Katie, a 54-year-old postmenopausal chemical engineer, presents with several months of progressively worsening pruritis affecting the vulva, perianal region and natal cleft.

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<p>Katie, a 54-year-old postmenopausal chemical engineer, presents with several months of progressively worsening pruritis affecting the vulva, perianal region and natal cleft (pictured).</p><p>She has tried treating this with a topical antifungal, but this has not helped. The intense itch is affecting her ability to work and sleep. She also has new dyspareunia and a first episode of anal fissure.</p><p>She is usually well, with a background of Hashimoto’s thyroiditis, euthyroid on 50µg levothyroxine daily, her only medication.</p><p>There are no new exposures and no close contacts are affected.</p><p>On examination, there are white plaques on both labia minora, extending to the perineum and the natal cleft, and an anal fissure. </p>

Dr Kate Kelso is a GP and medical editor at Australian Doctor.