Although lichen planus is usually a desquamative lesion of the vagina, occasional patients develop lesions on the vulva near the inner aspects of the labia minora and vulvar vestibule. Patients may have areas of whitish, lacy bands (Wickham striae) of keratosis near the reddish ulcerated-like lesions characteristic of the disease (see Figure 42.1C). Typically, complaints include chronic vulvar burning and/or pruritus and insertional (i.e., entrance) dyspareunia and a pro-fuse vaginal discharge. Because of the patchiness of thislesion and the concern raised by atypical appearance of the lesions, biopsy may be warranted to confirm the diagnosis in some patients. In lichen planus, biopsy shows no atypia. Examination of the vaginal discharge in these patients fre-quently reveals large numbers of acute inflammatory cells without significant numbers of bacteria. Accordingly, the diagnosis most often can be made by the typical history of vaginal/vulvar burning and/or insertional dyspareunia, coupled with a physical examination that shows the bright red patchy distribution; and a wet prep that shows large numbers of white cells. Histologically the epithelium is thinned, and there is a loss of the rete ridges with a lym-phocytic infiltrate just beneath, associated with basal cell liquefaction necrosis.
Treatment for lichen planus is topical steroid prepa-rations similar to those used for lichen simplex chronicus. This may include the use of intravaginal 1% hydrocorti-sone douches. Length of treatment for these patients is often shorter than that required to treat lichen simplex chronicus, although lichen planus is more likely to recur.