Vulval Skin Disorders

1. Vulval Skin Disorders Max Brinsmead PhD FRANZCOG April 2011

2. Incidence, Types and Presentation • Affects 1:5 women in a lifetime • Lichen sclerosis & atrophicus – 25% • Lichen planus • Associated with other skin disease • Lichen simplex with dermatitis • Psoriasis • Premalignant • Vulval warts • Vulval intraepithelial neoplasia (VIN) • Candidiasis • Presents with pruritis and or pain

3. Taking a History • Routine gynaecological questions • Ask about urinary and bowel incontinence • Any other skin problems? • Any other disorders • Especially auto immune disease • Immune deficiency • Drugs and OTC preparations • Systemic • Local applications • Smoking & other • Family History • Atopy i.e. eczema and allergies, asthma etc. • Autoimmune disorders

4. Common Vulval Irritants • Excessive drying – use of talc etc. • Topically applied deodorants, antiseptics , douches etc. • Soaps and detergents • Sanitary pads, incontinence pads etc. • Lubricants and rubber (condoms) • Dyes • Close fitting clothes especially synthetics • Itch and scratching, towel drying, nail polish etc.

5. Examination • Adequate exposure • Good light • Magnification (colposcopy) not mandatory • Lower genital tract, Pap and colposcopy only for suspected VIN • Examine mouth, scalp, nails and all skin • Especially elbows and knees

6. Investigations • Exclude diabetes, hypothyroidism & iron deficiency • Gram stain and culture for Candida • Tests for STDs when clinically indicated • Autoimmune tests for a diagnosis of lichen sclerosis or planus • Biopsy • Only for suspected VIN • Or failure to respond to treatment • Can be done with LA as an outpatient

7. Lichen sclerosis & atrophicus • More common in the postmenopausal • But it does not respond to hormones • Thickened, white skin = hyperkeratosis • Causes intense pruritis • Worse at night • Scratching leads to secondary skin damage • Other skin becomes atrophic causing stenosis, adhesions and scarring

8. Lichen sclerosis & atrophicus

9. Lichen planus • Can affect any skin but most commonly oral mucosa • Typically polygonal violaceous plaques & papules • Often ulcerated and painful on the vulva

10. Lichen simplex = Neurodermatitis • Erythema and swelling • Scratch injury • Lichenification but no atrophy

11. Vulval Intraepithelial Neoplasia • Comes in two forms: • Warty excrescences • Commonly women <55 years • Associated with HPV – typically Type 16 • Differentiated VIN • Commonly women >55 • About 5% of lichen sclerosis will have this as well • Progresses more quickly to squamous carcinoma

12. Differential Diagnosis • Not all that important because the treatment for lichen sclerosis, planus and simplex with dermatitis is the same… • Potent topical corticosteroids • Biopsy anything that is clinically suspicious… • Has a raised edge • Abnormal vessels visible • Hard to gentle palpation • Or does not respond to treatment

13. Treatment • General measures to protect vulval skin • Potent fluorinated corticosteroid applications • Advantan = Methylprednisone • Diprosone = Betamethasone propionate • Elocon = Mometasone • Clobetasol = the most potent available • Use ointment rather than cream • Prolonged use results in skin atrophy • Daily for a month • 2nd daily for a month • Twice weekly for a month • Weekly for a month • Then as required • A 30g tube should last 3 months

14. General Measures to Protect Vulval Skin • Shower rather than bath • Use neutral soap substitutes • Hands only – no flannels or sponges • Pat or blow dry – no towelling • Use water with inert emollient cream other times • Wear loose fitting silk or cotton • Remove underwaer whenever possible • Wash clothes in neutral soap or gel - avoid all biological (enzymes) detergents and bleaches • Avoid dyes – in dark clothes & toilet paper • Minimal use of vulval pads of any type • Avoid all OTC applications • Keep aqueous cream in the fridge for soothing

15. Treatment (2) • About 10% fail to respond to topical corticosteroids • Topical Tacrolimus, an immunodifier , is a second line treatment for lichen sclerosis • Usually occurs with supervision from a Dermatlogy Clinic • Because there is a small risk of malignant transformation • Warts can be treated with Imiquimod cream = Aldara • 15 – 80% response rate • Compliance is an issue • Some 15% of VIN will have unrecognised invasive disease disclosed by excision biopsy

16. Follow Up • 40 – 60% 0f VIN progresses to Ca over 8+ years • Can be reduced to <5% by adequate biopsy excision • And reconstructive surgery when required • Follow up with colposcopy and cytology • And encourage self examination • Relapse of lichen sclerosis is common • Up to 80% within 4 years • But it has a much smaller potential for malignant change so follow up can be with a GP

17. Some Rare Vulval Lesions • Beçhet’s Disease • Recurrent oral and genital ulcers • Extramammary Paget’s Disease • Florid eczema and lichenification • Biopsy to exclude underlying adenoCa & look for primary in breasts, GI or urinary tracts • Zoon’s Vulvitis • Infiltrated with plasma cells and haemosiderin • Vulval Crohn’s Disease • Granulomas, abscess, ulcers and sinuses • Usually associated with small gut pathology

18. Recurrent Candidiasis • First confirm the diagnosis • Requires swab and culture >48 hrs after fungicidal application • Exclude imidazole-resistant organisms • This requires the use of borates for treatment • Exclude diabetes • Avoid broad spectrum antibiotics • Recolonization of vaginal Acidophilus with natural yoghurt? • Use systemic antifungal = Oral Diflucan • Most respond to recurrent and intermittent Imidazole • Use Canesten PRN • There are many “natural therapies” • Try Tea Tree oil (Melaleucaalterniflora) 2 -3 drops in sweet almond oil on a tampon 8-hourly • There may be a role for immune boosting by transfusions with Transfer Factor