Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2025;15(3):5397 1 High-Resolution Imaging of Bullous and Hemorrhagic Lichen Sclerosus Using LC-OCT Simone Cappilli1, Maria Teresa Perri2, Vittoria Carbone2, Alessandro Di Stefani1,3 1 UOC di Dermatologia, Dipartimento Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy 2 Institute of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Roma, Italy 3 Pathology Unit, Department of Woman and Child’s Health and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy Citation: Cappilli S, Perri MT, Carbone V, Di Stefani A. High-Resolution Imaging of Bullous and Hemorrhagic Lichen Sclerosus Using LC-OCT. Dermatol Pract Concept. 2025;15(3):5397. DOI: https://doi.org/10.5826/dpc.1503a5397 Accepted: April 23, 2025; Published: July 2025 Copyright: ©2025 Cappilli et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/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: Simone Cappilli, UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Largo A. Gemelli 8, 00168 Rome, Italy. Orcid ID: 0000-0001-9813-2391. E-mail: simo.cappilli@gmail.com Case Presentation We report a 32-year-old female with a recent enlargement of a worrisome macule on the vulva. At physical exam we observed an ill-defined violaceous, hemorrhagic plaque on the right labia minora, showing a multicomponent pattern in dermoscopy, with a blue-whitish structureless area over a reddish background (Figure 1, A and B). The lesion was evaluated by line-field confocal optical coherence tomogra- phy (LC-OCT), revealing subepidermal large dark spaces and clusters of bright cells in the dermis (Figure 1C). His- topathology was diagnostic of bullous and hemorrhagic li- chen sclerosus (LS) for the presence of subepidermal cleft, partial homogenization of the underlying dermal collagen, and a lichenoid lymphocytic infiltrate (Figure 1D). The pa- tient was started on topical therapy with a high-potency steroid (clobetasol propionate) once daily for two months, obtaining a satisfactory result with clinical complete resolution and residual scar-like areas in dermoscopy and LC-OCT. Teaching Point Bullous and hemorrhagic variant of LS presents with flaccid hemorrhagic bullae that commonly occur in the extra-genital areas (trunk, proximal limbs) [1]. As herein the differential di- agnosis included melanoma, an LC-OCT (LC-OCT, DAMAE Medical, Paris, France), a newly introduced imaging device, was applied to better investigate the lesion. Technically, the device can acquire bi-dimensional (vertical/horizontal) videos/ images, and 3D cubes/slices up to superficial/mid-dermis [2]. Its application significantly raised the suspicion of this disease, detecting key clues with an impressive similarity to histopa- thology. Hence, for a fast, noninvasive approach of mucosal areas, it may have a valuable diagnostic role and may be easily repeated over time, limiting surgical procedures. 2 Image Letter | Dermatol Pract Concept. 2025;15(3):5397 References 1. Mani S, Oberoi B. Dermoscopic Keys in Extragenital Bul- lous Hemorrhagic Lichen Sclerosus. Dermatol Pract Concept. 2022;12:e2022063. DOI: 10.5826/dpc.1202a63. PMID: 35646427 2. Cappilli S, Paradisi A, Di Stefani A, et al. Line-Field Confocal Optical Coherence Tomography: A New Skin Imaging Technique Reproducing a “Virtual Biopsy” with Evolving Clinical Appli- cations in Dermatology. Diagnostics (Basel). 2024;14:1821. DOI: 10.3390/diagnostics14161821. PMID: 39202308 Figure 1. Clinical, dermoscopy, LC-OCT, and histopathology of bullous haemorrhagic lichen sclerosus of the vulva. (A) Poor-demarcated violaceous plaque with marginal erosions, (B) showing dermoscopic blue-white structures on a red background; (C) vertical LC-OCT revealing subepidermal vesiculation (yellow asterisk) and clusters of inflam- matory cells in the dermis (red arrow), (D) with a perfect correspondence to histopathology.