Vulval Disease Lecture framework for obstetrics and gynaecology core trainees

1. Vulval DiseaseLecture framework for obstetrics and gynaecology core trainees

2. Introduction • These presentations were prepared by Caroline Owen Consultant Dermatologist and David Nunns Consultant Gynaecologist on behalf of the BSSVD education group. • They are designed as a framework, to cover the vulval disease component of the core curriculum for obstetrics and gynaecology trainees, as set out by the RCOG. • The clinical images have been omitted for patient consent issues, and speakers are encouraged to insert their own pictures where indicated. • The lectures are intended only as a guide and resource.

3. Lecture one - Objectives • Assessment of vulval patient • History, examination, investigations • Treatment principles • Emollients and topical steroids • Overview of most common vulval dermatoses • Eczema, psoriasis, candidiasis, lichen sclerosus, lichen planus

4. StratOG guidance on appropriate practitioners and level of care for vulval conditions

5. Who sees vulval disease? • GP • Dermatology • Gynaecology • GUM • Urology We all need to get good at it – there is plenty out there….

6. Vulval disease 1. Assessment of the patient with a vulval problem 2. Treatment principles 3. Specific vulval dermatoses • Eczema (irritant contact dermatitis, allergic contact dermatitis, lichen simplex) • Psoriasis, recurrent candidiasis • Lichen sclerosus, lichen planus

7. Assessment of patient with vulval problem • PC • HPC • PMH • DH • FH • SH Good start but ………

8. Vulval clinic – history taking • Need time & box of tissues • Have often had many appointments, investigations, procedures already • Confused, wary, distressed • Relationships may be under pressure • May be struggling to conceive • May not have spoken to anyone else

9. Picture of end stage LS

10. Vulval clinic – history taking • Timescales • Interventions that have helped or not • Ask about sex • Ask about urinary continence • All topical applications • Hygiene/washing routine • Previous swabs, biopsies, investigations

11. Vulval clinic - examination • Good light • Whole skin (including mouth) • Be systematic – • mons pubis • crural folds • labia majora • labia minora • clitoris • introitus • fourchette • perianal area

12. Anatomy

13. Picture of a normal vulval

14. Terminology • Erythema • Macule – flat • Papule – raised <0.5cm • Nodule – > 0.5cm • Vesicle – blister < 0.5cm • Bulla – blister > 0.5cm • Ecchymosis, purpura, petichiae – bleeding/bruise

15. Terminology cont: • Erosion – loss of superficial epidermis • Ulcer – loss of epidermis +/- dermis • Glazed erythema – red, shiny skin but intact epidermis • Excoriation – scratch • Fissuring – splits/cuts • Lichenification – thickening • Atrophy – thinning, wrinkling • Fusion – scarring, loss of vulval architecture

16. 2 images of LS, one adult, one child

17. Vulval clinic - investigations • Consider GUM screen/referral • Viral and bacterial swabs (candida very common without obvious clinical signs) • Patch testing (if suspect allergic contact dermatitis) • Clinical photograph • Biopsy

18. Vulval biopsy • As outpatient • Local anaesthetic • 4mm punch biopsy (usually) • 5’0 vicryl rapide • Site – NOT eroded or ulcerated area • Incisional/punch biopsy for rashes, excision for lesions • Must document site and all clinical information with differential for pathologists • If performing excision be confident of required margins

19. 4 mm punch biopsy

20. Picture of erosive LP to demonstrate site of biopsy

21. Treatment principles 1 • Complex patients need multidisciplinary team • Dermatology • GUM • Urogynaecology • Pathology • Physiotherapy • Psychosexual counselling • GP • Patient support groups

22. Treatment principles 2 • Emollients emollients emollients • Topical steroids • Lubricants • Dilators (Amielle comfort or Fenmax)

23. Emollients Emollients Emollients • Moisturisers • Vital active treatment • Repairs skin’s barrier • Prevents penetration by allergens and irritants and bacteria • Reduces itch and makes skin feel more comfortable • Soap substitute & leave on moisturiser

27. Emollients • Lotions • light, spread easily, cooling but not very moisturising • Creams • Heavier than lotions but not as moisturising as ointments • Ointments • Do not contain any water, thick and can be difficult and greasy to apply but very good at moisturising

28. Emollients • Light • E45 • Double Base • Ung Merck • Diprobase cream • Greasy • Epaderm • Hydromol ointment • Emulsifying ointment • 50/50 white soft paraffin/liquid paraffin • Aqueous, too light – use only as soap substitute (need to wash off)

29. THE BEST EMOLLIENT IS THE ONE THE PATIENT WILL USE

30. Topical steroids • Very effective • Very safe • Underuse a MUCH greater problem than overuse

31. Topical Steroids • Steroids are produced naturally by the body • Anti-inflammatory • Allow skin a chance to repair • Side effects very rare, steroid atrophy extremely rare

32. Topical steroids • Can use on broken skin • Can use longer than 7 days • Ignore the word ‘sparingly’ • Can use potent and superpotent steroids on vulva (and often need to) • Better to reduce frequency than go up and down ‘steroid ladder’

33. Topical Steroids - guidelines • Don’t use more than twice daily • Must use with regular emollients • Stop using them once completely clear but continue with moisturisers • Start again if necessary • Use mirror to demonstrate correct site

34. Vulval disease Dermatoses • General dermatological dermatoses • Eczema psoriasis • Infections • Candidiasis • STIs • Specific vulval dermatoses • Lichen sclerosus, lichen planus Lesions • Benign • Bartholin cyst • Epithelial (sebaceous) cyst • Angiokeratoma • Malignant • VIN/SCC • BCC/melanoma Vulvodynia • Localised/ provoked or unprovoked

35. Vulval Eczema • Very common • Look for signs of eczema elsewhere • Defect in barrier function of skin • Often atopic • Always itchy • Often worse at night • Eczema = dermatitis • Irritant contact dermatitis / allergic contact dermatitis

36. Image of vulval eczema

37. 2 images of vulval eczema demonstrating excoriations and fissures

38. Vulval eczema with fissuring in crural folds

39. Vulval eczema - treatment • Emollients emollients emollients • Avoid soap • Loose cotton underwear • Topical corticosteroids • Consider irritants and allergens (wetwipes) • Pre-disposes to candidiasis (impaired barrier function) swab to check

40. Irritant contact dermatitis – chapped, damaged skin, can happen to anyone • Water, abrasives • Soap, shampoo • Wool/synthetic clothing • Cold weather • Allergic contact dermatitis – more common in those who already have eczema • Caused by a true allergic reaction to a specific substance (allergen) • Previous contact (often prolonged) with substance is needed to start the allergic reaction • Lasts forever • Diagnosed on patch testing • Consider if previously controlled eczema flares or start to react to topical treatments

41. 2 images of vulval eczema and lichen simplex

42. Images of lichen simplex on vulva and leg

43. Image of Perianal eczema

44. Vulval psoriasis • Appearances often deceptive • Look for signs of psoriasis elsewhere • May have family history • Often sore • Can be psychologically disabling

45. 4 images of psoriasis – plaque, flexural, vulval

46. Vulval psoriasis - treatment • Explain diagnosis • Loose cotton clothing • Emollients • Refer to dermatology (options are topical steroids/topical Vitamin D analogues/Immunomodulators/combination therapies • Trimovate/Alphosyl HC/ Curatoderm/Protopic • May need systemic therapy

47. Vulvovaginal candidiasis • Common • Difficult to diagnose clinically • Pain, itch, dyspareunia, swelling • Take a swab • Albicans in 80 -92% • Non-albicans (e.g. glabrata) in the rest • Often associated with eczema • Recurrent if >6 episodes in one year

48. Image of typical vulval candidiasis

49. 2 images of dry fragile vulva with satellite/ perifollicular superficial peeling often seen in VVC

50. Vulvovaginal candidiasis - treatment • Emollients – long term • Topical steroid at night during acute phase • Oral fluconazole – as stat treatment AND then maintenance therapy (usually weekly) • Relapse very common if treatment stops • Consider stopping OCP/HRT (related to ^ oestrogen) • No need to treat asymptomatic partners Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. Sobel et al NEJM 2004 351:876-883