Sexual abuse

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

Natalie Kissoon, MD, and Amy Goldberg, MD

A 7-year-old girl was brought in for evaluation after her mother found a lesion on the girl’s vaginal area. The child had complained of discomfort when the mother washed her genitals; the mother then examined her, found the lesion, and took a photograph (Figure 1). The child had not complained of genital pain prior to being washed by her mother. The girl denied genital trauma or sexual abuse when the mother asked her about these. The child’s mother took another photograph of the area approximately 1 week after the lesion was discovered (Figure 2). The child presented to her pediatrician’s office for evaluation and was referred to the child abuse pediatrician due to the pediatrician’s concern for trauma.

Vaginal Lesions Figures 1 & 2

At presentation, the child was afebrile with stable vital signs. She had no genital pain, bleeding, or discharge. A forensically informed interview was conducted with the child, during which she denied genital trauma or sexual abuse.

Findings on physical examination of the genitals showed hypopigmentation of the bilateral labia majora and perineal body. Erythematous irregular lesions were present on the inner aspect of the bilateral labia majora and the right labia minora, with a posterior labial adhesion. The hymen was contiguous and the vestibular fossa and posterior fourchette were atraumatic (Figure 3).

Vaginal Lesions Figure 3

Are this girl’s lesions signs of child sexual abuse?

(Answer and discussion on next page)

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.