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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 53 - Diagnosis and Management of Vulvar Skin Disorders

"All matter originates and exists only by virtue of a force which brings the particles of the atom to vibration. I must assume behind this force the existence of a conscious and intelligent mind. This mind is the matrix of all matter." - Max Planck


2017 Chardonnay from Eighteen Eighty Three


PB#224 - Published July 2020


Five Pearls

1. A systematic approach is required to evaluate and treat vulvar pain and pruritis.

2. In premenopausal women: contact dermatitis is most likely culprit.

3. In postmenopausal women: Genitourinary syndrome of menopause is your most likely culprit, and this relates to the natural increase in pH associated with the hypoestrogenic state.

4. Lichen sclerosus is best diagnosed through biopsy, because if left-untreated it can develop into vulvar squamous cell carcinoma

5. Topical steroids w/ topical anti-histaminic agents are the mainstay of therapy for inflammatory vulvar disorders.


Four major types of vulvar skin disorders

Contact dermatitis

- can present at any age

- chronic itching and burning

- the culprit for half of women who present with chronic vulvovaginal pruritis

- caused an irritant to the skin, including: moisture, sweat, urine, cleansers, fragrances, lubes, antibiotics, local anesthetics and other topical products

- can also be triggered by additives to sanitary or incontinence pads or bath water/tubs

- allergic contact dermatitis is a type IV delayed hypersensitivity reaction (also caused by a topical products or things like condoms)

Lichen simplex chronicus

- usually presents in middle to late adult life

- chronic, non-scarring inflammatory disease

- intense, unrelenting itching and scratching, especially in the evening

- the culprit for 10-35% of women who present with chronic vulvovaginal pruritis

- also a secondary complication of any pruritic vulvar condition (including environmental factors like heat, sweating, contact dermatitis, candidiasis, and lichen sclerosus)

- correlates w/ personal or immediate family history of seasonal allergies, asthma, or childhood eczema


Lichen sclerosus

- chronic scarring disorder

- usually affects the anogenital skin in postmenopausal women and prepubertal girls (both low estrogen!)

- prevalence is unknown because it's often asymptomatic and goes unrecognized, but estimates are 1:32 nursing home residents and 1:60 in general postmenopausal population

- etiology is unclear, but AI processes and genetic factors are thought to play a role

- left untreated can develop into squamous cell carcinoma (2-5% risk)


Lichen planus

- scarring inflammatory disorder of the vulvovaginal area that can also affect the skin and oral mucosa (70% have oral involvement)

- affects perimenopausal and menopausal women

- etiology is unknown, but thought to be associated w/ dysfunctional cell-mediated immune system

- concomitant AI disorders are seen in 1/3 of patients

- <1% estimated prevalence




So you are seeing a new patient for vulvar itching...where to start?

- comprehensive medical history and ROS, silly

- ask about onset, duration, location, relationship to menstrual cycle, and any possible precipitating factors

- if their primary complaint is pain, evaluate for inflammatory conditions, neoplasia, infections, or neurological disorders

- if other causes are ruled out, she may have run-of-the-mill vulvodynia

- it's not uncommon to have both a pain disorder and a specific skin disorder (e.g. lichen sclerosus)

- physical exam: gentle, systematic approach; specific skin disorders are often associated with changes in skin, color, or architecture

- look for fissures, erosions, excoriations, ulcers, loss of vaginal rugae, clitoral hood retraction, and other lesions


Credit to: PMID: 28778641

- speculum exam may be appropriate as tolerated to look for erythema, erosion, ulceration, synechiae, or discharge of the vagina and cervix

- pH and Whiff test can be helpful in evaluating any discharge or for the overall pH of the vulvovaginal region

- consider culturing and testing for infection when appropriate


Pearl: Remember that vulvovaginal pH increase (becomes more alkaline) with transition to postmenopausal state due to loss of estrogen and resulting loss of acid-producing lactobacilli! The hypoestrogenic state leads to changes in the architecture of the vulva, which can in and of itself be very itchy and bothersome. This condition is called genitourinary syndrome of menopause.


When should I perform a biopsy?

- lesion is atypical: new pigmentation, indurated, affixed to underlying tissue, bleeding, or ulcerated

- concern for malignancy

- if patient is immunocompromised (e.g. HIV) --> higher risk of neoplasia compared to general population

- unclear diagnosis

- poor response to or worsening with standard therapy


How do I biopsy?

- small lesions can usually be completely excised using punch method

- use a shave technique or a variation calls the snip biopsy

- local anesthetic can be super helpful!




Contact dermatitis: diagnosis and treatment

Diagnosis

- clinical history without evidence of other disorders on exam

Treatment

- removal of suspected allergen or irritant

- vulvar care such as patting the area dry after bathing (versus rubbing), cleaning the vulva with water alone, rinsing the vulva after urination, and using adequate lube during intercourse

- topical steroid or oral antipruritic PRN

- topical steroid for be used once or twice daily depending on the potency, severity, and patient preference

- ointments are generally alcohol-free (compared to creams, lotions, and gels), so they won't dry out the skin

- some oral antihistamines are sedating (hydroxyzine) while others are non-sedating (loratadine, cetirizine)

- avoid topical antihistamines because they are famous for causing allergic contact dermatitis

- tricyclic antidepressants and SSRIs are 2nd line


Lichen simplex chronicus: diagnosis and treatment


Diagnosis

- clinical history and the appearance of erythematous, scaling, lichenified plaques; you may also see excoriations and erosions from scratching; over the long term, the skin may begin to appear thickened and leathery

- might as well snag a fungal culture to look for concurrent vulvovaginal candida infection

Treatment

- same as for contact dermatitis only you'll likely need a high potency steroid

- f/u 4 weeks after initiation of a high potency steroid

Lichen sclerosus: diagnosis and treatment


Diagnosis

- clinical history (dyspareunia, tearing, among the other stuff)

- porcelain-white plaques and papules w/ areas of ecchymosis

- skin famously appears white and crinkled like cigarette paper

- the vaginal epithelium is generally spared, but the vulvovaginal epithelial junction is often involved, sometimes causing a narrowing of the introitus

- you may also see phimosis of the clitoral hood, fissures, or fusion of the labia minora

- biopsy is recommended given many other conditions can mimic lichen sclerosus


Treatment

- may be prolonged or indefinite

- initial treatment: medium- and high-potency steroid

- sample regimen: clobetasol 0.05% qHS for 4 weeks, alternate nights for 4 weeks, then twice weekly for 4 weeks

- reassess after 3 months of treatment, then again at 3 and 6 months for resolution (may require more frequent visits if poorly controlled)

- re-biopsy may be necessary if new, funky lesions appear during or after treatment

- long-term maintenance therapy through weekly topical steroids is recommended (low likelihood of forming striae, atrophy, or secondary infection on treated skin even over the long-haul)

- if treatment doesn't work, best to get a biopsy if you haven't already (are you treated the right condition?)

- consider superimposed secondary infection or concurrent lichen simplex chronicus or contact dermatitis

- if you've run the gamut of high dose topical steroids, you may consider intra-lesion steroid injections

- worst case scenario? you can try topical calcineurin inhibitors (e.g. tacrolimus) can be considered; no long-term safety data on these agents

- refer to a vulvar dermatoses specialist may be required for the most severe or refractory cases

Lichen planus: diagnosis and treatment


Diagnosed

- same as the others only this one is commonly associated w/ discharge

- look for lacy striated skin; you may also see dusky, pink papules

- hypertrophic subtype: can appear of thickened white, warty papules

- erosive subtype: deep, painful, erythematous lesion often seen in posterior vestibule or labia minora

- lesions are friable and, over time, may adhere together eventually resulting in synechiae or complete obliteration of the vagina

- oral involvement is common, so check their mouth

- microscopy of discharge will reveal inflammatory cells along with immature parabasal cells and basal cells

- pH usually increased to 5-6

- biopsy may be indicated (see above for indications)

- may mimic pemphigoid disorders and pemphigus vulgaris


Treatment

- treat with twice daily topical steroid and reevaluate in 2-3 months

- topical calcineurin an be considered in the worst cases

- also should recommend vulvar care per usual

- refer to a periodontist if oral lesions present

- if vaginal epithelium is involved, recommend addition of intravaginal of hydrocortisone 25 mg BID w/ subsequent taper after symptoms resolve

- use vaginal dilators w/ intravaginal steroid therapy to help prevent scarring and obliteration of the vagina

- no evidence to support the use of systemic agents




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