ABSTRACT
A 6-year-old female presented with vaginal pain and itching that she had for several weeks. Her mother noted a few spots of dried blood in her underwear 1 day prior, prompting her visit to the paediatrician. She had also had constipation intermittently for the past several weeks and one episode of encopresis at daycare. Her development had been normal for her age, and she was toilet trained at age 3 and a half years. She lived with both of her parents and her 10-year-old brother. She had not missed any school, but appeared clearly uncomfortable, and teachers reported that she often asked to go to the toilet. When her mother asked if anyone ‘touched’ her, she shook her head ‘no’. The results of her urinalysis were normal. Her physical examination is shown in Images 130a and 130b. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig130a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig130b.jpg"/>
What does the image show?
What is the treatment for this condition?
Is a report to the authorities for suspected child abuse appropriate?
296The patient had lichen sclerosus, an inflammatory dermatitis most commonly affecting pre-menarchal girls and post-menarchal women. Lichen sclerosus affects the vulva and can extend perianally as seen in this patient, resulting in the classic ‘figure eight’ pattern of hypopigmentation and inflammation. The involved skin becomes atrophic and parchment like. The skin changes can lead to pruritus, fissures and bleeding. Patients can present with intense vaginal soreness and irritation, dysuria and bowel symptoms such as painful defecation, constipation or encopresis. 1 Some patients can also be asymptomatic in spite of skin changes. Physical findings of bleeding, fissures and irritation can often be mistaken for child sexual abuse. 2
Lichen sclerosus is treated with topical corticosteroids. 1
Lichen sclerosus can be prone to the Koebner phenomenon (skin lesions following lines of trauma or external irritation) and can be exacerbated by abuse such as fondling or penetration, but the cause of this skin condition is low oestrogen in conjunction with an inflammatory response that is possibly autoimmune in nature. 2 The classic skin changes in a figure-eight pattern in this child should prompt the diagnosis, and the mother can be reassured and no report needs to be made.
