WASHINGTON, DC — As the Founder and Director of the Vulvar Health Program in the Department of Dermatology at The George Washington University, Washington, DC, Emily Murphy, MD, wants dermatologists to appreciate the value of checking the vulvar skin during skin checks in their older female patients, particularly because they may no longer be seeing their gynecologists.

She also advises keeping differentials broad as a host of vulvovaginal inflammatory conditions are common in older patients.

At the ElderDerm 2025 conference on dermatology in the older patient population, Murphy presented two cases of such patients. The first was a 65-year-old woman who presented with a vulvar rash. Her vulvar skin was hypopigmented with thin, shiny plaques and texture change — “kind of a crinkly texture” — of the bilateral labia majora, clitoral hood, and posterior fourchette, and with areas of hyperkeratosis.

The patient’s clitoris was buried by the clitoral hood, and the labia minora was largely obliterated, said Murphy, assistant professor in the Department of Dermatology at The George Washington University, which held the meeting.

The patient had a history of prurigo nodularis, for which she was receiving treatment with nemolizumab, and oral lichen planus (LP). She reported some itching but was most affected by frequent, painful tears of the skin. She had briefly been treated with clobetasol, and while seeing a number of providers, had been switched to hydrocortisone cream and then topical compounded naltrexone, “both of which cause burning,” Murphy said.

Despite her history of LP, the patient had the classic clinical signs of lichen sclerosus (LS), an autoimmune inflammatory condition with peak incidences in prepubertal women and in postmenopausal women in their 40s and 50s — but with a reach into the older ages as well.

LS: Clinical Features, Diagnosis, Management

The skin disease is characterized by hypopigmentation and depigmentation, often with texture change (wrinkling, shiny), and sometimes with hyperkeratosis or erosions. The involvement of the clitoral hood is common, and petechiae and fissures may often be visible from thinning. Unlike LP, LS does not involve the vagina. And if left untreated, significant scarring can occur, Murphy said.

LS is “largely” a clinical diagnosis, but it can be confirmed with pathology. Biopsy early in the disease process will show epidermal atrophy, a zone of papillary dermal hyalinization, and then a band-line infiltrate (red, white, and blue). Later on, “you see more epidermal hyperkeratosis and a broader band of dermal hyalinization,” she said. “If you’re concerned about LS, make sure it’s read by a dermpath because very early, it’s not so obvious,” she said.

In the case of the 65-year-old patient, the clinical vulvar changes were so classic that Murphy decided not to perform a biopsy unless the patient responded inadequately to the treatment. In such cases, “I don’t usually do a biopsy, I’ll usually treat first,” she said. “I don’t think there’s a right or wrong, but if you’re not going to do a biopsy, it’s important to take a good photo” to document the clinical evidence.

Sarah Cigna, MD, an Ob/Gyn, who collaborates with Murphy on running a new joint Vulvar Dermatology Clinic for particularly challenging cases, offered a different opinion at the meeting. “Given that there were some areas of thickening, I’d take advantage of that moment with active disease to do a biopsy,” she said.

Thorough treatment with clobetasol 0.05% ointment twice a day for 4 weeks, followed by once-daily application for another 8 weeks led to significant improvement, with some release of the clitoral hood. At the 12-week follow-up, Murphy said, “she still had a lot of textural change, particularly at the posterior fourchette, and I counseled her to make sure she’s applying the steroid there.”

After 12 weeks of treatment with a high-potency topical steroid, most patients switch to two to three times per week dosing for maintenance. Lifelong maintenance is required, with a return to daily use for up to 12 weeks when flares occur, Murphy said.

Detailed counseling about the use of a topical steroid is critical. In an interview after the meeting, she said patients should be counseled that “a lentil- to pea-sized amount is enough,” and about where to apply the steroid. Using a mirror during the exam and counseling can help.

Other therapies are rarely needed, but when they are, options to consider are topical calcineurin inhibitors, topical JAK inhibitors, and systemic medications including retinoids, methotrexate, hydroxychloroquine, TNF inhibitors, and interleukin-4 inhibitors, Murphy said at the meeting, referring to a 2024 literature review of systemic therapy for LS.

Murphy’s patient did not pursue surgical lysis of clitoral adhesions, but had she been concerned about sexual dysfunction, she would have been a good candidate for this option, Murphy said. “Dermatologists should know about this procedure and when to reach out to an Ob/Gyn to consider pursuing it,” she noted after the meeting.

At the meeting, Cigna, assistant professor of obstetrics and director of the Ob/Gyn sexual medicine fellowship at The George Washington University, said that surgical lysis of clitoral adhesions is “a small office procedure for mild cases” and is “closer to a neonatal circumcision” for more involved cases.

“I talk to patients about how it’s like unzipping a zipper. We’re looking for tissue planes already there…It doesn’t require much cutting, there’s not much blood loss, and healing is fairly easy compared to what you might think because we’re working with scar tissue,” Cigna said.

Puzzling Eruption in a Patient With LS

In another case presented by Murphy at the meeting, a 70-year-old patient with a history of LS presented with extensive erythema of the labia majora and genitocrural folds along with innumerable tiny pustules. The patient reported vulvar pain and little itching. She had used clobetasol nightly for about 2 weeks and had recently taken a single 200 mg dose of fluconazole. She uses topical estradiol 2-3 times a week.

“This patient threw me off,” Murphy said. “It was so inflamed and extensive, I wondered, among other things, whether it was a pustular psoriasis. She did not want to do a biopsy, so I did a swab and started her on doxycycline.”

The culture returned positive for Candida. In retrospect, this made sense, she said, because “the classic medical school teaching is a white clumpy discharge, but it doesn’t always present that way.” Vestibular erythema, including in the skin folds, is common. Scaling is also possible, as are pustules and erosions.

Murphy’s patient was treated successfully with three doses of fluconazole, 200 mg, every 72 hours followed by weekly doses for 4 weeks.

Cigna said she typically recommends dual therapy with oral fluconazole and topical nystatin (either a powder or ointment), “because I find that oral fluconazole can take a really long time to penetrate.” Patients also “still need a little steroid when everything is so inflamed, for symptom relief,” she said.

There is some evidence that topical estrogen can trigger vulvovaginal candidiasis, but estradiol cream can be so helpful in patients with symptoms of genitourinary syndrome of menopause that “it’s a hard counseling moment,” Cigna said. “We try to convince the patient to keep going with the estradiol cream and keep treating the yeast at the same time, recognizing that the estradiol didn’t ‘cause’ the yeast infection but rather brought out something they were at risk for.”

In some cases of recurrent vulvovaginal candidiasis, a full 6 months of treatment may be advisable to “knock it out,” Murphy said.

A Word on Vulvar Examination

To check the vulvar skin, dermatologists can “just ask their patients, do you want me to look in the vulva?” Murphy said in an interview after the meeting, noting that vulvar disorders such as LS are not always symptomatic in the early stages. “Most patients will say yes.”

Dermatologists’ medical assistants typically instruct patients to leave on their underwear for a skin check, but “this creates an extra barrier,” she added. “Why not work with your MAs [medical assistants] to include that underwear is to be taken off? This makes it easy because patients may expect [a vulvar check].” Permission should always be secured, but the goal, she said, should be to “normalize it.”

Murphy and Cigna reported having no relevant disclosures.