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Evaluation and Medical Management of Vulvar Dermatoses

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Presentation on theme: "Evaluation and Medical Management of Vulvar Dermatoses"— Presentation transcript:

1 Evaluation and Medical Management of Vulvar Dermatoses
Katherine “Casey” Monahan, FNP-C, Dermatology Providence Little Co. of Mary Dermatology & Laser Center

2 Types Dermatitis – acute inflammation Contact dermatitis
Dermatoses – chronic inflammation Lichen simplex chronicus Lichen sclerosus Lichen planus

3 History Specific areas to address include: Major complaints
Hygienic practices Types of clothing Medications Personal and family history Sexual history Major complaints: Pruritus? Pain? What are exacerbating factors? Hygienic practices: daily use of panty liners, feminine products, baby wipes? Occlusive clothing: lycra garments? Confining undergarments, such as non-cotton underwear or thongs? Medications applied to the vulva or intravaginally, such as anti-fungal therapy, or other agents, such as contraceptives, perfumed or deodorized soap, to the vulva? Personal and/or family history of eczema, allergies, or hay fever? Any history of diabetes, malignancy, or autoimmune disease?

4 Physical Examination & Diagnostics
Inspect the entire vulvar and perianal area with good lighting Inspect the mouth Swabs for microbiology Skin biopsy Patch testing Take note of even trivial skin changes, such as small tears, which can produce severe symptoms Inspection of as well to ensure lichen planus is not missedmouth to rule out lichen planus (common to have concurrent oral and vulvar involvement) Biopsy for definitive diagnosis and to rule out dysplasia if suspected Patch testing in cases of contact dermatitis


6 Exogenous (Contact) Dermatitis
Vulvar dermatitis (eczema) – the most common vulvar dermatosis Two types of contact dermatitis Allergic (20% of cases) Irritant (80% of cases) Endogenous dermatitis refers to atopic dermatitis, which can affect the vulva but will not be discussed in this presentation Vulvar dermatitis: accounts for one-third to one-half of vulvar complaints Allergic: the allergen induces an immune response Irritant: the trigger/irritant itself directly damages the skin Can be difficult to distinguish from each other and can occur together

7 Contact Dermatitis Vulvar tissue more permeable than exposed skin
Typically, allergens are new exposures Allergic reactions require prior exposure to a product Irritants cause an immediate response, whereas allergic reactions occur 12 to 72 hours after exposure Thus, vulvar tissue more vulnerable and susceptible to contact dermatitis than other regions Allergens – Products used for months to years can create allergic reactions The body creates antibodies to allergens and symptoms occur upon the second or third exposure Delayed reactions with allergens as the body must first build an immune response

8 Contact Dermatitis Signs and Symptoms
Redness, swelling, and scaling of the labia minora Superficial fissures Pain and burning at rest Introital dyspareunia Generalized pruritus less common Fissures in the skin around the vestibule Generalized pruritis: may occur with true allergic episodesmay occur with true allergic episodes

9 Contact Dermatitis

10 Contact Dermatitis Allergens
Fragrances, preservatives, topical medications, and rubber Propylene glycol Irritants Anti-fungal, anti-bacterial, and steroidal creams/ointments Preservatives, stabilizers, and delivery vehicles in drugs, as well as the drugs themselves Propylene glycol: commonly used in topical and oral preparations, causes an irritant or allergic reaction in 12.5% of patients. When ingested, a recurrence of vulvar dermatitis seen in nearly 50% of patch test positive cases Metronizadole (Flagyl) is a drug that is a common irritant

11 Contact Dermatitis Irritants Allergens Soaps Bubble baths Baby wipes
Talcum powder Urine Feces Deodorants Sanitary protection Benzocaine Chlorhexidine Perfume Neomycin Nickel Nail polish Latex Spermicides

12 Contact Dermatitis Management
Identify and eliminate causative agent(s) Replace all known irritant agents with hypoallergenic moisturizing preparations Local measures Oatmeal colloidal soaks Ice packs Mild steroidal ointment in petroleum Aqueous 4% Xylocaine solution Identification -- Can confirm with patch testing Moisturzing local preparations, such as hydrophilic (water-holding) agents Soaks: several times daily Ice packs, such as frozen peas! Xylocaine for anesthetic purposes

13 Contact Dermatitis Patch testing

14 Lichen Simplex Chronicus (“LSC”)
Occurs in chronic cases of dermatitis, resulting from rubbing and scratching Characterized by skin lichenification and excoriation, together with pigmentary abnormalities Accentuation of skin lines/markings Leathery texture Long-continued trauma to the skin over numerous months Lichenification = thickening Excoriations = scratch marks hyperpigmentation

15 LSC Note the accentuation of normal skin markings and leathery texture

16 LSC Management Goal: cessation of pruritus Avoid scratching
High-potency steroid cream/ointment initially, then medium- to lower-strength topical steroids Occlusion of medium-potency steroids Intralesional kenalog injections (5 – 10mg/ml) Unna boot Goal: break the habitual itch-scratch cycle Medium to lower topical steroids as lesions resolve Occlusion – Cordran tape Unna boot: for complete occlusion. May break itch-scratch cycle in severe cases

17 Lichen Sclerosus Lichen Sclerosus et Atrophicus (“LS&A”)
Most common vulvar dermatosis/disease Chronic, inflammatory, autoimmune disease of the skin and mucosae, preferentially affecting the vulva Most common among post-menopausal women (up to age 90 yrs.); females predominately May affect children (from age 5 mos.) and young adults If untreated, can result in fusion around the clitoris (phimosis), atrophy and splitting of the vestibule, severe narrowing of the vaginal orifice, and, rarely, vulvar cancer (squamous cell carcinoma (“SCC”)) 20% of patients have at least one autoimmune disease (vitiligo, alopecia areata, or thyroid disease) SCC: Lifetime risk for women being followed < 5% HPV not found in majority of cancers arising in genitalia

18 LS&A Signs Atrophy White patches surrounded by erythematous or violaceous halos Lesions may coalesce into large atrophic erosions, making the skin smooth, wrinkled, soft, and white Excoriations or superficial fissures *characteristic signs that help distinguish LS&A * Atrophy: wrinkling of skin, parchment-like Fissures: secondary to scratching or intercourse

19 LS&A Signs Thickened areas
Vulvar and perineal involvement leads to “figure-eight” or “hourglass” shape around the anus Obliteration of architecture with loss of labia minora, clitoral hood, and urethral meatus Labial stenosis or fusion Thickened areas: LSC from scratching and rubbing

20 LS&A Note the figure-eight or hourglass configuration of the vulva and perineum

21 LS&A Complete obliteration of the vulvar architecture with loss of labia minora and clitoral hood in the third slide on the far-right

22 LS&A Symptoms – mean duration 99 months Intense pruritus Soreness
Burning Dyspareunia Symptoms: mean duration of 99 months if left untreated Intense pruritus: 96% of patients 15% of patients have vulvodynia symptoms at initial presentation Vulvodynia symptoms: burning and soreness instead of the typical pruritus associated with LS&A

23 LS&A Management Biopsy Clobetasol ointment = drug of choice
Effective in 90% of patients with reversal of epidermal atrophy Biopsy: for diagnostic confirmation or to r/o SCC Biopsy: white color or atrophic surface most fruitful areas Clobetasol: “super-potent,” group I category Clobetasol: apply BID for one month, then daily for two weeks, then PRN or change to lower-strength steroids for maintenance

24 LS&A Refractory/Severe Cases Cortisone injections
Oral retinoid therapy and topical tretinoin Maintenance with testosterone ointment and progesterone cream Surgery rarely indicated Retinoids: may be helpful in some cases Testosterone and progesterone: have less efficacy than bland emollient Surgery: rare indications, except for excision of dysplasia or correction of adhesions

25 Lichen Planus Chronic, inflammatory, autoimmune disease involving:
Glabrous skin (flexor surfaces of arms and legs) Hair-bearing skin and scalp Nails Mucous membranes of the oral cavity and vulva >70% of patients between the ages of 30 and 60 years Mucous membranes: 90% of such cases involve buccal mucosa; >50% gingiva; 40% tongue

26 Lichen Planus Vulvo-vaginal-gingival syndrome: involves vulva and vagina with gingivitis Oral lesions may precede or follow vulvovaginal lesions by months or years or may be simultaneous Vaginal mucosa involved in two-thirds of cases In one-third of cases, reticulate buccal involvement 10% have concurrent cutaneous lesions This syndrome is present in five percent of patients who present with yellow-sticky discharge

27 Lichen Planus Vulvovaginal signs
Rarely presents as the classic widespread shiny, violaceous, pruritic, flat-topped papules Erosive/ulcerative form most common presentation in mucous membranes Mucosal: white reticulate or lace-like changes (Wickham’s striae) or erosions Vulvar: erythematous erosions with narrow rim of white reticulation Vaginal: glazed erythema, easy friability Flat-topped papules occur on the flexor surfaces of upper extremities or on penile shaft

28 Lichen Planus Vulvovaginal symptoms
Pruritus on hair-bearing vulvar skin Severe burning pain in the vestibule or vagina Vestibule or vagina: dyspareunia (painful intercourse)

29 Lichen Planus May be subtle and mistaken for vulvodynia
Typically, morphology similar to vulvar lichen sclerosus Late scarring with loss of labia minora and clitoral hood Adhesion formation in upper part of vagina Total vaginal obliteration Erosive mucosal cases considered pre-malignant Vaginal obliteration occurs in long-standing, untreated cases Adhesions form in the absence of sexual activity or regular vaginal dilation Erosive cases are pre-malignant given their increased risk for SCC. Biopsy suspicious areas!

30 Lichen Planus Classic violaceous, flat-topped papules on the extremities

31 Lichen Planus Buccal mucosa with Wickham’s striae (white, lace-like pattern) White ulcerative lesion in second slide

32 Lichen Planus Erythematous erosions on gums and ulcer on the tongue

33 Lichen Planus Severely erythematous erosions with narrow rims of white, whereas we saw white patches surrounded by rims of erythema or violaceous halos in LS&A Total obliteration of vulvar architecture with absence of labia minora and clitoral hood in all 4 slides

34 Lichen Planus Fixed vulvar lesion that warrants a biopsy to rule out SCC

35 Lichen Planus Management
Biopsy: histological evaluation superior to direct immunofluorescence Topical and/or intravaginal steroid = first-line therapy Biopsy: Rim of white reticulation around eroded lesion most fruitful area For diagnostic confirmation and to rule out SCC if fixed erosive lesions Difficult condition to treat!

36 Lichen Planus Vulvar management
Clobetasol or another high-potency topical steroid ointment BID Long-term maintenance with low or mid-potency topical steroid ointment Calcineurin inhibitors: tacrolimus (Protopic) and pimecrolimus (Elidel) cream BID or suppository QHS Oral hydroxychloroquine (Plaquenil), cyclosporine, azathioprine (Imuran), etanercept (Enbrel), methotrexate Clobetasol: if marked erosions have occurred Protopic and Elidel: may burn, especially on raw areas Oral medications in severe cases Typical methotrexate dose: 5 to 10 mg PO or SC weekly

37 Lichen Planus Vaginal management Anusol hydrocortisone suppositories
Vaginal dilation Surgery Anusol suppositories: for pain relief and to keep vagina open by reducing inflammation. Use BID for 2 months, then daily for 2 months, then 1-3 times weekly for maintenance Vaginal dilation: to keep vagina open Surgery: done in severe cases to open the vestibule or uncover the clitoris from under adhesions

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