P L Wood and T Bevan Find that unrecognised vulval dystrophy in young girls may wrongly suggest childhood sexual abuse

Lichen sclerosus et atrophicus in young girls can present as haemorrhagic areas on the vulva. Failure to consider this diagnosis and to treat the condition appropriately may lead to a mis diagnosis of child sexual abuse, resulting in a lengthy and distressing investigation for all concerned, particularly the parents. There was extensive publicity surrounding these issues in the United Kingdom after events in Cleveland in 1987. We present three patients with lichen sclerosis et atrophicus. In each case, investigations into child sexual abuse had been instigated before an appropriate referral and correct diagnosis were made.

Case reports

Case 1
A 6 year old girl was admitted to hospital as an emergency under the care of the pae diatricians. There was a history of a suspected accidental fall, after which the girl's mother noticed blood staining on her daughter's underwear. The girl lived with her mother and her mother's partner and visited her natural father once a week.

The local social services department had already been involved about six months previously because of a history of suspected, unexplained perineal trauma. At that time, after a visit to her father, the girl had complained of soreness around the vulva, and a brown discharge had been noticed on her underwear. The girl's mother had described continuing vaginal ulceration which did not heal completely. The symptoms had persisted despite antibiotic treatment, acyclovir for suspected genital herpes simplex infection (which prompted further investigation because of the association with child sexual abuse), and reassurance. The child protection investigations had proved inconclusive, and the child's mother had been particularly upset at the failure to define the problem.

Physical examination in hospital showed two bruises less than 0.5 cm in diameter on the left labia minora, a transverse tear of the upper part of the clitoris, a superficial skin laceration between the labia minora and labia majora, and two scratch marks on the right labia minora. The findings were considered to be accidental, but the girl's mother remained concerned by the fact that there was no resolution to a condition that had been continuing for some months, and a gynaecological opinion was sought.

The girl attended a paediatric gynaecology clinic. A history of vulval soreness spanning one year was elicited. Clinical examination showed findings compatible with lichen sclerosus et atrophicus that is, ivory or white areas of hypopigmentation (often affecting vulval and perianal areas in a figure of eight pattern); a tendency to fine wrinkling; and areas of bruising or blistering (figure). Topical treatment with 1% hydrocortisone cream was begun, to good effect. Anaerobic bacteria were cultured on vaginal swabs, and this infection was treated with metronidazole. The girl's symptoms improved with the treatment, and the vulval dystrophy resolved. Because social services had been involved with the case, they were notified about the diagnosis (with the Mother's consent).

 

Typical vulval changes of lichen sclerosus et atrophicus in a young girl

Case 2
A general practitioner telephoned the paediatric gynaecology clinic about a patient- a 6 year old girl whose condition might be explained by "abuse of some sort." He had identified bleeding from the labial area and at follow up had noticed bruising of the labia and introitus.

The girl attended the paediatric gynaecology clinic with both parents. She had complained of soreness on one occasion only-while being dried after a bath supervised by her father, who had noticed redness of the vulva. The girl had no other symptoms. Physical examination showed some clitoral oedema, bilateral bruising of the labial edges, and an overall pale appearance. She had continued to have intermittent vulval bruising despite antifungal cream prescribed by the general practitioner and a course of metronidazole for an infection of anaerobic organisms cultured on a vaginal swab. The abnormal vulval appearances resolved after a course of 1% hydrocortisone cream, initially applied twice daily.

Case 3
A 4 year old girl with a history of vulval infections over the previous 9-10 months was referred to the paediatric gynaecology clinic by her general practitioner. The infections had been associated with bruising and a "blood blister," and her family had wondered about the possibility of sexual abuse to the extent that her father had telephoned social services for help and advice. The parents had noticed that their daughter had been lying on top of her teddy bear and rubbing herself. She had had several episodes of these symptoms, which were treated with courses of antibiotics. The girl's general practitioner remarked that she had been shocked by the vulval redness, inflammation, bruising, and ulceration. The child's parents were anxious and distressed and requested a further opinion.

Physical examination at the paediatric gynaecology clinic showed the typical changes of lichen sclerosus et atrophicus. The girl was treated successfully with 1% hydrocortisone cream.

Comment

Lichen sclerosus et atrophicus generally affects the anogenital region. It is most often found in women but is also seen in young girls and was first reported in young girls about 30 years ago.¹ Because the condition is uncommon before puberty, however, general practitioners and paediatricians who have not come across lichen sclerosus et atrophicus in children may have a low index of suspicion and may fail to recognise the typical appearances. This lack of awareness persists despite recent reports highlighting the existence of the condition in children and noting confusion with regard to the misdiagnosis of childhood sexual abuse, of which there is an increased general awareness.^2,3

The symptoms of itching and soreness can be troublesome, and a young child may try various ways of obtaining relief, some of which may be mistakenly interpreted as masturbatory behaviour.⁴ Masturbation is not uncommon in children,⁵ but rubbing may lead to concerns over possible sexual abuse if it is perceived as inappropriate childhood behaviour.

The appearances of lichen sclerosus et atrophicus include localised haemorrhages (figure).⁶ A clue to the true diagnosis is the delineation of thinned skin, which gives a well demarcated parchment-type appearance, often in an hourglass shape.

The presence of lichen sclerosus et atrophicus may, in itself, increase the susceptibility to trauma, since the skin becomes thin and easily damaged. As a result, the effect of minor injuries may be magnified-for example, wiping with toilet tissue may cause bruising.³

Vulval bruising, which is not always accompanied by the more typical symptoms of lichen sclerosus et atrophicus such as soreness or pruritus, can raise suspicions of possible childhood sexual abuse. These suspicions warrant an appropriate investigation, which can be upsetting for all concerned. Failure to recognise that the underlying changes are caused by lichen sclerosus et atrophicus, and to treat these accordingly, can therefore lead to inappropriate investigations. Nevertheless, the condition and sexual abuse may coexist. Hymenal trauma is an important marker in helping to determine whether sexual abuse has occurred, regardless of the presence of lichen sclerosus et atrophicus.⁷ Expert diagnosis is necessary to ensure a correct diagnosis, relevant further investigations, and treatment (box).

All the families concerned in these cases were greatly relieved when the correct diagnosis was identified. There was also a degree of upset and resentment that a child sexual abuse inquiry had unnecessarily been initiated because of a failure to recognise the underlying disorder. The misdiagnosis of lichen sclerosus et atrophicus in young girls remains a problem. Despite previous published reports, general practitioners and paediatricians are still failing to consider the diagnosis or recognise its typical appearances. Contributors: Both authors were involved in the care of the patients. TB carried out the literature searches; PLW wrote the paper and will be guarantor.