Suicidal ideation in patients with vulvar lichen sclerosus

What is known about this subject in regard to women and their families? Vulvar lichen sclerosis (VLS) is a chronic inflammatory dermatosis associated with decreased quality of life and increased risk of developing anxiety and depression. What is new from this article as messages for women and their families? Patients with VLS who develop suicidal ideation present with diverse symptoms and physical exam findings, and suicidal ideation may not correlate with increased disease severity alone. Patients with VLS, particularly those with comorbidities such as anxiety, depression, sexual dysfunction, vulvar pain, and irreversible architectural changes, may benefit from suicide risk screening. Providing psychiatric resources for individuals in distress is integral and reinforces the shared responsibility of healthcare practitioners in caring for the holistic well-being of patients with VLS. Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis associated with anxiety, depression, and reduced quality of life.1,2 Given the psychological impact of VLS, we aimed to explore the relationship between VLS and patient-reported suicidal ideation (SI) directly attributable to the condition. Among 422 patients with VLS treated at a gynecologic dermatology clinic, 9 patients reported SI.3 Six patients were included for reporting active SI and affirming the question: "Have you ever considered suicide because of this condition?" Demographics, symptoms, and clinical findings were collected, and baseline photographs were scored using the 2018 International Society for the Vulvovaginal Disease Delphi Consensus guidelines.4 All 6 patients were non-Hispanic and White, with a mean age of 53 years (range: 23–71). Common symptoms included vulvar itching, pain, dyspareunia, and urinary incontinence (Table 1). Physical examination revealed diverse findings, including hypopigmented and lichenified white plaques, ulcerations, agglutination, and introital stenosis (Table 2). Most patients exhibited mild disease severity, suggesting that SI may not correlate with increased disease severity. Other factors, such as psychiatric comorbidities, likely impact SI in these patients, which makes early screening for all patients with VLS more imperative. Table 1 - Demographic variables and patient-reported symptoms of vulvar lichen sclerosus Variables examined Results Gender: female 6/6 cases Race: White 6/6 cases Ethnicity: not Hispanic/Latino 6/6 cases Mean age at initial presentation 52.5 years Mean age at diagnosis 42.0 years Psychiatric history Depression 5/6 cases Anxiety 4/6 cases VLS symptoms Itch 5/6 cases Pain unrelated to intercourse 6/6 cases Changes/decrease in sexual function 5/6 cases Dyspareunia 5/6 cases Dysuria 3/6 cases VLS, vulvar lichen sclerosus. Table 2 - Frequency and severity of vulvar lichen sclerosus clinical signs and architectural changes Variable Frequency Milda Severea VLS signs Fissures 4/6 cases 3 1 Whitening 4/6 cases 2 2 Crinkly/fine wrinkling/parchment-like skin 4/6 cases 2 2 Erosions 2/6 cases 1 1 Ulcerations 1/6 cases 0 1 Hyperkeratosis 2/6 cases 1 1 Excoriations 2/6 cases 0 2 Lichenification 3/6 cases 1 2 Sclerosis 5/6 cases 5 0 Telangiectasia 3/6 cases 3 0 Petechiae/ecchymosis 2/6 cases 1 1 VLS architectural changes Clitoral hood fusion 6/6 cases 2 4 Labial fusion/resorption 6/6 cases 2 4 Narrowing of the introitus 5/6 cases 2 3 Anterior changes 3/6 cases 1 2 Perianal involvement 3/6 cases 2 1 Formation of posterior commissure bands 2/6 cases 1 1 VLS, vulvar lichen sclerosus.aSeverity based on the 2018 ISSVD Delphi Consensus for VLS using a 4-point Likert scale (0–3, indicating increasing severity), with scores of 1 considered mild and 2 or 3 considered severe. Psychiatric comorbidities were prevalent, with 5 patients having a history of depression and 4 of anxiety (Table 1). One patient attributed her SI to the incessant VLS-related pain that made "life very hard to consider carrying on." Another expressed a preference for death over living with VLS-related discomfort "for the rest of her life." Two patients worried about VLS affecting their ability to have fulfilling romantic relationships. When each patient expressed SI, the dermatologist asked about active plans, to which none voiced. After each visit, the physician ensured immediate assistance or psychiatry referral was available if needed. Routine suicide risk screening during dermatologic intake assessments may help identify at-risk patients. All healthcare professionals share the responsibility of recognizing individuals with SI and referring them to appropriate resources. Physicians can be trained to offer support, including the U.S. National Suicide Prevention Hotline (dial 988). For patients with passive SI, open-ended questionnaires may identify related VLS aspects. Support groups may help patients struggling with isolation, while tailored medical management may address pruritus control. Prompt risk assessment, safety planning, and coordination with psychiatry are important for patients with specific suicidal plans.5 Study limitations include retrospective design and lack of a formal quality of life assessment. While our study focused on SI at initial presentation, patients undergoing treatment may also develop SI, and future research should incorporate longitudinal tracking of SI, larger sample sizes, and validated screening instruments to quantify psychiatric symptoms. Our findings bring awareness to the important role dermatologists can play in recognizing SI in patients with VLS. Incorporating suicide risk screening, particularly for those with comorbidities, may enable early intervention and improve mental health outcomes. Given the intimate and isolating nature of VLS, encouraging patients to join support groups should be considered. Finally, providing psychiatric resources for individuals in distress is integral, reinforcing healthcare professionals' shared responsibility for the holistic well-being of patients with VLS. Conflicts of interest None. Funding None. Study approval The authors confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies (UT Southwestern IRB approval no. STU-2019-0892). Author contributions MMM and HRC had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. MMM conceived and designed the study. HRC and MN performed data acquisition, analysis, and interpretation. MMM, HRC, MN, and SJ contributed to the drafting and revision of the manuscript.