INTRODUCTION

Lichen sclerosis (LS) is a chronic inflammatory condition of the vulva with a colossal impact on quality of life. Although its exact etiopathogenesis has not yet been established, several theories have been put forward, including autoimmune and hormonal. Its clinical presentation may be heterogeneous. It may mimic various inflammatory or tumor conditions of the vulva. Dermoscopy, a non-invasive tool, has established its usefulness in the diagnosis, post-treatment follow-up, management, and prognosis of VLS [1,2]. This study aimed to describe the dermoscopic characteristics of a large series of eighty LSV cases and to correlate them with the duration of the disease.

MATERIALS AND METHODS

Patients and Data Collection

We performed a retrospective analysis of a total of 608 photographs taken from eighty patients.

All patients had a histologically confirmed diagnosis of VLS. The histological examination was conducted by means of dermoscopy directed at the most important site. All patients were in the active phase of the disease, except for two, who were in the near terminal phase with complete stenosis of the vaginal orifice (Fig. 1a). Hypopigmented, indurated papules or macules related or not with pink and/or brown macules were the clinical lesions examined on dermoscopy. Age was not an exclusion criterion, nor was the existence of LS in other skin or mucosal sites.

Figure 1: (a) Clinical picture showing a complete stenosis of the vaginal orifice.(b) Clinical picture showing whitish, sclerotic plaques, hooding of the clitoris with effacement of the labia minora, and homogeneous, pigmented macules.

RESULTS

From the eighty patients, 608 dermoscopic images were analyzed. The mean age was 45 (ranging from 6 to 86). Hooding of the clitoris, fusion of the labia minora with the labia majora, and whitish sclerotic plaques or homogeneous pigmented macules were the most commonly observed clinical features (Fig. 1b).

On the dermoscopic examination, we described both the vascular and non-vascular patterns. (Fig.2) The vascular pattern was dominated by decreased total vascular density, accounting for 68%. Polymorphic vessels were found in 51.2% (Fig. 2a). These included linear vessels, globular or dotted vessels, and telangiectasias. Linear vessels were detected in 46.3% of the cases in various calibers and sizes. No spermatozoa-like vessels were found in any of the patients on dermoscopic examination. The architectural organization of the vessels was characterized by an irregular distribution with a share of 55%. No vascular distribution in the periphery of the lesions was observed in any of the cases. Red to purple spots, dots, or cells corresponding to bloodstains were seen in 31.2% (Fig. 2b).

Figure 2: a) Polymorphous vessels made of hairpins, linear vessels, and dot-like vessels. b) Pale background, dot-like vessels, purpuric spots and globules, peppery appearance. c) Pale background, yellowish-white, structureless areas. d) Milky-red areas, ice sliver-like structures, linear and dot-like vessels. e) Comedo-like openings. f) Pale background, pigmented linear reticulations.

Concerning the non-vascular pattern, a whitish background was detected in the majority of the lesions (80%), with irregular, whitish, structureless areas (66.3%) (Fig. 2c). The milky-red areas were observed in 52.5% of the cases (Fig. 2d).

Regarding the ice chip-like structures, they were observed in 43.8% of the patients (Fig. 2d), and yellowish, comedo-like openings were present in 38.8% of the cases (Fig. 2e). Brownish linear reticulations or brown structureless areas were observed in 35% of the cases and a peppery appearance in 42.5% of the cases (Fig. 2f).

We also, by cross-tabulations, statistically evaluated the association of each dermoscopic sign found with disease duration. We found that dotted vessels were more likely to be seen in VLS lesions with a less than 12 months duration than in lesions with a longer duration (p = 0.03, Fisher’s exact test). No other significant associations were found. Table 1 summarizes the dermoscopic features.

Table 1: Dermoscopic features of the 80 included lesions.

DISCUSSION

The dermoscopic features of VLS have been described in a few case series. Our results were consistent with those reported in the literature [1–3]. VLS presents fairly characteristic dermoscopic patterns. It mainly combines irregularly arranged spotted or linear vessels, a peppery appearance, and white areas without a structure. According to the results of a series reported in the literature, different colors frequently coexist in the same patient [2].

The whitish background and structureless areas represent the dominant dermoscopic features of LSV, observed even in the absence of skin lesions. These dermoscopic features correspond to sclerosis and hyalinization which are the main pathological changes in LS [2].

Other dermoscopic structures described in the literature, which were also observed in our cases, may coexist, in particular, ice chip-like structures, which may have different morphologies, either linear or triangular or lanceolated in shape, which correspond to hyperkeratosis of the adnexal structures [2]

Comedo-like openings may be considered a valuable dermoscopic finding that may be seen in extragenital LS as well as in VLS [2,5,6], especially located on the cutaneous side of the vulvar lesions [2] and correlated on histology with dilated infundibula with follicular cornified plugging [2].

Our patients also had grayish-blue dots in the typical peppery pattern, corresponding to upper dermal and perifollicular melanophages, because of inflammation, explaining why it occurs also in other types of chronic inflammation of the genitals and, therefore, why it cannot be used to diagnose VLS [1,3,7]. The disappearance of red blood globules or dots or well-circumscribed purpuric patches are good indicators for the response to treatment and are the most frequent dermoscopic features in LSV. They correspond to the spots of blood [3,8,9].

A marked decrease in vessel concentration was featured in our study in the context of VLS lesions when compared with unaffected vulvar surfaces is the other dermoscopic signs of the disease. In detail, highly scattered linear vessels were remarked in most of the cases studied, while hairpin and dotted vessels were observed in less than half the cases [2].

The correlation between the vascular pattern and the duration of the disease is controversial. In our study, we found a significant association between dermoscopically assessed dotted vessels and the early stages of LSV, with a significant p value. Indeed, according to Borghi et al., it is likely that dotted vessels occur mainly in the early stages of the disease, which is consistent with our series, while Larre Borges et al. found no such association [3]. It is interesting to note that the presence of dotted vessels appears to depend on the duration of VLS, considering that they appeared mainly in the early stage of the disease. It may be hypothesized that the dotted vessels express the dilated blood vessels immediately beneath the basement membrane, as shown by histology in the early stage of the disease. However, in later stages of progression, dermal fibrosis overrides the vascular changes and may determine the disappearance of the dotted vessels on dermoscopy [3].

CONCLUSION

The recognition of the specific dermoscopic structures of VLS enables it to be diagnosed early and improves its differential diagnosis with other genital inflammatory diseases, particularly in cases of clinical doubt.

Herein, we highlight the characteristic dermoscopic signs of VLS, such as decreased total vascularity, polymorphic vessels with irregular arrangements, yellowish-white structureless areas over a diffuse whitish background, comedo-like openings, and ice chip-like structures. We also found a significance between dotted vessels and the early stage of the disease. However, further studies are needed to confirm the results of our study.

REFERENCES

Notes