Lichen sclerosus mistaken for child sexual abuse

A 3‐year‐old girl presented to the primary care clinic at King Abdulaziz Medical City (KAMC) with asymptomatic white discoloration of the vulva of 3 months’ duration. Dysuria, genital itching, and vaginal discharge followed 2 months later. The discharge was yellowish‐greenish in color and occasionally associated with blood‐tinged staining of the underwear. The mother had noted that the genital skin changes had worsened in the last 2 weeks and that the genital itching and dysuria had become more frequent. There was no history of trauma, behavioral problems, abnormal sexual behaviour, encopresis, or any underlying disease. On questioning the mother, the possibility of sexual abuse could not be ruled out as she reported that the father was drug and alcohol dependent and behaved inappropriately when under the influence of these factors. Because of this possibility, the girl and her parents were referred to the suspected child abuse and neglect (SCAN) team at KAMC for further evaluation.The physician, social worker, and child psychiatrist interviewed the girl, her three older brothers, and the parents separately. The girl and her siblings denied any abnormal touching by an adult. The mother reported that she and the father had been separated for 1 year; however, the couple had been reunited for the last month and were currently living together. The mother linked the appearance of the genital changes to the time the father returned; however, no definite history of sexual abuse was obtained. The father denied any sexual or other abnormal encounter with the child. On examination, the child was well developed and well nourished, cooperative, and showed no abnormal fear of genital or anal examination. Genital examination revealed sharply demarcated, hypopigmented, atrophic plaques symmetrically surrounding the labia majora (Fig. 1). Three sharply demarcated, 0.5 cm, nonpalpable, reddish purpuric macules on the medial aspect of both the labia majora and the base of the clitoris were noted (Fig. 2). Two sharply defined healing erosions were noted on the left side distal to the introitus. The hymenal ring could not be seen, but the hymenal orifice was not dilated. The introitus and the anus appeared normal. Because of the genital findings and the mother's concerns, the possibility of sexual abuse was contemplated. Extensive laboratory testing for sexually transmitted diseases, including syphilis, chlamydia, human immunodeficiency virus, and gonorrhea, were negative. Urine analysis and culture were negative. Routine vaginal culture grew group B β‐hemolytic streptococcus, and the patient was treated with amoxicillin‐clavulanate orally for 10 days. Due to a lack of evidence of sexual abuse, the SCAN team decided to follow up the child and to investigate further before reporting to the protective agency.Photograph of the vulva showing atrophic, hypopigmented, sharply defined plaquesimagePhotograph of the vulva showing three sharply demarcated purpuric macules on both the labia majora and the base of the clitorisimageAn arranged dermatology consultation concluded that the findings were diagnostic of lichen sclerosus (LS). A skin biopsy obtained from the right labia majora showed atrophic epidermis with follicular plugging. Homogenized eosinophilic amorphous collagen replaced the papillary and upper reticular dermis. These findings were also diagnostic of LS. A 4‐week course of twice‐daily mometasone furoate 0.1% ointment (Elocom, Scherring, USA) was given with a dramatic resolution of all symptoms. At a 4‐week follow‐up visit, the signs had greatly ameliorated with the disappearance of bruising and atrophy. Only mild hypopigmentation persisted.