VULVAR DERM

IS IT?

• Anatomical
• Infectious
• Inflammatory
• Neoplastic

PRESENTATION:

• Pain
• Feels "different" - "bump"
• Looks "different"
• Women's descriptors are often inaccurate or vague
• Ask about other Derm dx

KNOW ANATOMY

• Hair bearing vs non-hair bearing skin
• Let pathologist know where biopsy is from

DERM

• Mons pubis: keratinized epithelium
• Vestibule: non-keratinized
• Clitorus: like erectile corpus cavernosum of penis
• Labia minora: sensory nerves
• Labia Majora: apocrine and sebaceous glands and hair follicles

URETHRA AND GLAND OPENINGS:

• Paraurethral glands: skene
• Major vestibular glands: bartholin
• Minor vestibular glands: mucus secreting
• Anogenital sweat glands: coiled, ductal - betwn labia

VULVAR LESIONS:

• Macules: not elevated
• Papules: solid, well defined, elevated
• Plaque: elevated nearly flat skin
• Verruca: warty
• Color: tan, brown, pink, red white

DIAGNOSIS:

• Description - color, placement, timing, pain, response to treatment
• Vulvar biopsy: punch or shave - in formalin or Michel for immunohistology

LICHENS

LICHEN SCLEROSIS:

• Presents age 1-80 - etiology unknown
• By exam: Dermal change, inflammation and epithelial thinning
• C/o pruritis

SYMPTOMS:

• Pruritis
• Scratching
• Dysuria,scarring, dyspareunia,apareunia
• May be asymptomatic

EXAM:

• Ivory white plaques with cellophane sheen
• From clitorus to gluteal cleft
• "Figure of eight" pattern
• Extra genital disease 15%
• Usually does not involve vagina

SECONDARY CHANGES:

• Excoriations
• Erosions
• Lichenification
• Loss of labia or vulvar structures
• Burying of clitorus
• 4% develop SCC

DIAGNOSIS

• Biopsy to confirm and r/o vitiligo, lichen simplex chronicles, lichen planus, circatricial pemphigus, SCC

TREATMENT

• Educate patient regarding chronicity
• Stop irritants - treat any concurrent infection
• Cool ventilated clothing
• Super potent steroids as a taper - clobetasol ointment 0.05% - many regimens
• Refer if not controlled - f/u frequently and do not hesitate to biopsy again
• There is no medical therapy that reverses scarring

LICHEN SIMPLEX CHRONICUS

CAUSES

• Infection: candida
• Dermatoses: atopic dermatitis, psoriasis, LS, LP, contact dermatitis
• Metabolic: FE deficiency anemia, diabetes
• Neoplasia: VIN
• Usually end of itch/scratch/itch cycle -

CAUSES

• Altered skin barrier d/t allergen, irritant or pathogen that results in compromised immunoregulatory process
• Stress makes it worse

CLINICAL PRESENTATION:

• Relentless pruritis - nocturnal
• Worse w/ heat, stress, menses
• Nothing helps
• Marked Lichenification and "rubbed raw"
• Excoriations and crusts

DIAGNOSIS:

• R/O other conditions
• May need biopsy depending on history
• Refer for allergen testing

TREATMENT

• Stop irritants
• Stop itch/scratch/itch cycle
• Nighttime sedation, white gloves, cold soaks
• Super potent steroid x 2 wks, then everyother day for 2 wks, then switch to mid dose topical steroid if still needed
• If excoriated start with Vaseline and anti fungal as steroid will burn,
• Look for combination of causes and follow-up

LICHEN PLANUS

CAUSES

• Altered cell mediated immunity in older women
• Effects skin and mucus membrane ( mouth, vulva, vagina, nails, scalp, esophagus, nose, conjunctiva, ears, bladder)
• Diagnosis can be missed in many of these places

CLINICAL PRESENTATION:

• Papulosquamous w/ white Lacey pattern, can look like LS if hypertrophic, with white scarring and destruction
• Erosive - desquamative, is vulvovag and gingival - vulva has a glazed erythema - painful, glossy, scarring at vestibule and minora, atrophy, purulent malodorous vaginal discharge
• Structural - Vagina can be obliterated

DIAGNOSIS

• Biopsy can be non specific - immunoflourescence can be done
• Check other sites - mouth
• Ask about pain, dyspareunia, depression/ anger, dysuria, dyspareunia
• R/O pemphigus, drug eruption, LS

TREATMENT

• Stop irritants, pain control, sedation, clobetasol ointment up to twice a day
• Intralesional steroid
• Intravaginal steroid - hydrocortisone acetate 40-80 mg qhs short term - if severe, hctz acetate 10% in compounded in replens type base (300-500 mg nightly x 14 then taper per response)

PROGNOSIS

• Course is uncertain
• 10% resolve
• 50 % asymptomatic
• 15% do poorly

ATROPHIC VULVOVAGINITIS

PROCESS:

CAUSES

• Decreased or absent estrogen D/T age, oophrectomy, medication, nursing

PRESENTATION

• History of estrogen deficiency
• C/O dryness, dyspareunia
• C/O dysuria, urgency, frequency d/t urethritis

DIAGNOSIS

• History
• Clinical exam reveals thinning pubic hair and smoothness/thinning of vulvar skin
• Pararbasal and inflammatory cells on wet prep

TREATMENT

• Topical estrogen
• Systemic estrogen
• This can complicate LS
• Protect tissue from daily irritation d/t hygiene practices, sexual activity, shaving

CONTACT DERMATITIS

DEFINITION

• Inflammation d/t external agent that acts as irritant or allergen
• Acute, subacute, chronic

PRIMARY IRRITANT CONTACT DERMATITIS

• Prolonged or repeated exposure to an irritant or caustic agent
• This is non-immunologic
• The response is immediate
• Over washing, drying cream based products
• Wetness chronically
• Co-exists w/ LS or LP

ALLERGIC CONTACT DERMATITIS

• Happens 1-2 days after contact w/ allergen
• Top offending agents are neomycin, benzocaine (vagisil), poison ivy, preservatives (parabens and propylene glycol), latex, paper products and perfumes

PRESENTATION

• Acute or chronic itching, burning, irritation
• Hx of exposure to irritant

DIAGNOSIS

• Blistered, erosive eruption if acute
• If chronic, excoriations with honey colored crusting or dryness, erythema and scaliness
• History of exposure to irritant or allergen
• Refer for allergy testing prn
• Bx may be necessary

TREATMENT

• Stop exposure to irritant or allergen
• Clobetasol 0.05% ointment bid x 5-7 days, then once a day x 1 week and stop
• Bland emollients, sedation at hs
• Consider prednisone taper
• Antibiotic if secondary infection

CROHN'S DISEASE

DESCRIPTION

• Autoimmune chronic inflammatory disorder of the GI tract from mouth to anus

PRESENTATION

• Abdm pain, diarrhea, cramping
• Anemia, weight loss, jt pain
• Sores or fistula in the rectal area and rarely vulva

VULVAR SX

• Fistula, abscesses, ulcers, perianal fistula
• Metastatic Crohn's Disease causes 90% of vulvar lesions - "knife cut" linear ulcers in anatomical folds - swelling of labia uni or bilateral -
• Perianal skin tags - these are a harbinger of Crohn's in 40-70% - they can look like hemorrhoids

THINK CROHN'S

• Vulvar swelling/edema d/t granule atoms infiltration and impaired lymphatic drainage.
• Ulcerations - knife cut or aphthous ulcers
• Suppurations - like hidradenitis
• Perianal swelling, fissures, skin tags

DIAGNOSIS

• Biopsy and GI work-up
• R/O TB, HIV, syphilis, immunosuppressive HSV, sarcoidosis, SCC, granule a inguinale

TREATMENT

• Systemic corticosteroids - combination therapy
• Locally - super potent steroids for short term (2 weeks) or calcineurin inhibitor tacrolimus (protopic) 0.1% ointment twice a day gif it doesn't burn
• Surgery is not curative, but can debunk lymphangiectasia or strictures

REMEMBER

• Follow-up - most of these conditions are chronic
• If no improvement or expected response to treatment - go back to assessment/diagnosis

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