pathological precision, and the term kraurosis (Greek, dry) became unsuit- able because it was used to imply contraction of the vulva, which could be the end result of more than one condition. Indeed those who believe that these vulval disorders are all stages or varients of a single process have placed them under one heading -vulval dystrophy -but we believe that some subdivision should be made. The following classification is used here:
Primary atrophy, often formerly described as kraurosis. Lichen sclerosus et atrophicus.
Hypertrophic dystrophy, often formerly described as leukoplakia.
Primary atrophy For unknown reasons the skin of the vulva may undergo atrophy. This tends to occur at the time of the climacteric, and it is natural to assume that withdrawal of oestrogens is the cause. However, atrophy may take place before the climacteric, and atrophy does not always occur after the menopause, so some other factor may be involved.
Histological examination of normal skin shows a well defmed wavy line between the epidermis and the dermis. There is progressive maturation in the epidermis from the basal cells through the prickle cells to the keratinized cells on the surface. As the superficial cells are rubbed off, they are replaced from the deeper layers. The dermis consists of collagen fibrils with asso- ciated fibroblasts.
In primary atrophy the whole epidermis becomes thin and the wavy line between it and the dermis becomes flattened. There are very few prickle cells and almost no keratin. Immediately below the epidermis, the dermis shows hyalinization and the fibrillary structure is lost. There is also infiltration with lymphocytes and plasma cells.
The clinical appearances mirror the histological changes, for the skin looks red and shiny because of its thinness. The labia minora are shrunken, and the introitus may contract so that dyspareunia occurs. The complaint is of soreness rather than pruritus. The skin involved is that of the genital area; the adjacent skin of the thighs and perineum is not involved.
An initial trial of treatment with oestrogens is worth while, although many cases of true primary atrophy show no response. Dienoestrol cream is applied locally, or ethinyloestradiol 10 micrograms daily is given by mouth. Otherwise bland ointments such as calamine cream, or zinc and ichthyol cream are used to reduce soreness. If there is superadded in. flammation, betamethasone cream or hydrocortisone cream may be helpful.
These patients must be followed up for many years, as hypertrophic changes (see below) may appear later. If there is any doubt about this, biopsy should be performed.
Lichen sclerosus et atrophicus This disorder is of unknown cause. Similar lesions are sometimes found on other parts of the body. There are areas of slightly thickened ivory-coloured skin, which are often symmetrical and may extend onto adjacent parts of the thighs or perineal region. (Primary atrophy and hypertrophic dystrophy
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