Vaginal Lesions in a 7-Year-Old: Are They Signs of Sexual Abuse?

Answer: The lesions are lichen sclerosus, not abuse.

Based on the evaluation and the mother’s recorded natural history, a diagnosis of lichen sclerosus was made. Lichen sclerosus (LS) is a chronic inflammatory skin disease that usually involves the genital region but can have extragenital involvement.^1,2 One study reported a prevalence of 1 in 900 for childhood LS.³ The etiology is unknown, but the disease has been associated with infection, trauma, and autoimmune, genetic, and hormonal factors.^1,2 The disease is most common in prepubertal children and postmenopausal women, which suggests that low estrogens levels contribute to the etiology.

LS is a clinical diagnosis. There is a characteristic appearance of atrophic, hypopigmented, thinned, and wrinkled skin on the labia majora. The pattern frequently is likened to a figure of eight when the perineum and perianal areas are involved.³ If the skin remains intact, minimal trauma can lead to classic subepithelial hemorrhage from disruption of capillaries. In a less commonly described presentation, particularly in cases in which the skin integrity has been disrupted, small or even large hematomas can form, which was the case with our patient. Fissures can be present in the perianal areas or around the labia minora.

Most children with LS are asymptomatic and present after the lesion is noted by either the parent or the child. If symptoms occur, they usually are mild and can include pruritus and dysuria. Constipation secondary to withholding due to pain can occur in cases with anal fissures.³

Sexual abuse may be suspected, because the findings in LS look like acute trauma without a history of accidental trauma. One study of 72 LS cases found that up to 70% had an initial diagnosis of sexual abuse.⁴ The Koebner phenomenon is where LS becomes apparent in previously uninvolved skin after any cutaneous trauma. Thus, sexual abuse can be an inciting factor for LS. Therefore, a thorough evaluation should be completed to rule out sexual abuse.

While LS symptoms usually decrease after puberty, some researchers have found that symptoms can continue into adolescence and lead to changes in vulvar architecture such as labial dysmorphism.^5,6 Children who are asymptomatic do not routinely require treatment. Parents should be reassured that LS will resolve without intervention. Parents should be counseled to discourage scratching of the affected area, and if children are mildly symptomatic, warm sitz baths and/or emollients can be effective.¹ 

Natalie Kissoon, MD, is an attending physician at the Center for Miracles and an assistant professor of pediatrics (clinical) at The University of Texas Health Science Center at San Antonio.

Amy Goldberg, MD, is an attending physician at the Lawrence A. Aubin, Sr. Child Protection Center at Hasbro Children’s Hospital, and an associate professor of pediatrics (clinical) at the Warren Alpert Medical School of Brown University, in Providence, Rhode Island.

References

1. Fistarol SK, Itin PH. Diagnosis and treatment of lichen sclerosus: an update. Am J Clin Dermatol. 2013;14(1):27-47.
2. Monsálvez V, Rivera R, Vanaclocha F. Lichen sclerosus. Actas Dermosifiliogr. 2010;101(1):31-38.
3. Hudson MJ, Swenson AD, Kaplan R, Levitt CJ. Medical conditions with genital/anal findings that can be confused with sexual abuse. In: Jenny C, ed. Child Abuse and Neglect: Diagnosis, Treatment and Evidence. Philadelphia, PA: Elsevier Saunders; 2011:chap 12.
4. Powell J, Wojnarowska F. Childhood vulvar lichen sclerosus: an increasingly common problem. J Am Acad Dermatol. 2001;44(5):803-806.
5. Powell J, Wojnarowska F. Childhood vulvar lichen sclerosus: the course after puberty. J Reprod Med. 2002;47(9):706-709.
6. Smith SD, Fischer G. Childhood onset vulvar lichen sclerosus does not resolve at puberty: a prospective case series. Pediatr Dermatol. 2009;26(6):725-729.