1. Genital Dermatology Michael S. Policar, MD, MPH
Professor of Ob, Gyn, and Repro Sciences
Univ of California SF School of Medicine

2. Genital Skin Rashes Infectious Non-infectious Candidiasis Psoriasis
Tinea Cruris
Tinea Versicolor
Erythrasma
Non-infectious
Psoriasis
Seborrheic dermatitis
Intertrigo
Atopic dermatitis (eczema) 2

3. Vulvar Candidiasis Vulva will be very itchy; often excoriated
Presentation
Erythema + satellite lesions
Occasionally: thrush, LSC thickening if chronic
Diagnosis: skin scraping KOH, candidal culture
Treatment
Topical antifungal therapy daily for 7-14 days, or fluconazole 150 mg PO repeat in 3 days
Plus: TAC 0.1% or 0.5% ointment QD-BID

4. Vulvar Candidiasis

5. Tinea Cruris: “Jock Itch”
Asymmetric lesions on proximal inner thighs
Plaque rarely involves scrotum; not penile shaft
Well demarcated red plaques with accentuation of scale peripherally; no satellite lesions
Fungal folliculitis: papules, nodules or pustules within area of plaque
Treatment
Mild: topical azoles BID x10-14d, terbinafine
Severe: fluconazole 150 mg QW for 2-4 weeks
If inflammatory, add TAC 0.1% on 1st 3 days

7. Tinea Cruris: Rash and Pustules

8. Psoriasis
Background
Fast mitotic rate in skin triggers inflammatory response
30% have family history
New onset often preceded by strept infection (eg, throat)
Drugs may unmask in older patients: b-blockers, lithium, NSAIDS, terbinifine, gemfibrozil
Other triggers: stress, alcohol, cold
Findings
Red or pink irregular patches with elevated silver scales
Commonly involves elbows, knees, scalp, nails
May involve mons, vulva, crural folds

9. Psoriasis

10. Psoriasis: Treatment Decrease mitotic rate
Tar (LCD 5% in TAC 0.1% ointment)
Topical retinoids (Tazarac)
Decrease inflammation
Steroid ointment (e.g., TAC)
Calciprotriene (Dovonex); vitamin D derivative
Clobetasol- Dovonex combination
Tar preparations, topical steroids
Don’t use oral prednisone, as withdrawal may cause pustular psoriasis

11. Intertrigo Occlusion, rubbing of skin chafing, inflammation
If moist, often superinfection with candida or tinea
May lichenify to LSC
Findings
Dull red, shiny skin fold; if moist, white surface
Follows clothing lines; under breasts, pannus
No satellites; border not sharp
Treatment
Keep skin clean and dry; use cornstarch
Reduce friction with bland emollient
Treat secondary infection with topical imidazole

12. Vulvar “Eczema” Atopic dermatitis “Endogenous eczema”
Contact dermatitis: “Exogenous eczema”
Irritant contact dermatitis (ICD)
Allergic contact dermatitis ACD)
Lichen Simplex Chronicus
“End stage” eczema

13. Contact Dermatitis Irritant contact dermatitis (ICD)
Elicited in most people with a high enough dose
Rapid onset vulvar itching (hours-days)
Allergic contact dermatitis (ACD)
Delayed hypersensitivity
10-14 days after first exposure; 1-7 days after repeat exposure
Atopy, ICD, ACD can all present with
Itching, burning, swelling, redness
Small vesicles or bullae more likely with ACD

14. Contact Dermatitis Common contact irritants
Urine, feces, excessive sweating
Saliva (receptive oral sex)
Repetitive scratching, overwashing
Detergents, fabric softeners
Topical corticosteroids
Toilet paper dyes and perfumes
Hygiene pads (and liners), sprays, douches
Lubricants, including condoms

15. Contact Dermatitis Symmetric Raised, bright red, intense itching
Extension to areas of irritant contact

16. Contact Dermatitis Common contact allergens Poison oak, poison ivy
Topical antibiotics, esp neomycin, bacitracin
Spermicides
Latex (condoms, diaphragms)
Vehicles of topical meds: propylene glycol
Lidocaine, benzocaine
Fragrances

17. Contact Dermatitis: Treatment
Exclude contact with possible irritants
Restore skin barrier with sitz baths, compresses
After hydration, apply a bland emollient
White petrolatum, mineral oil, olive oil
Short term mild-moderate potency steroids
TAC 0.1% BID x10-14 days (or clobetasol 0.05%)
Fluconazole 150 mg PO weekly
Cold packs: gel packs, peas in a “zip-lock” bag
Doxypin or hydroxyzine (10-75 mg PO) at 6 pm
If recurrent, refer for patch testing

18. Why Not Steroid-Antifungal Combination Drugs?
Which products should be avoided?
Lotrisone
Clotrimazole and Betamethasone 0.5%
Mycolog II
Nystatin and Triamconolone acetonide)
Why avoid them?
Inflammation usually clears up before fungal infection
Steroid overshoot  skin atrophy
Local immunosuppression (from steroid) may blunt antifungal effect

19. Genital Skin Itching Infections Candidiasis Tinea cruris Dermatitis
Dermatoses
Lichen sclerosus
Lichen simplex chronicus (LSC)
LS + LSC
Neoplasms
Paget’s Disease (women)
Vulvar Intraepithelial neoplasia (VIN)
Penile Intraepithelial neoplasia (PIN)
Infections
Candidiasis
Tinea cruris
Dermatitis
Psoriasis
Seborrheic dermatitis
Eczema

20. ISSVD 1987: Vulvar Dermatoses
Type
ISSVD Term
Old Terms
Atrophic
Lichen sclerosus
Lichen sclerosus et atrophicus
Kraurosis vulvae
Hyper-plastic
Squamous cell hyperplasia
Hyperplastic dystrophy
Neurodermatitis
Lichen simplex chronicus
Systemic
Other dermatoses
Lichen planus
Psoriasis
Pre-malignant
VIN
Hyperplasic dystrophy/atypia
Bowen’s disease
Bowenoid papulosis
Vulvar CIS
ISSVD: International Society for the Study of Vulvar Disease

21. 2006 ISSVD Classification of Vulvar Dermatoses
No consensus agreement on a system based upon clinical morphology, path physiology, or etiology
Include only non-Neoplastic, non-infectious entities
Agreed upon a microscopic morphology based system
Rationale of ISSVD Committee
Clinical diagnosis  no classification needed
Unclear clinical diagnosis  seek biopsy diagnosis
Unclear biopsy diagnosis  seek clinic pathologic correlation

22. 2006 ISSVD Classification of Vulvar Dermatoses
Pathologic pattern
Clinical Corrrelates
Spongiotic
Atopic dermatitis, allergic contact dermatitis, irritant contact dermatitis
Acanthotic
Psoriasis, LSC (primary or superimposed), (VIN)
Lichenoid
Lichen sclerosus, lichen planus
Dermal homogenization
Lichen sclerosus
Vesicolobullous
Pemphigoid, linear IgA disease
Acantholytic
Hailey-Hailey disease, Darier disease, papular genitocrural acantholysis
Granulomatous
Crohn disease
Vasculopathic
Apthous ulcers, Behcet disease, plasma c. vulvitis

23. Lichen Sclerosus: Natural History
Most common vulvar dermatosis
Prevalence: 1.7% in a general GYN practice
Cause: autoimmune condition
Bimodal age distribution: older women and children, but may be present at any age
Chronic, progressive, lifelong condition

24. Lichen Sclerosus: Natural History
Most common in Caucasian women
Can affect non-vulvar areas
Part (or all) of lesion can progress to VIN, differentiated type
Predisposition to vulvar squamous cell carcinoma
1-5% lifetime risk (vs. < 0.01% without LS)
LS in 30-40% women with vulvar squamous cancers

25. Lichen Sclerosus: Findings
Symptoms
Most commoly, itching
Often irritation, burning, dyspareunia, tearing
58% of newly-diagnosed patients are asymptomatic
Signs
Thin white “parchment paper” epithelium
Fissures, ulcers, bruises, or submucosal hemorrhage
Changes in vulvar architecture: loss of labia minora, fusion of labia, phimosis of clitoral hood
Depigmentation (white) or hyperpigmentation in “keyhole” distribution: vulva and anus
Introital stenosis 25

26. “Early” Lichen Sclerosus Hyperpigmentation due to scarring
Loss of labia minora

27. Lichen Sclerosus
Thin white
epithelium
Fissures

28. “Late” Lichen Sclerosus
Agglutination of clitoral hood
Loss of labia minora
Introital narrowing
Parchment paper epithelium

29. 68 year old woman with urinary obstruction
Labial agglutination over urethral meatus

30. Lichen Sclerosus: Treatment
Biopsy mandatory for diagnosis
Preferred treatment
Clobetasol 0.05% ointment QD x4 weeks, then QOD x4 weeks, then twice-weekly for 4 weeks
Taper to med potency steroid (or clobetasol) 2-4 times per month for life
Explain “titration” regimen to patient, including management of flares and recurrent symptoms
30 gm tube of ultrapotent steroid lasts 3-6 mo
Monitor every 3 months twice, then annually 30

31. Lichen Sclerosus: Treatment
Second line therapy
Pimecrolimus, tacrolimus
Retinoids, potassium para-aminobenzoate
Testosterone (and estrogen or progesterone) ointment or cream no longer recommended
Explain chronicity and need for life-long treatment
Adjunctive therapy: anti-pruritic therapy
Antihistamines, especially at bedtime
Doxypin, at bedtime or topically
If not effective: amitriptyline, desipramine PO
Perineoplasty may help dyspareunia, fissuring 31

32. Lichen Simplex Chronicus = Squamous Cell Hyperplasia
Cause: an irritant initiates a “scratch-itch” cycle
LSC classified as
Primary (idiopathic)
Secondary (superimposed upon lichen sclerosus, candida vulvitis; vulvar contact dermatitis)
Presentation: always itching; burning, pain, and tenderness
Thickened leathery red (white if moisture) raised lesion
In absence of atypia, no malignant potential
If atypia present , classified as VIN 32

33. Lichen Simplex Chronicus

34. L. Simplex Chronicus: Treatment
Removal of irritants or allergens
Treatment
Triamcinolone acetonide (TAC) 0.1% ointment BID x4-6 weeks, then QD
Other moderate strength steroid ointments
Intralesional TAC once every 3-6 months
Anti-pruritics
Hydroxyzine (Atarax) mg QHS
Doxepin mg PO QHS
Doxepin (Zonalon) 5% cream; start QD, work up

35. Lichen Sclerosus + LSC “Mixed dystrophy” deleted in 1987 ISSVD System
15% all vulvar dermatoses
LS is irritant; scratching  LSC
Consider: LS with plaque, VIN, squamous cell cancer of vulva
Treatment
Clobetasol x12 weeks, then steroid maintenance
Stop the itch!!

36. Epidermoid Cysts Usually multiple, but can be single
Contain sebaceous material; liquid or dried
Usually have yellow or cream color
May have “BB shot” or “dried bean” texture
No treatment, unless infected

37. Epidermoid Cyst
Scrotum
STD Atlas, 1997

38. Vestibular Cysts 38

39. Hidradenoma Peculiar to Caucasian women Sweat gland origin
Grows in interlabial sulcus
0.5-2 cm diameter; solid
Initially non tender, but can develop an umbilicated center that later ulcerates
Benign tumor, although path closely mimics adenocarcinoma
Treatment: shells out easily with excision 39

40. Genital Skin: Large Tumors
Bartholin duct cyst
Bartholin duct cancer
Vulvar carcinoma (squamous, basal cell)
Hydrocoele (cyst) of Canal of Nuck
Vulvar hematoma
Vulvar edema
Benign solid tumors
Lipoma, leiomyoma, fibroma

41. Bartholin Duct (BD) and Gland (BG)
Bartholin duct and gland at 5, 7 o’clock cephalad (deep) to hymeneal ring
Makes serous secretion to “lubricate” introitus
If BD is transected or blocked, fluid accumulates
Non-infected: BD cyst
Infected: BD abcess or BG cellulitis
All surgical treatments are designed to drain fluid and create a new duct

42. Bartholin Gland: Infectious Conditions
Bartholin gland cellulitis
Painful red induration of lateral perineum at 5 or 7 o’clock, but no palpable abscess
Most commonly due to skin streptococcus
Treatment: oral cephalosporin, moist heat
Will either resolve or point as abcess
Admit immunecompromised women (especially diabetics) for IV antibiotics and close observation
May develop necrotizing fasciitis

43. Bartholin Duct: Infectious Conditions
Bartholin duct abscess
Usually due to Staph, but may contain anaerobes
Fluctulent painful abscess; if uncertain, needle aspiration will confirm pus
Treatment: I&D, then insert Word catheter for 6 weeks
Antibiotics usually not needed, unless
Cellulitis (cephalosporin)
Anaerobic smell with drainage (metronidazole)

44. BD Abscess: I&D Inject 3 cc. lidocaine
Retract abscess laterally to select incision site… inside the hymeneal ring if possible
Inject 3 cc. lidocaine
1 cm incision with #15 blade perpendicular to abscess
Lyse loculations with clamp
Irrigate cavity with saline
Insert Word catheter; inflate until snug fit in abscess cavity
Tuck nipple into vagina

45. Word Catheter: Correct Position

46. Bartholin Duct: Non Infectious
Bartholin duct cyst
Nontender cystic mass
Treat only if symptomatic or recurrent
Tx: marsupialize or insert Word catheter x 6 weeks
Bartholin duct carcinoma
Most common in women over 40
Can be adenoca, transitional cell, or squamous cell
Firm non-tender mass in region of Bartholin gland
Suspect if recurrent BD cyst or abcess with firm base after drainage

47. Management of Vulvar Hematoma
Almost all are due to straddle injuries
Initial management
Pressure
Ice packs
Watchful waiting
Complex management
Use if extreme pain or failure of conservative mgt
Incise inside hymeneal ring, evacuate clots
Pack with strip gauze, sitzbaths

48. Genital Skin: White Lesions
Lichen sclerosus
Lichen simplex chronicus
LS+LSC
Tinea versicolor
Intertrigo
VIN/ PIN
Depigmentation disorders
Vitiligo
Partial albinism
Leukoderma

49. Vulvar Intraepithelial Neoplasia (VIN): Prior to 2004
Grading of VIN-1 through VIN-3, based upon degree of epithelial involvement
The mnemonic of the 4 P’s
Papule formation: raised lesion (erosion also possible, but much less common)
Pruritic: itching is prominent
“Patriotic”: red, white, or blue (hyperpigmented)
Parakeratosis on microscopy 49

50. ISSVD 2004: Squamous VIN
Since VIN 1 is not a cancer precursor, abandon use of the term
Instead, use “condyloma” or “flat wart”
Combine VIN-2 and VIN-3 into single “VIN” diagnosis
Two distinct variants of VIN
VIN, usual type
Warty type
Basaloid type
Mixed warty-basaloid
VIN, differentiated (simplex) type

51. ISSVD 2004:VIN, Usual Type Includes (old) VIN -2 or -3
Usually HPV-related (mainly type 16)
More common in younger women (30s-40s)
Often asymptomatic
Lesions usually elevated and have a rough surface, although flat lesions can be seen
Often multifocal (incl periurethral and perianal areas) and multicentric in 50%
Strongly associated with cigarette smoking
Regression is less likely and progression to invasion more likely with the basaloid type

52. VIN, Differentiated (Simplex) Type
Includes (old) VIN 3 only
Usually in older women with LS, LSC, or LP
Not HPV related
Less common than usual type
Patients usually are symptomatic, with a long history of pruritus and burning
Findings
Red, pink, or white papule; rough or eroded surfaces
A persistent, non-healing ulcer
More likely to progress to SCC of vulva than warty- basaloid type

53. White VIN 53

54. VIN, usual (basaloid) type

56. VIN: warty-basaloid type

57. Vulvar Intraepithelial Neoplasia
Precursor to vulvar cancer, but low “hit rate”
Greater risk of invasion if immunocompromised (steroids, HIV), >40 years old, previous lower genital tract neoplasia
Treatment
Wide local excision (few lesions), laser ablation
Topical agents: 5FU cream, imiquimod
Skinning or simple vulvectomy
Recurrence is common (48% at 15 years)
Smoking cessation may reduce recurrence rate 57

58. Treatment of VIN with Imiquimod
Treatment with 5% imiquimod BIW x16-20 weeks
Study n
IMQ response
Control response
Comment
vanSeters 2008 52
81% 0%
Progression to cancer in 6% pts over 12 mo
Mathiesen 2007 21
10%
67% ↓ dosing 2o to AE Le
2007 33
77%
No controls mo
- IMQ: %
- Surgery: 53%
Rosen 49
86%

59. Leukoderma Most commonly seen after herpetic and syphlytic ulcers
Lack of pigmentation in scarred area from trauma or ulceration
Most commonly seen after herpetic and syphlytic ulcers
No family history, as with albinism or vitiligo
No biopsy or treatment necessary

60. Vitiligo
Congenital absence of pigment

61. Genital Skin: Dark Lesions (% are in women only)
36% Lentigo, benign genital melanosis
22% VIN
21% Nevi (mole)
10% Reactive hyperpigmentation (scarring)
5% Seborrheic keratosis
2% Malignant melanoma
1% Basal cell or squamous cell carcinoma 61

62. Vulvar Intraepithelial Neoplasia62

63. Hyperpigmented
VIN 63

64. Lichen Sclerosus with Scarring64

65. Vulvar Melanoma: ABCDE Rule
A: Asymmetry
B: Border Irregularities
C: Color black or multicolored
D: Diameter larger than 6 mm
E: Evolution
Any change in mole should arouse suspicion
Biopsy mandatory when melanoma is a possibility 65

66. Atypical Nevus Early Melanoma66

67. Nodular Melanoma Metastatic Melanoma67

68. Indications for Vulvar Biopsy
Papular or exophtic lesions, except obvious condylomata
Thickened lesions (biopsy thickest region) to differentiate VIN vs. LSC
Hyperpigmented lesions (biopsy darkest area), unless obvious nevus or lentigo
Ulcerative lesions (biopsy at edge), unless obvious herpes, syphilis or chancroid
Lesions that do not respond or worsen during treatment
In summary: biopsy whenever diagnosis is uncertain

69. Tips for Vulvar Biopsies
Where to biopsy
Homogeneous : one biopsy in center of lesion
Heterogeneous: biopsy each different lesions
Skin local anesthesia
Most lesions will require ½ cc. lidocaine or less
Epinephrine will delay onset, but longer duration
Use smallest, sharpest needle: insulin syringe
Inject anesthetic s-l-o-w-l-y
Alternative: 4% liposomal lidocaine (30 minutes) or EMLA (60 minutes) pre-op 69

70. Stretch skin; twist 3 or 4 mm Keyes punch back-and-forth until it “gives” into fat layer70

71. Tips for Vulvar Biopsies
Lift circle with forceps or needle; snip base
Hemostasis with AgNO3 stick or Monsel’s solution
Silver nitrate will not cause a tattoo
Suturing the vulva is almost never necessary
Separate pathology container for each area biopsied 71