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Evaluation and Medical Management of Vulvar Dermatoses

Evaluation and Medical Management of Vulvar Dermatoses. Katherine “Casey” Monahan, FNP-C, Dermatology Providence Little Co. of Mary Dermatology & Laser Center. Types . Dermatitis – acute inflammation C ontact dermatitis Dermatoses – chronic inflammation Lichen simplex chronicus

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Evaluation and Medical Management of Vulvar Dermatoses

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  1. Evaluation and Medical Management of Vulvar Dermatoses Katherine “Casey” Monahan, FNP-C, Dermatology Providence Little Co. of Mary Dermatology & Laser Center

  2. Types • Dermatitis – acute inflammation • Contact dermatitis • Dermatoses – chronic inflammation • Lichen simplex chronicus • Lichen sclerosus • Lichen planus

  3. History • Specific areas to address include: • Major complaints • Hygienic practices • Types of clothing • Medications • Personal and family history • Sexual history

  4. Physical Examination & Diagnostics • Inspect the entire vulvar and perianal area with good lighting • Inspect the mouth • Swabs for microbiology • Skin biopsy • Patch testing

  5. Exogenous (Contact) Dermatitis • Vulvar dermatitis (eczema) – the most common vulvar dermatosis • Two types of contact dermatitis • Allergic (20% of cases) • Irritant (80% of cases)

  6. Contact Dermatitis • Vulvar tissue more permeable than exposed skin • Typically, allergens are new exposures • Allergic reactions require prior exposure to a product • Irritants cause an immediate response, whereas allergic reactions occur 12 to 72 hours after exposure

  7. Contact Dermatitis • Signs and Symptoms • Redness, swelling, and scaling of the labia minora • Superficial fissures • Pain and burning at rest • Introital dyspareunia • Generalized pruritus less common

  8. Contact Dermatitis

  9. Contact Dermatitis • Allergens • Fragrances, preservatives, topical medications, and rubber • Propylene glycol • Irritants • Anti-fungal, anti-bacterial, and steroidal creams/ointments • Preservatives, stabilizers, and delivery vehicles in drugs, as well as the drugs themselves

  10. Contact Dermatitis Irritants Allergens Benzocaine Chlorhexidine Perfume Neomycin Nickel Nail polish Latex Spermicides • Soaps • Bubble baths • Baby wipes • Talcum powder • Urine • Feces • Deodorants • Sanitary protection

  11. Contact Dermatitis • Management • Identify and eliminate causative agent(s) • Replace all known irritant agents with hypoallergenic moisturizing preparations • Local measures • Oatmeal colloidal soaks • Ice packs • Mild steroidal ointment in petroleum • Aqueous 4% Xylocaine solution

  12. Contact Dermatitis

  13. Lichen Simplex Chronicus (“LSC”) • Occurs in chronic cases of dermatitis, resulting from rubbing and scratching • Characterized by skin lichenification and excoriation, together with pigmentary abnormalities • Accentuation of skin lines/markings • Leathery texture

  14. LSC

  15. LSC • Management • Goal: cessation of pruritus • Avoid scratching • High-potency steroid cream/ointment initially, then medium- to lower-strength topical steroids • Occlusion of medium-potency steroids • Intralesionalkenalog injections (5 – 10mg/ml) • Unna boot

  16. Lichen Sclerosus Lichen Sclerosus et Atrophicus(“LS&A”) • Most common vulvar dermatosis/disease • Chronic, inflammatory, autoimmune disease of the skin and mucosae, preferentially affecting the vulva • Most common among post-menopausal women (up to age 90 yrs.); females predominately • May affect children (from age 5 mos.) and young adults • If untreated, can result in fusion around the clitoris (phimosis), atrophy and splitting of the vestibule, severe narrowing of the vaginal orifice, and, rarely, vulvar cancer (squamous cell carcinoma (“SCC”))

  17. LS&A • Signs • Atrophy • White patches surrounded by erythematous or violaceous halos • Lesions may coalesce into large atrophic erosions, making the skin smooth, wrinkled, soft, and white • Excoriations or superficial fissures • *characteristic signs that help distinguish LS&A *

  18. LS&A • Signs • Thickened areas • Vulvar and perineal involvement leads to “figure-eight” or “hourglass” shape around the anus • Obliteration of architecture with loss of labia minora, clitoral hood, and urethral meatus • Labial stenosis or fusion

  19. LS&A

  20. LS&A

  21. LS&A • Symptoms – mean duration 99 months • Intense pruritus • Soreness • Burning • Dyspareunia

  22. LS&A • Management • Biopsy • Clobetasol ointment = drug of choice • Effective in 90% of patients with reversal of epidermal atrophy

  23. LS&A • Refractory/Severe Cases • Cortisone injections • Oral retinoid therapy and topical tretinoin • Maintenance with testosterone ointment and progesterone cream • Surgery rarely indicated

  24. Lichen Planus • Chronic, inflammatory, autoimmune disease involving: • Glabrous skin (flexor surfaces of arms and legs) • Hair-bearing skin and scalp • Nails • Mucous membranes of the oral cavity and vulva • >70% of patients between the ages of 30 and 60 years

  25. Lichen Planus • Vulvo-vaginal-gingival syndrome: involves vulva and vagina with gingivitis • Oral lesions may precede or follow vulvovaginal lesions by months or years or may be simultaneous • Vaginal mucosa involved in two-thirds of cases • In one-third of cases, reticulate buccal involvement • 10% have concurrent cutaneous lesions

  26. Lichen Planus • Vulvovaginal signs • Rarely presents as the classic widespread shiny, violaceous, pruritic, flat-topped papules • Erosive/ulcerative form most common presentation in mucous membranes • Mucosal: white reticulate or lace-like changes (Wickham’s striae) or erosions • Vulvar: erythematous erosions with narrow rim of white reticulation • Vaginal: glazed erythema, easy friability

  27. Lichen Planus • Vulvovaginalsymptoms • Pruritus on hair-bearing vulvar skin • Severe burning pain in the vestibule or vagina

  28. Lichen Planus • May be subtle and mistaken for vulvodynia • Typically, morphology similar to vulvar lichen sclerosus • Late scarring with loss of labia minora and clitoral hood • Adhesion formation in upper part of vagina • Total vaginal obliteration • Erosive mucosal cases considered pre-malignant

  29. Lichen Planus

  30. Lichen Planus

  31. Lichen Planus

  32. Lichen Planus

  33. Lichen Planus

  34. Lichen Planus • Management • Biopsy: histological evaluation superior to direct immunofluorescence • Topical and/or intravaginal steroid = first-line therapy

  35. Lichen Planus • Vulvar management • Clobetasol or another high-potency topical steroid ointment BID • Long-term maintenance with low or mid-potency topical steroid ointment • Calcineurin inhibitors: tacrolimus (Protopic) and pimecrolimus (Elidel) cream BID or suppository QHS • Oral hydroxychloroquine (Plaquenil), cyclosporine, azathioprine (Imuran), etanercept (Enbrel), methotrexate

  36. Lichen Planus • Vaginal management • Anusolhydrocortisone suppositories • Vaginal dilation • Surgery

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