Why can lichen sclerosus be mistaken for vitiligo, and how can they be distinguished clinically?
Lichen sclerosus and vitiligo can look similar at first glance because both can cause light or white patches on the skin. But clinically, they behave very differently, and a good vulvar exam usually makes the distinction clear.
Lichen sclerosus is an inflammatory, often autoimmune condition that affects the vulva most commonly. Here at Alloy, we talk about it because it often shows up around menopause and can be confused with symptoms of hormonal dryness and thinning. In lichen sclerosus, the skin becomes thin, white, and almost papery. You might see fissures, itching that’s often intense, and changes to the architecture of the vulva. That can mean the labia minora start shrinking or even disappearing, or the clitoral hood becomes thickened or stuck down. These structural changes are what help differentiate it. Treating it requires a high potency steroid, not estrogen alone.
Vitiligo, on the other hand, is just a loss of pigment. In women of color especially, Dr. Sameena Rahman points out that this is where the confusion often happens, because changes in pigment can lead clinicians to assume vitiligo when the underlying problem is actually lichen sclerosus. But vitiligo doesn’t cause thinning, tearing, scarring, or architectural changes. The skin surface usually looks and feels normal, just lighter.
If you’d like a clear visual explanation, Dr. Rahman talks about why the two can get mixed up and what to look for in this chapter:Understanding lichen sclerosus.
If there’s ever doubt, a biopsy can settle the diagnosis. And if symptoms like itching continue even after using vaginal estrogen, that’s another cue to be checked for lichen sclerosus.
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