Dermatology: Practical and Conceptual


Dermatology Practical & Conceptual

Letter | Dermatol Pract Concept. 2021;11(4):e2021133 1

Dermoscopy as a Useful Tool in Differentiation of 
Genital Lesions: Lichen Sclerosus

Ružica Jurakić Tončić 1, Tatjana Matijević 2, Marija Milković Periša3,  
Daška Štulhofer Buzina1, Romana Čeović 1

1 Department of Dermatology and Venereology, School of Medicine, University of Zagreb, University Hospital Centre Zagreb,  

Zagreb, Croatia

2 Department of Dermatology and Venereology, University Hospital Centre Osijek, Osijek, Croatia

3 Department of Pathology, School of Medicine, University of Zagreb and Department of Pathology and Cytology, University Hospital Centre 

Zagreb, Zagreb, Croatia

Key words: genital lesion dermoscopy, lichen sclerosus, venerology

Citation: Tončić RJ, Matijević T, Periša MM, Buzina DŠ, Čeović R. Dermoscopy as a useful tool in differentiation of genital lesions: lichen 
sclerosus. Dermatol Pract Concept. 2021;11(4):e2021133. DOI: https://doi.org/10.5826/dpc.1104a133

Accepted: January 21, 2021; Published: October, 2021

Copyright: ©2021 Tončić et al. This is an open-access article distributed under the terms of the Creative Commons Attribution  
License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original 
authors and source are credited.

Funding: None.

Competing interests: None.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Ruzica Jurakić Tončić, MD, PhD. Department of Dermatology and Venereology, University Hospital Centre Zagreb, 
School of Medicine, University of Zagreb, Zagreb, Croatia. Email: rjtoncic@gmail.com

Introduction 

Lichen sclerosus (LS) is a chronic inflammatory disease of 

unknown etiology that most commonly affects the anogenital 

area, with a higher prevalence in women. It is characterized 

by ivory-white sclerotic plaques with thin wrinkled skin sur-

face and frequently seen erosions and fissures [1]. Pruritus 

is the most common symptom of genital lichen sclerosus 

(GLS), significantly impairing the quality of life and can be 

accompanied by dyspareunia in women. Scarring can lead 

to loss of normal anatomical architecture along with disease 

progression [1]. Early diagnosis and proper treatment are of 

particular importance. Although in most cases of advanced 

disease diagnosis is usually straightforward, early diagnosis 

can sometimes be challenging and present some diagnostic 

uncertainties. 

Case Presentation

A 59-year-old, otherwise healthy woman, presented with a 

dark macule on her vulva which appeared spontaneously a 

few weeks before her visit. The patient had a fair phototype, 

multiple solar lentigines, and other signs of sun-damaged skin. 

Clinical examination revealed a notably dark asymmetrical 

pigmented lesion with indistinct borders on the clitoral hood 

(Figure 1 A). Dermoscopy showed multiple red and white 

structureless areas with a blue-white zone on the left part 

of the lesion (Figure 1, B and C). The observed dermoscopic 

features with a chaotic arrangement was alerting, biopsy was 

recommended also considering the fact that this was a new-

ly-onset lesion. Due to its hemorrhagic component, the lesion 

was first suspected to be a vascular tumor, and the main clini-

cal concern was to exclude malignancy, especially melanoma. 



2 Letter | Dermatol Pract Concept. 2021;11(4):e2021133

However, the biopsy was not performed immediately due to 

coronavirus pandemic and health system reorganization. A 

month after the first visit and before she underwent the biopsy, 

the patient came again to our clinic to report the change of the 

lesion. Another clinical examination of the suspected lesion 

showed that hemorrhagic component completely disappeared 

and now only a delicate area of leukoplakia was noticed. 

In addition, a similar finding was also detected on the right 

labium minus. Control dermoscopy was performed. Multi-

ple patchy structureless white and milky-pinkish areas on a 

whitish background with a small erosion area were observed 

(Figure 2). The patient also complained about pruritus affect-

Figure 1. Clinical and dermoscopic presentation of the lesion at the first visit. (A) Clinical presentation. 

(B, C) Dermoscopic presentation of the lesion showing multiple red and white structureless areas (arrow) 

with a blue-white zone on the left part of the lesion (asterisk).

Figure 2. Dermoscopic presentation of the lesion at the second vis-

it: multiple patchy structureless white and milky-pinkish areas on 

a whitish background (asterisk) with a small erosion area (arrow).

ing the genital area. Biopsy was recommended again, this time 

not because of a suspected malignant lesion, but because of LS 

suspicion. Full-thickness skin biopsy was performed, and the 

histological examination showed hyalinization of the dermis 

with moderate inflammatory infiltrate, indicating LS. After rul-

ing out malignancy and the confirming LS diagnosis, a potent 

local corticosteroid was prescribed with a good control of the 

disease and the regression of all clinical signs and symptoms. 

Conclusion

Genital LS can present a diagnostic challenge in its early 

stages. It is known that LS plaques can commonly show signs 

of hemorrhage due dermal capillaries’ fragility and chronic 

scratching, but dermal hemorrhage is quite rare as a first sign 

of the disease [2]. Also, it is notable from our case that pur-

pura in set of genital LS lesion can give bizarre dermoscopic 

appearance, mimicking a potentially malignant lesion. 

Dermoscopic patterns of large case series of genital LS 

were observed in few studies to date, and the features that 

we observed on the second visit were mentioned as one of the 

most consistent findings [2]. However, even though dermos-

copy can help establishing a diagnosis of LS, its role is still 

limited. To confirm diagnosis histopathological examination 

can sometimes be required in cases of diagnostic uncertainty, 

especially when the disease is in its early stages, and to rule 

out malignant diagnoses affecting the genital region. We 

believe that genital LS can be considered as a possible differ-

ential diagnosis of melanoma in the genital region.



Letter | Dermatol Pract Concept. 2021;11(4):e2021133 3

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