1. Max Brinsmead MB BS PhD May 2015
Vulval Skin Disorders
Max Brinsmead MB BS PhD
May 2015

2. Incidence, Types and Presentation
Affects 1:5 women in a lifetime
Lichen sclerosis & atrophicus – 25%
Lichen planus
Associated with other skin disease
Lichen simplex with dermatitis
Psoriasis
Premalignant
Vulval warts
Vulval intraepithelial neoplasia (VIN)
Candidiasis
Presents with pruritis and or pain

3. Taking a History Routine gynaecological questions
Ask about urinary and bowel incontinence
Any other skin problems?
Any other disorders
Especially auto immune disease
Immune deficiency
Drugs and OTC preparations
Systemic
Local applications
Smoking & other
Family History
Atopy i.e. eczema and allergies, asthma etc.
Autoimmune disorders

4. Common Vulval Irritants
Excessive drying – use of talc etc.
Topically applied deodorants, antiseptics , douches etc.
Soaps and detergents
Sanitary pads, incontinence pads etc.
Lubricants and rubber (condoms)
Dyes
Close fitting clothes especially synthetics
Itch and scratching, towel drying, nail polish etc.

5. Examination Adequate exposure Good light
Magnification (colposcopy) not mandatory
Lower genital tract, Pap and colposcopy only for suspected VIN
Examine mouth, scalp, nails and all skin
Especially elbows and knees

6. Investigations Exclude diabetes, hypothyroidism & iron deficiency
Gram stain and culture for Candida
Tests for STDs when clinically indicated
Autoimmune tests after a diagnosis of lichen sclerosis or planus
Biopsy
Only for suspected VIN
Or failure to respond to treatment
Can be done with LA as an outpatient

7. Lichen sclerosis & atrophicus
More common in the postmenopausal
But it does not respond to hormones
Thickened, white skin = hyperkeratosis
Causes intense pruritis
Worse at night
Scratching leads to secondary skin damage
Other skin becomes atrophic causing stenosis, adhesions and scarring

8. Lichen sclerosis & atrophicus

9. Lichen planus Can affect any skin but most commonly oral mucosa
Typically polygonal violaceous plaques & papules
Often ulcerated and painful on the vulva

10. Lichen simplex = Neurodermatitis
Erythema and swelling
Scratch injury
Lichenification but no atrophy

11. Vulval Intraepithelial Neoplasia
Comes in two forms:
Warty excrescences
Commonly women <55 years
Associated with HPV – typically Type 16
Differentiated VIN
Commonly women >55
About 5% of lichen sclerosis will have this as well
Progresses more quickly to squamous carcinoma

12. Differential Diagnosis
Not all that important because the treatment for lichen sclerosis, planus and simplex with dermatitis is the same…
Potent topical corticosteroids
Biopsy anything that is clinically suspicious…
Has a raised edge
Abnormal vessels visible
Hard to gentle palpation
Or does not respond to treatment

13. Treatment General measures to protect vulval skin
Potent fluorinated corticosteroid applications
Advantan = Methylprednisone
Diprosone = Betamethasone propionate
Elocon = Mometasone
Clobetasol = the most potent available
Use ointment rather than cream
Prolonged use results in skin atrophy
Daily for a month
2nd daily for a month
Twice weekly for a month
Weekly for a month
Then as required
A 30g tube should last 3 months

14. General Measures to Protect Vulval Skin
Shower rather than bath
Use neutral soap substitutes
Hands only – no flannels or sponges
Pat or blow dry – no towelling
Use water with inert emollient cream other times
Wear loose fitting silk or cotton
Remove underwaer whenever possible
Wash clothes in neutral soap or gel - avoid all biological (enzymes) detergents and bleaches
Avoid dyes – in dark clothes & toilet paper
Minimal use of vulval pads of any type
Avoid all OTC applications
Keep aqueous cream in the fridge for soothing

15. Treatment (2)
About 10% fail to respond to topical corticosteroids
Topical Tacrolimus, an immunodifier , is a second line treatment for lichen sclerosis
Usually occurs with supervision from a Dermatlogy Clinic
Because there is a small risk of malignant transformation
Warts can be treated with Imiquimod cream = Aldara
15 – 80% response rate
Compliance is an issue
Some 15% of VIN will have unrecognised invasive disease disclosed by excision biopsy

16. Follow Up 40 – 60% 0f VIN progresses to Ca over 8+ years
Can be reduced to <5% by adequate biopsy excision
And reconstructive surgery when required
Follow up with colposcopy and cytology
And encourage self examination
Relapse of lichen sclerosis is common
Up to 80% within 4 years
But it has a much smaller potential for malignant change so follow up can be with a GP

17. Some Rare Vulval Lesions
Beçhet’s Disease
Recurrent oral and genital ulcers
Extramammary Paget’s Disease
Florid eczema and lichenification
Biopsy to exclude underlying adenoCa & look for primary in breasts, GI or urinary tracts
Zoon’s Vulvitis
Infiltrated with plasma cells and haemosiderin
Vulval Crohn’s Disease
Granulomas, abscess, ulcers and sinuses
Usually associated with small gut pathology

18. Recurrent Candidiasis
First confirm the diagnosis
Requires swab and culture >48 hrs after fungicidal application
Exclude imidazole-resistant organisms
This requires the use of borates for treatment
Exclude diabetes
Avoid broad spectrum antibiotics
Recolonization of vaginal Acidophilus with natural yoghurt?
Use systemic antifungal = Oral Diflucan
Most respond to recurrent and intermittent Imidazole
Use Canesten PRN
There are many “natural therapies”
Try Tea Tree oil (Melaleuca alterniflora) 2 -3 drops in sweet almond oil on a tampon 8-hourly
There may be a role for immune boosting by transfusions with Transfer Factor

19. Any Questions or Comments?
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