Non-healing vulval ulcer in long-standing lichen sclerosus

Invasive vulval squamous cell carcinoma arising in lichen sclerosus (dVIN pathway) — gynae-oncology MDT

Learning points

• Vulval lichen sclerosus carries an approximate 4–5% lifetime risk of progression to vulval SCC (HPV-independent, differentiated VIN / dVIN precursor).
• HPV-driven vulval SCC arises via the usual VIN / uVIN pathway; LS-driven SCC via the dVIN pathway. Treatment is different but the gynae-oncology MDT manages both.
• Adequate topical clobetasol REDUCES long-term SCC risk in LS by controlling inflammation — under-treated LS is the higher-risk scenario.
• Vulval SCC is staged with the FIGO / gynae-oncology TNM, not the cutaneous AJCC 8 algorithm.
• Surgery is the mainstay (wide local excision; radical vulvectomy for advanced disease) with inguinofemoral lymphadenectomy (or sentinel node biopsy in selected patients) for ≥ T1b disease.
• Lifelong gynae-oncology and dermatology surveillance is required for vulval SCC arising in LS.