Genital lichen planus is a debilitating disorder that lacks definitive recommendations regarding diagnosis and treatment.

Objective

The aim of this study was to present best practices from available evidence for the diagnosis and treatment of genital lichen planus.

Evidence Acquisition

We conducted a narrative review of the literature on genital lichen planus by searching PubMed using the following search terms: "vulvar lichen planus" OR (vulvar diseases[mesh] OR vulva[mesh]) AND lichen planus[mesh] OR vulvar[ti] AND "lichen planus"[ti]. We included all languages and years in the search.

Results

The search resulted in 273 citations that we reviewed for relevancy and selected 60 as the foundation for this review that focuses on genital sites. Diagnosis can be made without biopsy, and when a biopsy is taken, the pathologic findings may be nonspecific. Topical ultrapotent corticosteroids are most commonly used as first-line treatment of genital lichen planus.

Conclusions and Relevance

When patients present with genital lichen planus, a complete review of systems and a thorough physical examination should be performed because of the prevalence of extragenital sites. Treatment of genital disease should start with a topical, ultrapotent steroid, and follow-up visits should occur to ensure improvement and to monitor for adverse drug reactions and malignancy.

Anogenital High-Grade Squamous Intraepithelial Lesion Comorbid With Vulvar Lichen Sclerosus and Lichen Planus

OBJECTIVE

The aim of the study was to describe the clinicopathologic features of vulvovaginal or anal high-grade squamous intraepithelial lesion (HSIL) comorbid with lichen sclerosus and/or lichen planus (LS/LP).

METHODS

The local pathology database identified 37 consecutive cases from 2007 to 2019 of vulvar, vaginal, or anal HSIL among women who had a histopathologic diagnosis of vulvar LS/LP. Cases had p16 and p53 immunoperoxidase stains. Clinical data included age, relative location of HSIL and LS/LP, immune-modifying conditions, tobacco use, treatment type, and follow-up. Histopathologic data included HSIL morphology categorized as warty-basaloid or keratinizing, p16 and p53 patterns within HSIL, and features of LS/LP.

RESULTS

The mean age was 69 years with a median follow-up up 42 months. Lichen sclerosus, alone or in combination with LP, was the comorbid dermatosis in 89%. Lichen sclerosus/lichen planus was overlapping or adjacent to HSIL in two-thirds of cases and located separately in the remainder. Rates of tobacco use and immunologic dysfunction were each 40%. In cases of co-located LS and HSIL, sclerosis was absent under the neoplasia in 57%. Twenty-four percent of HSIL cases showed keratinizing morphology; block-positive p16 and suprabasilar-dominant p53 helped distinguish HSIL from human papillomavirus-independent neoplasia.

CONCLUSIONS

Histopathologic identification of comorbid HSIL and LS/LP may be challenging because of keratinizing morphology and loss of diagnostic features of LS. Clinicopathologic correlation and use of p16 and p53 are essential to achieve an accurate diagnosis and enact disease-specific management plans.

Clinicopathologic Diagnostic Criteria for Vulvar Lichen Planus

OBJECTIVE

The aim of the study was to describe the clinical and histopathologic features required for a clinicopathologic diagnosis of vulvar lichen planus (LP), which is divided into 3 types: erosive, classic, and hypertrophic.

MATERIALS AND METHODS

The International Society of the Study of Vulvovaginal Diseases tasked the Difficult Pathologic Diagnoses committee with development of a consensus document for the clinicopathologic diagnosis of vulvar LP, lichen sclerosus, and differentiated vulvar intraepithelial neoplasia. The LP subgroup reviewed the literature and formulated diagnostic criteria, then approved by the International Society of the Study of Vulvovaginal Diseases membership.

RESULTS

The clinicopathologic diagnosis of erosive LP incorporates 5 criteria: (a) a well-demarcated, glazed red macule or patch at labia minora, vestibule, and/or vagina, (b) disease affects hairless skin, mucocutaneous junction, and/or nonkeratinized squamous epithelium, (c) evidence of basal layer damage, categorized as degenerative or regenerative, (d) a closely applied band-like lymphocytic infiltrate, and (e) absent subepithelial sclerosis. The clinicopathologic diagnoses of classic and hypertrophic LP each require a characteristic clinical appearance accompanied by hyperkeratosis, hypergranulosis, acanthosis, basal layer degeneration, a closely applied lymphocytic infiltrate, and absent dermal sclerosis, with hypertrophic LP showing marked epithelial abnormality compared with classic LP.

CONCLUSIONS

Clinicopathological correlation yields the most reliable diagnosis of vulvar LP. Disease appearance overlaps with other physiologic, dermatologic, infectious, and neoplastic entities; a low threshold for biopsy at all morphologically distinct areas is recommended. Use of the histopathologic criteria described in this document may reduce the nondiagnostic biopsy rate for clinically diagnosed LP.

Oral lichen planus: a microbiologist point of view

Oral lichen planus (OLP) is a chronic disease of uncertain etiology, although it is generally considered as an immune-mediated disease that affects the mucous membranes and even the skin and nails. Over the years, this disease was attributed to a variety of causes, including different types of microorganisms. This review analyzes the present state of the art of the disease, from a microbiological point of view, while considering whether or not the possibility of a microbial origin for the disease can be supported. From the evidence presented here, OLP should be considered an immunological disease, as it was initially proposed, as opposed to an illness of microbiological origin. The different microorganisms so far described as putative disease-causing agents do not fulfill Koch’s postulates; they are, actually, not the cause, but a result of the disease that provides the right circumstances for microbial colonization. This means that, at this stage, and unless new data becomes available, no microorganism can be envisaged as the causative agent of lichen planus.

Erosive Vulvar Lichen Planus and Risk of Vulvar Neoplasia

OBJECTIVE

The aim of the study was to assess the risk of vulvar cancer and precursors in a cohort of women with vulvar lichen planus (LP) and the clinical and therapeutic features of these patients.

MATERIALS AND METHODS

A retrospective cohort study, including all the women with the diagnosis of vulvar LP, followed in one institution during a period of 11 years, was performed. Demographic and clinical data, as well as treatment, follow-up, and histology results, were evaluated.

RESULTS

A total of 127 women were diagnosed with vulvar LP. The mean follow-up time was 3.9 ± 0.5 years (range = 1-11 years). Ultrapotent topical corticosteroids were first-line treatment in 91.8% (n = 112), with 32 cases (25.2%) needing an alternative treatment. Overall, 30 biopsies were performed in 19 women (15%). Vulvar high-grade squamous intraepithelial lesion was diagnosed in 3 women (2.4%), 2 (1.6%) of whom were later diagnosed with vulvar squamous cell carcinoma. No cases of differentiated vulvar intraepithelial neoplasia were observed.

CONCLUSIONS

Premalignant/malignant transformation in women with vulvar LP under surveillance and compliant with treatment is low. A close follow-up seems to be crucial to prevent future malignancy. Biopsies should be performed whenever a suspicious lesion seems during follow-up.

Diagnostic Criteria for Differentiated Vulvar Intraepithelial Neoplasia and Vulvar Aberrant Maturation

OBJECTIVE

The aim of the study was to describe the features required for diagnosis of differentiated vulvar intraepithelial neoplasia (dVIN) and vulvar aberrant maturation (VAM).

MATERIALS AND METHODS

The International Society of the Study of Vulvovaginal Diseases tasked the difficult pathologic diagnoses committee to develop consensus recommendations for clinicopathologic diagnosis of vulvar lichen planus, lichen sclerosus, and dVIN. The dVIN subgroup reviewed the literature and formulated diagnostic criteria that were reviewed by the committee and then approved by the International Society of the Study of Vulvovaginal Diseases membership.

RESULTS

Differentiated vulvar intraepithelial neoplasia is the immediate precursor of human papillomavirus (HPV)-independent vulvar squamous cell carcinoma and shows a spectrum of clinical and microscopic appearances, some overlapping with HPV-related neoplasia. The histopathologic definition of dVIN is basal atypia combined with negative or nonblock-positive p16 and basal overexpressed, aberrant negative, or wild-type p53. The most common pattern of dVIN is keratinizing with acanthosis, aberrant rete ridge pattern, and premature maturation. The morphologic spectrum of keratinizing dVIN includes hypertrophic, atrophic, acantholytic, and subtle forms. A few dVIN cases are nonkeratinizing, with basaloid cells replacing more than 60% of epithelium. Vulvar aberrant maturation is an umbrella term for lesions with aberrant maturation that arise out of lichenoid dermatitis and lack the basal atypia required for dVIN.

CONCLUSIONS

Evaluation of women at risk for dVIN and VAM requires a collaborative approach by clinicians and pathologists experienced in vulvar disorders. Close surveillance of women with lichen sclerosus and use of these recommendations may assist in prevention of HPV-independent squamous cell carcinoma through detection and treatment of dVIN and VAM.

Putative precancerous lesions of vulvar squamous cell carcinoma

Precursor lesions of vulvar squamous cell carcinoma (VSCC) can be divided into two major biologic and prognostic groups: HPV-associated and HPV-independent VSCC. These two pathways are categorized as usual vulvar intraepithelial neoplasia (uVIN) with progression to basaloid or warty VSCC and differentiated vulvar intraepithelial neoplasia (dVIN) with progression to the more common keratinizing VSCC. While the HPV-dependent pathway to squamous cell carcinoma is well-understood, the development of squamous cell carcinoma from HPV-independent lesions is less clear. The majority of HPV-independent lesions fall into the dVIN category, and mutations in TP53 have been implicated as the driver behind their development. Other less common HPV-independent precursor lesions, termed differentiated exophytic vulvar intraepithelial lesion (DEVIL) and vulvar acanthosis with altered differentiation (VAAD), have also been characterized as precursors to keratinizing and verrucous VSCC. Inflammatory conditions of the vulva such as lichen sclerosus and lichen simplex chronicus also put patients at risk for developing VSCC. We herein evaluate the available evidence and biologic basis for these VSCC precursor lesions, among other speculated entities, and discuss their clinical, diagnostic, and prognostic features.

Erosive Vulvovaginitis Associated With Borrelia burgdorferi Infection

We describe a case of acute erosive vulvovaginitis accompanying Borrelia burgdorferi infection. The patient is a 57-year-old woman previously diagnosed with Lyme disease who presented with a painful erosive genital lesion. At the time of the outbreak, she was being treated with oral antibiotics, and she tested serologically positive for B burgdorferi and serologically negative for syphilis. Histological examination of biopsy tissue from the lesion was not characteristic of dermatopathological patterns typical of erosive vulvar conditions. Dieterle-stained biopsy sections revealed visible spirochetes throughout the stratum spinosum and stratum basale, and anti–B burgdorferi immunostaining was positive. Motile spirochetes were observed by darkfield microscopy and cultured in Barbour-Stoner-Kelly–complete medium inoculated with skin scrapings from the lesion. Cultured spirochetes were identified genetically as B burgdorferi sensu stricto by polymerase chain reaction, while polymerase chain reaction amplification of treponemal gene targets was negative. The condition resolved after treatment with additional systemic antibiotic therapy and topical antibiotics. In cases of genital ulceration that have no identifiable etiology, the possibility of B burgdorferi spirochetal infection should be considered.

Vulvar intraepithelial neoplasia: Classification, epidemiology, diagnosis, and management

Vulvar intraepithelial neoplasia (VIN) is classified into two entities: differentiated (dVIN) and vulvar high-grade squamous intraepithelial lesions (vH-SIL). dVIN is a premalignant lesion that develops on an existing vulvar lesion such as lichen sclerosus, while vH-SIL is associated with HPV infection. The two entities differ in terms of pathophysiology, background, prognosis, and management. The incidence of VIN in young women is rising and recurrence is common, even after radical surgery, which can cause significant disfigurement. Alternative strategies include topical treatments, ablation, and a watch-and-wait approach. There is currently no consensus on how these lesions should be managed. We review the literature in this field.

'Primary gingival and later primary vulval carcinomas arising in lichen planus: report of a case and clinical suggestions for diagnosis of a neglected disease'

Lichen planus (LP) is a chronic immune-mediated dermatosis mainly affecting skin, oral, and genital mucosa. The heterogeneous clinical presentation, spectrum of symptoms depending on subtype and overlap with other vulval and cutaneous disorders can lead to challenging in diagnosis. We report an unusual case of vulval SCC arising within a patient with initial oral mucosal lichen planus who later developed lichen planus of the vulva. Discussion of this case is important as it typifies the difficulties in diagnosis of vulvo-vaginal disorders and potential complications. Evidence is available that lichen planus may be potentially precancerous condition and is associated with SCC development. This case may confirm an inherent oncologic potential of the disease. All efforts must be made by specialists involved in the management of this disease to obtain an early diagnosis, ensure proper treatment and adequate follow up. This highlights the need to perform vulval examination in patients with symptoms or with a history muco-cutaneous LP and if necessary consider referral to specialist center for biopsy and management.

Classic and Hypertrophic Vulvar Lichen Planus

OBJECTIVES

Three types of lichen planus (LP) occur on the vulva: erosive, classic, and hypertrophic. The latter 2 occur on keratinized skin and little is known about their clinicopathologic appearance.

MATERIALS AND METHODS

Vulvar biopsies of keratinized skin reported as LP or "lichenoid" between 2011 and 2017 were reviewed. Inclusion required age of older than 18 years, a lichenoid tissue reaction, and insufficient abnormal dermal collagen to diagnose lichen sclerosus. Clinical and histopathologic data were collected and cases were categorized as hypertrophic, classic, or nonspecific lichenoid dermatosis. Descriptive statistics were performed and groups were compared with the Fisher exact test.

RESULTS

Sixty-three cases met criteria for inclusion. Twenty-nine (46%) cases were categorized as hypertrophic LP, 21 (33%) as classic LP, and 13 (21%) as nonspecific lichenoid dermatosis. There were no significant differences in age, primary symptom, biopsy location, or duration of disease between the 3 groups. When compared with classic and nonspecific disease, hypertrophic LP was less likely to have comorbid dermatoses and more likely to be red, diffuse, have scale crust, and contain plasma cells in the infiltrate. Nonspecific disease had similar clinical features to classic LP but was less likely than the other 2 categories to have a dense lymphocytic infiltrate and exocytosis.

CONCLUSIONS

Vulvar LP on keratinized skin has a diversity of appearances and presents a clinicopathologic challenge. Further research is required to understand the natural history of hypertrophic LP and the underlying diagnosis of nonspecific lichenoid cases.