183) A 65 year old woman presents with a white plaque on her vulva. It is associated with occasional itching. She has no other hypo-pigmented lesions on her body. She denies any post-coital bleeding. Physical examination reveals a white colored plaque on the vulva. The lesion is atrophic, thin with a crinkled surface and is well-demarcated. There is atrophy of the labia minora. Most appropriate next step in managing this patient?
A) Topical Corticosteroids
B) Fluconazole
C) Vulvar Biopsy
D) HPV testing
E) Topical Testosterone
Archer USMLE Step 3 Blog 
ccccccc to rule out cancer
with elderly, itchy vulva,white plaques,I would need to rule out cancer so biopsy the tissue. even though its invasive i would need to do that.
C) Vulvar Biopsy – Lichen Sclerosis
Treat with Topical Clobetasol
C…………
vulvar biopsy..
A
Per kaplan
The two benign lesions of the vulva which present as vulvar itching without malignant predisposition are Lichen sclerosis and squamous hyperplasia.
Lichen sclerosis (this pt) appears as bluish white papula which can coalesce into white plaques. On palpation they feel thin and parchment like .
Histologically they show epithelial thinning.
Squamous hyperplasia appears as white focal or diffuse areas which are firm and cartilaginous on palpation. Histologically shows keratin and epithelial proliferation.
The treatment in either case is topical corticosteroid (clobetasol) cream
Good reasoning but next step in managing is to check for malignancy before disregarding it as benign and treating with steroids.
c
http://www.macmillan.org.uk/information-and-support/diagnosing/causes-and-risk-factors/pre-cancerous-conditions/vulval-lichen-planus-sclerosis.html