A 57-year-old woman presents with worsening vulvar itching for six months. The itching is intense and continuous, and increases at night. She has also begun to experience mild dysuria and dyspareunia, starting from around a month ago. These symptoms are the cause of significant distress and frustration. She claims to have good hygiene and denies exposure to common irritants. She is married and has had only one sexual partner in her entire life. Her last menstrual cycle was five years ago. Aside from common symptoms during perimenopause, she has had no other health concerns. Her medical and surgical histories are unremarkable.
The biopsy shows epidermal atrophy, follicular plugging, and homogenized collagen in the upper dermis, with dermal edema and a lichenoid lymphocytic infiltrate.
The swab is negative for the KOH whiff test, clue cells, yeast, and Trichomonas.
The transvaginal ultrasound scan shows no abnormalities.
The patch test shows no reaction to any of the substances.