Oakley, Amanda
Te Whatu Ora Waikato
Women commonly present with vulval skin diseases and conditions at menopause due to intermittent or persistent itch, pain, dyspareunia, a rash, or a lesion of concern. The history should explore previous skin diseases, incontinence, comorbidities, medications, and vulval treatments. Evaluate symptoms using a verbal or written 10-point Likert scale, and their impact by completing the vulval life quality index (VLQI). The vulval examination includes the mons pubis, groin creases, introitus, perineum, hair-bearing, glabrous, and perianal skin. Relevant inflammatory diseases may be found in the scalp, ears, flexures (psoriasis); shoulders, breasts, abdomen, and buttocks (lichen sclerosus); shins, lower back, wrists and oral mucosa (lichen planus); and feet and toenails (tinea). Atrophy and resorption of vulval skin can be due to lichen sclerosus (skin only), lichen planus (skin and mucous membranes), or oestrogen deficit. Inflammatory skin diseases may be red or white bilateral and symmetrical plaques, whereas neoplasia is unilateral and focal. Dermoscopy assesses structural pigmentary symmetry (benign melanosis) or asymmetry (potentially malignant). Baseline photographs are important for monitoring disease and the effect of treatment. Investigations may include vaginal swabs (abnormal discharge), scrapings (scaling of buttocks or thighs), and biopsies (diagnostic uncertainty or potential malignancy).