1. Vulvar Conditions February 18, 2016 Lisa Abel MSN, WHNP-BC, ARNP

2. Acute vulvar conditions Contact dermatitis Infections - fungal - viral (HPV, HSV, molluscum) - bacterial including MRSA - parasites - Trichomoniasis

3. Chronic vulvar conditions Dermatoses Lichen sclerosus Lichen planus Lichen simplex chronicus

4. Chronic Vulvar Conditions (con’t) Infections HPV (VIN or condyloma) Fungal (recurrent or chronic yeast) Allergic contact dermatitis

5. One of the most important components when seeing a patient with a vulvar condition is…. To obtain a detailed history, history and history. Often details that seem insignificant are important in determining the cause

6. Vulvar Irritants Soaps/detergents, wipes, lotions, perfumes Panty liners/pads, sanitary products Sweat, semen, urine, feces Constrictive clothing Vaginal secretions Douches

7. Vulvar candidiasis

8. Candida Symptoms: Itching, burning, swelling and abnormal discharge Physical findings Erythematous, well demarcated patches Hyphae, buds and WBCs on wet prep

9. Treatment Clotrimazole, Miconazole, Diflucan, Terconazole Recurrent infections – Boric acid 600 mg per vagina for 2 weeks; then once a week as a maintenance dose

10. Contact dermatitis

11. Contact Dermatitis Skin reacts to irritant or allergen Symptoms can be quick with an irritant or more delayed with allergen response Symptoms of irritation and pain with irritant; itch and sometimes irritation and pain with allergen Clinical findings Erythema, vesicles, fissures, excoriation

12. Treatment Remove agent causing symptoms Treat secondary infections Topical steroid or oral if severe reaction Oral antihistamines

13. Psoriasis

14. Symptoms – Itching, burning, erythematous (varies in intensity) Physical findings – erythematous, silvery-white scales, well-demarcated, slightly raised plaques Treatment – Topical steroids, refer out

15. Lichen Sclerosus (LS)

16. LS Cause unknown but likely related to autoimmune disease Incidence rate unknown because may be under reported Most commonly seen in prepubetal girls and at menopause Symptoms: Intensely pruritic white plaques, dyspareunia, burning Occasionally asymptomatic

17. Physical findings Skin looks thin, white and crinkly Usually symmetrical changes May have areas of excoriation from itching Narrowing at introitus, loss of contour and fusing of labia, fissures

18. Diagnosis/Work up Biopsy is best – okay to start treatment before definitive diagnosis Rule out other causes such as yeast, HSV or comorbidities

19. Treatment Important to treat because chronic condition and can cause vulvar anatomical changes First line treatment is potent topical steroid. Most commonly used is Clobetasol propionate 0.05 % ointment. Usually apply Clobetasol once a day or BID for 2 weeks then every other day for 2 to 4 weeks then taper to twice weekly (30 gm tube should last 3 months) Estrogen cream if estrogen deficiency contributing to pruritus

20. Follow up Return after a month of treatment to evaluate response Draw picture of effected areas in EHR - helpful in determining at future visits if decreasing clinical signs Increased risk for Squamous Cell Carcinoma (SCC) so monitor for this and instruct patient to return to clinic for skin changes or increase in symptoms

21. Lichen Planus (LP)

22. LP Chronic, progressive and erosive dermatoses Uncommon - Effects only 1 to 2 % of the population Almost always seen in menopausal women Believed to be autoimmune disorder Zendell (2015)

23. Symptoms Burning, dyspareunia, pruritus, vaginal discharge Involves vestibule as well as vagina May also have cutaneous and oral lesions (65 %) Zendell, 2015

24. Physical Findings Erosions that are deep red, well demarcated, erythematous in posterior vestibule White lacy striae on mucosa Possible lesions in mouth

25. Diagnosis Biopsy of nonerosive area Viral culture (HSV) Wet prep – many WBCs

26. Treatment: Also start with potent topical steroid. Most commonly used is Clobetasol propionate 0.05 % ointment. HOWEVER - May need oral steroids, Methotrexate, immunosuppressive medications (mycophenolate) Estrogen cream after erosions heal if estrogen deficient Comfort measures – sitz baths, perineal irrigation bottles Often best to refer out or co-manage with specialist

27. Lichen Simplex Chronicus (LSC)

28. LSC A severe chronic form of contact dermatitis Lichenfication of the skin Skin becomes thick and leathery due to constant trauma

29. Symptoms Intense itching May have excoriation and secondary infection Skin can be hypopigmented or hyperpigmented Diagnosis Symptoms and clinical signs Biopsy

30. Treatment Topical steroid - start strong and then as skin heals some, move to low potency Eliminating allergens and triggers Interrupt itch-scratch cycle; oral medications at bedtime ? Silk underwear

31. Vulvodynia

32. Complex and multifaceted disorder May affect 1 in 6 women Limited RCTs and consensus on treatment modalities Uncertain causes: genetics, neuropathic pain, infections, hormonal influence, psychosocial (Eppsteiner et al, 2014; Sadownik, 2014)

33. Symptoms Burning or tearing pain Can be intermittent or constant Can start because of provoking factor like intercourse, menstrual cycle, touch or occur spontaneously May also occur with vaginismus Skin looks normal

34. Diagnosis Eliminating other causes Patient history On exam, use swab and methodically touch areas of vulva to isolate area of symptoms Treatment is complicated. May want to refer or co-manage with specialist.

35. Treatment Options Topical lidocaine Topical Gabapentin Amitriptyline/baclofen cream Estrogen cream Tricyclic antidepressants (TCA) Corticosteroid injections Psychotherapy Physical therapy (PT)

36. - Lukewarm water - Avoid triggers if know - No soaps, scented lotions - Consider options for providing a skin barrier Skin care is very important in the management of vulvar conditions

37. Vulvar Squamous Intraepithelial Lesions (SILs)

38. Current Terminology for SILs LGSIL of vulva (flat condyloma, vulvar LGSIL, HPV effect) HGSIL of vulva (vulvar HGSIL, VIN usual type) DVIN (differentiated-type VIN) Unlike cervical cancer, only approximately 20 % of invasive vulvar cancer is associated with HPV. (Bornstein, ISSVD 2015)

39. Symptoms Lesions vary greatly in color – brown, red, white, gray Pruritus in 60 % (Nelson, 2015) May be asymptomatic Diagnosis Biopsy

40. Treatment – Refer to Gyn oncologist Cold knife incision Laser Immunomodulator therapy Photodynamic therapy ? HPV vaccine used with therapy All treatment modalities have a 30 – 50 % reoccurrence rate (Nelson et al, 2015)

41. What are the diagnoses?

42. Source: medical.theclinic.com (downloaded 1/30/16) This is a 58 year old G 1 P 1 who presents with a new history of vulvar pruritus and pain. The skin is very sensitive to touch. She denies a history of HSV but recently noticed a open area near vagina. What is her most likely diagnosis?

44. 62 year old G 4 P 3013 with Lichen Sclerosus diagnosed 3 years ago. She presents with persistent itching unresponsive to her steroid cream. What is her most likely diagnosis? Source: https//classconnections.3.amazonaws.com/797/flashcards/1448797/screen_shot_2013-02-05_at_121022_pm 1360088835883.png (downloaded 1/30/16)

45. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Benign Vulvar Dermatoses. Rodriguez, Maria; MD, MPH; Leclair, Catherine Obstetrical & Gynecological Survey. 67(1):55-63, January 2012. DOI: 10.1097/OGX.0b013e318240cc72 39 year old G 0 presents with complaints of pruritus and burning. She states she recently used a new scented lotion to area. What is her diagnosis?

46. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Benign Vulvar Dermatoses. Rodriguez, Maria; MD, MPH; Leclair, Catherine Obstetrical & Gynecological Survey. 67(1):55-63, January 2012. DOI: 10.1097/OGX.0b013e318240cc72 Fig. 3. Contact dermatitis. A color version of this figure is available online at www.ObGynSurvey.com.

47. Contact Dermatitis

48. Vulvovaginal candidiasis

49. Source: med.cmu.ac.th (downloaded 1/30/16) This is a 45 year old G 2 P 2 who presents with a history of severe pruritus for months or possibly up to a year. She is uncertain what may have started the symptoms. She finds that she even scratches the area during her sleep. What is her most likely diagnosis?

50. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Benign Vulvar Dermatoses. Rodriguez, Maria; MD, MPH; Leclair, Catherine Obstetrical & Gynecological Survey. 67(1):55-63, January 2012. DOI: 10.1097/OGX.0b013e318240cc72 Classic lichen simplex chronicus. A color version of this figure is available online at www.ObGynSurvey.com.

51. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Benign Vulvar Dermatoses. Rodriguez, Maria; MD, MPH; Leclair, Catherine Obstetrical & Gynecological Survey. 67(1):55-63, January 2012. DOI: 10.1097/OGX.0b013e318240cc72 This is a 38 year old that presents for her annual exam. You begin the speculum exam and noticed this lesion. What are the possible diagnoses?

52. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Fig. 9 Benign Vulvar Dermatoses. Rodriguez, Maria; MD, MPH; Leclair, Catherine Obstetrical & Gynecological Survey. 67(1):55-63, January 2012. DOI: 10.1097/OGX.0b013e318240cc72 Fig. 9. Vulvar intraepithelial neoplasia (figure courtesy of Dr. Hope Heffner). A color version of this figure is available online at www.ObGynSurvey.com.

53. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Benign Vulvar Dermatoses. Rodriguez, Maria; MD, MPH; Leclair, Catherine Obstetrical & Gynecological Survey. 67(1):55-63, January 2012. DOI: 10.1097/OGX.0b013e318240cc72 22 year old G 0 with complaints of persistent yeast infections for almost a year. She has tried OTC medications. She was seen by a ARNP and prescribed Fluconazole and Terconazole. Her symptoms have persisted. Intercourse is painful. What is her diagnosis?

54. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Fig. 6 Benign Vulvar Dermatoses. Rodriguez, Maria; MD, MPH; Leclair, Catherine Obstetrical & Gynecological Survey. 67(1):55-63, January 2012. DOI: 10.1097/OGX.0b013e318240cc72 Fig. 6. Lichen sclerosus. A color version of this figure is available online at www.ObGynSurvey.com.

55. Case study 29 year old G 0 P 0 presents for her annual exam. She has had the same sexual partner for 4 years. She reports dyspareunia and rarely able to achieve vaginal penetration during intercourse. She denies vaginal discharge, odor or pruritus. She currently uses OCPs for BC but plans to have a BTL. She complains of low libido. On exam, external genitalia is within normal limits. She has a painful area at the posterior fourchette. What is her diagnosis? What treatment options might you suggest?

56. Other vulvar conditions

57. Angiokeratoma

58. Folliculitis from shaving Source: http://production.australiandoctor.com

59. Thank you

60. Topical corticosteroids potency Very High: Clobetasol 0.05%, Halobetasol propionate 0.05% High: Triamcinolone 0.5%, Desoximetasone 0.05% Medium: Triamcinolone 0.025%, Hydrocortisone valerate 0.2% Low: Hydrocortisone acetate 0.1%, Hydrocortisone 0.5%, 1%, 2.5%

61. References Powell AM, Nyirjesy P. Recurrent vulvovaginitis. Best Pract Res Clin Obstet Gynaecol. 2014;28:967-976. Guerrero A, Venkatesan A. Inflammatory vulvar dermatoses. Clin Obstet Gynecol. 2015;58(3):464-475. Kai A, Lewis. Long-term use of an ultrapotent topical steroid for the treatment of vulval lichen sclerosus is safe. J Obstet Gynaecol. 2015; doi: 10.3109/01443615.2015.1049252. Rodriguez ML, Leclair CM. Benign Vulvar Dermatoses. Obstet Gynecol Surv. 2012;67(1): 55-63. Zendell K. Genital lichen planus: Update on diagnosis and treatment. Semin Cutan Med Surg. 2015;34: 182-186. Alef Thorstensen K, Birenbaum DL. Recognition and management of vulvar dermatologic conditions: Lichen Sclerosus, Lichen Planus and Lichen Simplex Chronicus. J Midwifery Womens Health. 2012;57: 260-275. Eppsteiner E, Boardman L, Stockdale C. Vulvodynia. Best Pract Res Clin Obstet Gynaecol. 2014;28:1000- 1012. Sadownik LA. Etiology, diagnosis and clinical management of vulvodynia. Int J Womens Health. 2014:6: 437-449. Nelson EL, Bogliatto F, Stockdale CK. Vulvar intraepithelial neoplasia (VIN) and condylomata. Clin Obstet Gynecol. 2015;58(3): 512-525. Bornstein J, Bogliatto F, Haefner HK, et al. The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) terminology of vulvar squamous intraepithelial lesions. J Lower Gent Tract Dis. 2016;20:11-14.