“White Patches of the Vulva"

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

White Patches of the Vulva — Vitiligo or Lichen Sclerosus?

White patches of the vulva (leucoderma) are common and have several causes, from harmless vitiligo to lichen sclerosus and, rarely, cancer. This sheet gives how to tell them apart, when to biopsy, how to treat, and how to counsel.

🎯 AT A GLANCE — VULVAL WHITE PATCHES (LEUCODERMA)

“Leucoderma” is the common word for white skin patches, usually vitiligo; but on the vulva the commonest cause of white patches is lichen sclerosus, so do not assume it is vitiligo (RACGP)

Vitiligo: well-defined loss of colour, normal skin texture, no itch; it affects the genital skin less often than lichen sclerosus does

Lichen sclerosus: white, sclerotic skin with itching, fissures and erosions; loss of the labia minora, fusion of the folds or a buried clitoris point to it

Lichen sclerosus carries a risk of vulval squamous cell cancer of about 5%, so a punch biopsy of the white sclerotic area is highly recommended

Other causes include lichen planus, lichen simplex chronicus, post-inflammatory loss of colour, vulval pre-cancer (VIN), Paget disease and candidiasis

None of these is infectious; lichen sclerosus is not a sexually transmitted infection; leucoderma is not leprosy (from memory)

Feel the skin as well as looking at it: smooth means vitiligo is likely, thin or sclerotic means think of lichen sclerosus, and anything hard, raw or lumpy needs a biopsy.

🚨 DO NOT JUST REASSURE — BIOPSY OR REFER IF…

There is an ulcer, a hard lump, a warty or raised area, or a non-healing erosion — biopsy at once to exclude squamous cell carcinoma (from memory)

A white plaque is thick, or white patches are pigmented or red — biopsy to exclude vulval pre-cancer (VIN) and Paget disease

The diagnosis is in doubt — a punch biopsy of the white sclerotic area is highly recommended

Treatment fails — reconsider the diagnosis, adherence to treatment, infection, irritants, VIN and cancer (RACGP)

Scarring changes the anatomy or closes the opening — refer to a vulval clinic, dermatologist or gynaecologist

A girl or child has white patches with itch or bleeding — refer to a paediatric dermatologist or gynaecologist; lichen sclerosus also occurs in girls (from memory)

STEP 1 · RECOGNISE — which kind of white patch is it?

🔍 TELLING THE CAUSES APART

Cause	What it looks and feels like	Symptoms
Vitiligo	Well-defined, chalk-white patches; skin texture is normal; patches often on other parts of the body too	None; no itch
Lichen sclerosus	White, thin, sclerotic or wrinkled skin, often around the vulva and anus; fissures and erosions; atrophy, fusion of the labia, burying of the clitoris	Itch is prominent; soreness, pain on sex, bruising or splitting
Lichen planus	Red, raw areas with white lacy streaks; may involve the vagina (from memory)	Pain, burning, discharge (from memory)
Lichen simplex chronicus	Thickened, grey-white, scratched skin (from memory)	Severe itch with an itch-scratch cycle (from memory)
Post-inflammatory loss of colour	Lighter patches after dermatitis or injury; texture normal; often fades	Depends on the earlier condition
VIN, Paget disease	White, red or pigmented plaques that persist	Itch or none; a patch that does not respond
Candidiasis	Red skin with white curdy deposits (from memory)	Itch and discharge; swab, then treat

🩺 AT THE FIRST VISIT

Ask about itch, soreness, pain on sex, how long, and creams already used (steroids, irritants, herbal pastes)

Ask about family or personal autoimmune disease: lichen sclerosus is linked with thyroid disease, vitiligo, alopecia areata and pernicious anaemia

Examine the whole vulva, the perianal skin and the hair-bearing skin: texture, wrinkling, fissures, erosions, fusion of the folds, the clitoral hood

Look for white patches on the rest of the body (face, hands, elbows) (from memory)

Take a punch biopsy of the white sclerotic area (from the thickest or most unusual part (from memory))

Swab for candida if there is discharge; check thyroid function if she has lichen sclerosus or vitiligo (from memory)

STEP 2 · TREAT — by diagnosis

🧭 FROM PATCH TO DIAGNOSIS

💊 TREATMENT

Condition	Treatment	Notes
Lichen sclerosus	Ultrapotent or potent steroid ointment: twice a day until symptoms settle (1 to 2 weeks), once a day until the skin texture is normal (1 to 2 months), then on alternate days, about 3 months in all	Then a milder steroid twice a week to maintain, for example betamethasone valerate 0.02%; testosterone and oestrogen creams have no role
Skin care for lichen sclerosus	Soap substitute; barrier of soft paraffin; no scratching; loose underwear; avoid friction and irritants	Tell her it is not a sexually transmitted infection
Vitiligo of the vulva	Reassure; short, gentle courses of a topical steroid or a tacrolimus ointment (from memory)	Genital skin is thin, so avoid long courses of strong steroid; colour may return slowly or not at all (from memory)
Post-inflammatory loss of colour	Treat the cause and protect the skin	Often improves by itself
Lichen simplex chronicus	Break the itch-scratch cycle: a short course of steroid ointment, and a sedating antihistamine at night (from memory)	Look for a cause of the itch
Lichen planus, VIN, Paget disease	Refer to a vulval clinic, dermatology or gynaecology	Biopsy first

Review: at 4 to 6 weeks and at 3 months after starting steroid, then every 6 to 12 months during maintenance. She should examine herself regularly for life and come back at once about a sore, lump or change.

STEP 3 · COUNSEL AND PREVENT — what she needs to hear

🗣️ WHAT TO TELL HER

The white patch is not infectious: it cannot be caught from her or passed to her husband or children; it is not leprosy and not a sexually transmitted infection (from memory)

It is not caused by a food combination such as fish with milk, or by any wrongdoing (from memory)

Lichen sclerosus is a long-term condition that can be kept under control; treatment relieves itch and prevents scarring

Using the steroid correctly matters: apply a small amount to the whole affected area, as advised, and do not stop early (from memory)

Pain on sex often improves with treatment; ask about it, because many women do not mention it (from memory)

Tell her about the small cancer risk so that she checks herself and comes back, without frightening her

Stigma and marriage worries are common with leucoderma: ask, and offer support (from memory)

🛁 SKIN CARE AT HOME

Wash with plain water or a soap substitute; avoid perfumed soaps, washes and wipes

Apply soft paraffin as a barrier, particularly before exercise and after passing urine if the skin is sore (from memory)

Wear loose cotton underwear; avoid tight clothes and rubbing

Do not scratch; keep the nails short; treat constipation and leaking urine that irritate the skin (from memory)

⚠️ COMMON PITFALLS

Calling every white vulval patch vitiligo

Treating itch as candida again and again with no swab (from memory)

Using a weak steroid, or stopping early (from memory)

Giving oestrogen or testosterone cream for lichen sclerosus

Not taking a biopsy from a thick, raw or ulcerated area

Skipping follow-up, so a cancer is found late

Herbal pastes, psoralen paste, strong sun exposure or acids on genital skin (from memory)

Leaving the stigma and the question of her marriage unspoken (from memory)

Memory Aid

WHITE

Five steps for a white vulval patch.

W

Weigh the texture — smooth (vitiligo) or sclerotic (lichen sclerosus)

H

History — itch, pain on sex, autoimmune disease

I

Investigate — biopsy the white sclerotic area or anything unusual

T

Treat — ultrapotent ointment for lichen sclerosus, gentle care for vitiligo

E

Educate and examine again — not infectious, review, self-check for life

Remember: most white patches are harmless, but the one that is thick, raw or lumpy needs a biopsy.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the RACGP article “Whitish genital lesions” (Australian Journal of General Practice, 2021): causes of white vulval lesions, vitiligo versus lichen sclerosus, biopsy recommendation, steroid regimen and maintenance, general measures, cancer risk of about 5%, review times and autoimmune associations. Items marked “from memory” (vitiligo treatment, lichen planus and lichen simplex details, biopsy criteria, candidiasis, thyroid testing, child referral, myths and stigma, home remedies) were not checked. Wording, products and protocols differ between countries: follow your national programme and local protocol.