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Vulvar Conditions
February 18, 2016
Lisa Abel MSN, WHNP-BC, ARNP
Acute vulvar conditions
• Contact dermatitis
• Infections
- fungal
- viral (HPV, HSV, molluscum)
- bacterial including MRSA
- parasites
- Trichomoniasis
Chronic vulvar conditions
Dermatoses
• Lichen sclerosus
• Lichen planus
• Lichen simplex chronicus
Chronic Vulvar Conditions (con’t)
Infections
• HPV (VIN or condyloma)
• Fungal (recurrent or chronic yeast)
Allergic contact dermatitis
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
Vulvar Irritants
• Soaps/detergents, wipes, lotions, perfumes
• Panty liners/pads, sanitary products
• Sweat , semen, urine, feces
• Constrictive clothing
• Vaginal secretions
• Douches
Vulvar candidiasis
Candida
• Symptoms: Itching, burning, swelling and abnormal
discharge
Physical findings
• Erythematous, well demarcated patches
• Hyphae, buds and WBCs on wet prep
Treatment
• Clotrimazole, Miconazole, Diflucan, Terconazole
• Recurrent infections – Boric acid 600 mg per vagina
for 2 weeks; then once a week as a maintenance dose
Contact dermatitis
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
Treatment
• Remove agent causing symptoms
• Treat secondary infections
• Topical steroid or oral if severe reaction
• Oral antihistamines
Psoriasis
Psoriasis
Symptoms – Itching, burning, erythematous (varies
in intensity)
Physical findings – erythematous, silvery-white
scales, well-demarcated, slightly raised plaques
Treatment – Topical steroids, refer out
Lichen Sclerosus (LS)
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
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
Diagnosis/Work up
• Biopsy is best – okay to start treatment before
definitive diagnosis
• Rule out other causes such as yeast, HSV or
comorbidities
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
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
Lichen Planus (LP)
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)
Symptoms
• Burning, dyspareunia, pruritus, vaginal
discharge
• Involves vestibule as well as vagina
• May also have cutaneous and oral lesions
(65 %)
Zendell, 2015
Physical Findings
• Erosions that are deep red, well demarcated,
erythematous in posterior vestibule
• White lacy striae on mucosa
• Possible lesions in mouth
Diagnosis
•Biopsy of nonerosive area
•Viral culture (HSV)
•Wet prep – many WBCs
Treatment:
Often best to refer
out or co-manage
with specialist
• 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
Lichen Simplex
Chronicus (LSC)
LSC
• A severe chronic form of contact dermatitis
• Lichenfication of the skin
• Skin becomes thick and leathery due to
constant trauma
Symptoms
• Intense itching
• May have excoriation and secondary infection
• Skin can be hypopigmented or hyperpigmented
Diagnosis
• Symptoms and clinical signs
• Biopsy
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
Vulvodynia
Vulvodynia
• 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)
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
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.
Treatment Options
• Topical lidocaine
• Topical Gabapentin
• Amitriptyline/baclofen cream
• Estrogen cream
• Tricyclic antidepressants (TCA)
• Corticosteroid injections
• Psychotherapy
• Physical therapy (PT)
Skin care is very important in the
management of vulvar conditions
- Lukewarm water
- Avoid triggers if know
- No soaps, scented lotions
- Consider options for providing a skin
barrier
Vulvar Squamous
Intraepithelial Lesions
(SILs)
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)
Symptoms
• Lesions vary greatly in color – brown, red, white,
gray
• Pruritus in 60 % (Nelson, 2015)
• May be asymptomatic
Diagnosis
• Biopsy
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)
What are the
diagnoses?
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?
Source: medical.theclinic.com (downloaded 1/30/16)
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)
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?
Benign Vulvar Dermatoses.
Rodriguez, Maria; MD, MPH; Leclair, Catherine
Obstetrical & Gynecological Survey. 67(1):55-63, January
2012.
DOI: 10.1097/OGX.0b013e318240cc72
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
2
Fig. 3 . Contact dermatitis. A
color version of this figure is
available online at
www.ObGynSurvey.com.
Benign Vulvar Dermatoses.
Rodriguez, Maria; MD, MPH; Leclair, Catherine
Obstetrical & Gynecological Survey. 67(1):55-63, January
2012.
DOI: 10.1097/OGX.0b013e318240cc72
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
2
Contact Dermatitis
Vulvovaginal candidiasis
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?
Source: med.cmu.ac.th (downloaded 1/30/16)
Classic lichen simplex chronicus.
A color version of this figure is
available online at
www.ObGynSurvey.com
.
Benign Vulvar Dermatoses.
Rodriguez, Maria; MD, MPH; Leclair, Catherine
Obstetrical & Gynecological Survey. 67(1):55-63, January
2012.
DOI: 10.1097/OGX.0b013e318240cc72
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
2
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?
Benign Vulvar Dermatoses.
Rodriguez, Maria; MD, MPH; Leclair,
Catherine
Obstetrical & Gynecological Survey.
67(1):55-63, January 2012.
DOI: 10.1097/OGX.0b013e318240cc72
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
2
Fig. 9
Fig. 9 . Vulvar intraepithelial
neoplasia (figure courtesy of Dr.
Hope Heffner). A color version of
this figure is available online at
www.ObGynSurvey.com.
Benign Vulvar Dermatoses.
Rodriguez, Maria; MD, MPH; Leclair, Catherine
Obstetrical & Gynecological Survey. 67(1):55-63, January
2012.
DOI: 10.1097/OGX.0b013e318240cc72
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
2
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?
Benign Vulvar Dermatoses.
Rodriguez, Maria; MD, MPH; Leclair, Catherine
Obstetrical & Gynecological Survey. 67(1):55-63, January
2012.
DOI: 10.1097/OGX.0b013e318240cc72
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
2
Fig. 6
Fig. 6 . Lichen sclerosus. A color
version of this figure is available
online at www.ObGynSurvey.com.
Benign Vulvar Dermatoses.
Rodriguez, Maria; MD, MPH; Leclair, Catherine
Obstetrical & Gynecological Survey. 67(1):55-63, January
2012.
DOI: 10.1097/OGX.0b013e318240cc72
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
2
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?
Other vulvar conditions
Angiokeratoma
Folliculitis from shaving
Source: http://production.australiandoctor.com
Thank you
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%
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;28:10001012.
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.