Fusion of the prepuce over the glans clitoris and loss of the labia minora, along with whitened plaque and crinkled whitened skin, with patches of post inflammatory hyperpigmentation indicate lichen sclerosus.

The patient’s imperforate hymen is incised, and the old blood is released.

In the same patient, abdominal swelling resulting from hematocolpos is present.

An imperforate hymen in a 13-year-old adolescent who presented with an acute abdomen.

A Septate Hymen. (Courtesy Dr. G.D. Oliver.)

Labial Adhesion

One month later after treatment with a topical estrogen cream.

Labial adhesions in a 3-year-old girl with a tiny opening before treatment.

Sometimes, instead of fusing the prepuce to the glans clitoris, lichen sclerosus causes resorption of not only the labia minora, but also the prepuce and frenulum, leaving the clitoris exposed.

The prepuce is completely stuck to the buried clitoris. The white, cigarette-paper tissue surrounding the vaginal opening, the absence of labia minora, and the faint shadow of post-inflammatory hyperpigmentation tell the story of untreated lichen sclerosus.

Fusion of the prepuce in lichen sclerosus
Absence of the labia minora
Note the “figure of eight” of whitened skin surrounding the vulva and anal area.

Scarring of the prepuce to the glans clitoris in lichen sclerosus.
Note characteristic whitening of the skin.

Synechiae are tiny bridges of fused tissue, often in the vestibule. In this case, the woman has lost her labia minora already, as well as the frenulum and some of the prepuce, from lichen sclerosus.

The white, cigarette paper-like tissue above the clitoris is typical of lichen sclerosus, but note how the disease is also causing resorption of the labia minora. On the right side, there is a “stuck on” appearance; on the left, the tissue has begun to disappear.

Fusion of the labia minora in lichen sclerosus.

Absence of the labia minora as a result of lichen sclerosus
Absence of the prepuce for the same reason.
Note faint areas of hyperpigmentation where the left labium minus used to be.

This 45 year old woman’s lichen sclerosus has cause loss of normal anatomical features: labia minora and frenulum. The clitoris is partially exposed and there is whitening in the vestibule and post inflammatory hyperpigmentation in spotty areas around the vulva.

The patient reported itching and burning. The flattening on the right side could be a normal variant but could be related to early lichenoid changes. The entire exam must be completed to come to a diagnosis. In the absence of yeast, biopsy could be considered.

Asymmetry of the labia minora in a young woman with both condyloma and vulvar inflammation.

The patient’s tissue certainly looks normal in color, texture, and integrity. The difference in size between the left and right labia minora can be attributed to normal variance. However, since childhood lichen sclerosus may occur and may cause loss of normal anatomy, it is good to keep that in mind when the patient is seen for follow up visits.

In this case, the whitened, thickened skin on the patient’s left side, above the labium minus and above the clitoris makes it very likely that she has lichen sclerosus and her loss of labial tissue is related to that.

Young woman with complaint of vestibular burning and dyspareunia. We know that loss of architectural features can be related to conditions like lichen sclerosus and lichen planus. We do NOT know if flattening of the labia minora posteriorly represents early dermatosis or is a normal variant. Biopsy may help in diagnosis.