Barriers to identifying, diagnosing, and treating vulval lichen sclerosus in primary care: a mixed methods survey study

Background Vulval lichen sclerosus (VLS) is a skin condition which causes pain, itching, anatomical changes, and increases vulval cancer risk by up to 22 times. VLS is treatable, with use of topical steroids allowing symptom resolution and complication prevention. Diagnostic delay and misdiagnosis of VLS is common. Previous studies found that women attribute this to poor interactions with and knowledge of clinicians. Most VLS is diagnosed in primary care. Aim To investigate primary care clinicians’ views on confidence in identifying and managing vulval skin disease and VLS, barriers to diagnosis, education on vulval skin disease, and diagnostic criteria for VLS. Method A mixed methods survey was distributed via professional events and networks. Qualitative data was analysed in NVivo using inductive thematic analysis. Spearman’s rank correlation was used to correlate participant characteristics and confidence. Results There were 122 responses, the majority from GP trainees (48%) and GPs (43%). Confidence in diagnosing, identifying, and treating VLS positively correlated with female gender, time in role, and examination frequency. Themes identified include patients not knowing normal, male clinicians: deskilling and reluctance, lack of clinician knowledge, and uncertainty around diagnosis and treatment. 38% of participants never participated in teaching or learning on vulval skin disease. Almost all (98%) participants feel diagnostic criteria would be helpful. Conclusion This study illuminates the multiple barriers to diagnosis and treatment of VLS. The results confirm that clinicians share patient concerns that knowledge is poor, highlight the importance of developing clear diagnostic criteria, and will allow us to target training to those lacking in confidence.