Genital piercing: A warning for the risk of vulvar lichen sclerosus

Dear Editor A 42-year-old woman was referred to our clinic for a 10-year history of persistent vulvar itching that had recently increased. She had a clitoral piercing since the age of 26 years. Five years after the genital piercing, intimate itching began and it was associated with soreness at the piercing insertion site, which was sporadically treated by a physician with topical 0.1% mometasone furoate. Vulvar physical examination revealed pale shiny areas under the piercing and on the labia minora and three pigmented areas on the fourchette (Figure 1A). Dermoscopy showed patchy structureless whitish areas, decreased vessel concentration, and dotted vessels uniformly arranged over a pinkish background and the presence of structureless pigmented areas, which were characterized by a diffuse brown pigmentation (Figure 1B). Three 4-mm punch biopsies were performed, and the histopathological diagnosis was lichen sclerosus (LS) of the vulva and mucosal melanosis. The patient removed the piercing and the symptoms resolved. A regular follow-up visit for LS was performed. LS is a chronic inflammatory skin disease that causes progressive tissue scarring and atrophy. LS typically affects the anogenital region in 85%-98% of cases. For women, the labia minora, clitoral hood, and perianal area are particularly involved. This latter condition is also known as vulvar lichen sclerosus (VLS), which is one of the most common causes of symptomatic vulvar disease. Generally, VLS is associated with severe persistent pruritus, dryness, soreness, dysuria, and dyspareunia. It can also become functionally and cosmetically serious. Moreover, VLS is associated with a 4%5% lifetime risk of vulvar squamous cell carcinoma. Etiopathogenesis includes genetic susceptibility and various risk factors. Local injuries, infections, sexual hormones, and autoimmune diseases are suspected to play a contributory role. Despite the influence of these factors on LS etiology, trauma, and chronic irritation are believed to play an important role as triggers for LS development. The timeframe between trauma and the onset of the disease ranges from months to years. Intimate body piercing can cause local repeated trauma and persistent irritation, which, after a variable period, can lead to many complications such as a higher incidence of sexually transmitted diseases, cellulitis, abscesses, hypersensitivity reactions, bleeding, keloid formation, scarring, and the appearance of a lichen sclerosus and symptoms that were observed in this patient. To the best of our knowledge, this is the first report describing a case of VLS that developed in a young woman with a clitoral piercing in the absence of any other known additional risk factors for this condition. VLS likely began to appear in our patient 5 years after inserting the genital piercing, considering the appearance of vulvar itching and discomfort. The appearance of VLS at a young age can more easily cause phimosis, genital stenosis, and atrophy that can result in severe anatomical distortion. Furthermore, there is a strong association between VLS and vulvar squamous cell carcinoma. Thus, an early diagnosis, providing appropriate treatment, and long-term follow-up are crucial for avoiding serious complications such as vulvar cancer and functional disorders that lead to important physical and psychological sequelae, especially in a young woman who has a longer life expectancy than older women. Therefore, patients should understand that the presence of a genital piercing can lead to many sequelae and can represent a significant risk factor for the onset of VLS at a young age and for the consequent development of vulvar squamous cell carcinoma. Thus, it is crucial to encourage teenagers and young people to seek dermatologic care for any symptoms that may be related to piercing of the genital mucous membranes to avoid the onset of chronic diseases and their complications.