Evaluation and Medical Management of Vulvar
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Evaluation and Medical Management of Vulvar

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Evaluation and Medical Management of Vulvar




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Presentation on theme: "Evaluation and Medical Management of Vulvar"— Presentation transcript:

Slide1

Evaluation and Medical Management of Vulvar Dermatoses

Katherine “Casey” Monahan, FNP-C, Dermatology

Providence Little Co. of Mary Dermatology & Laser Center

Slide2

Types

Dermatitis – acute inflammation

C

ontact dermatitis

Dermatoses

– chronic inflammation

Lichen simplex

chronicus

Lichen

sclerosus

Lichen

planus

Slide3

History

Specific areas to address include:

Major complaints

Hygienic practices

Types of clothing

Medications

Personal and family history

Sexual history

Slide4

Physical Examination & Diagnostics

Inspect the entire vulvar and perianal area with good lighting

Inspect the mouth

Swabs for microbiology

Skin biopsy

Patch testing

Slide5

Slide6

Exogenous (Contact) Dermatitis

Vulvar dermatitis (eczema) – the most common vulvar

dermatosis

Two types of contact dermatitis

Allergic

(20% of cases)

Irritant

(80% of cases)

Slide7

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

Slide8

Contact Dermatitis

Signs and

S

ymptoms

Redness, swelling, and scaling of the labia

minora

Superficial fissures

Pain and burning at rest

I

ntroital

dyspareunia

Generalized pruritus less common

Slide9

Contact Dermatitis

Slide10

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

Slide11

Contact Dermatitis

Irritants

SoapsBubble bathsBaby wipesTalcum powderUrineFecesDeodorantsSanitary protection

Allergens

Benzocaine

Chlorhexidine

Perfume

Neomycin

Nickel

Nail polish

Latex

Spermicides

Slide12

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%

X

ylocaine

solution

Slide13

Contact Dermatitis

Slide14

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

Slide15

LSC

Slide16

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

Intralesional

kenalog

injections (5 – 10mg/ml)

Unna boot

Slide17

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

M

ost 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”))

Slide18

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 *

Slide19

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

Slide20

LS&A

Slide21

LS&A

Slide22

LS&A

Symptoms – mean duration 99 months

Intense pruritus

Soreness

Burning

Dyspareunia

Slide23

LS&A

Management

Biopsy

Clobetasol

ointment = drug of choice

Effective in 90% of patients with reversal of epidermal atrophy

Slide24

LS&A

Refractory/Severe Cases

C

ortisone

injections

Oral retinoid therapy and topical

tretinoin

Maintenance with testosterone ointment and progesterone cream

Surgery

rarely

indicated

Slide25

Lichen Planus

Chronic, inflammatory, autoimmune disease involving:

G

labrous skin (flexor surfaces of arms and legs)

H

air-bearing skin and scalp

Nails

M

ucous membranes of the oral cavity and vulva

>70% of

patients between the ages of 30 and 60 years

Slide26

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

Slide27

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

Slide28

Lichen Planus

Vulvovaginal

symptoms

Pruritus on hair-bearing vulvar skin

Severe burning pain in the vestibule or vagina

Slide29

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

Slide30

Lichen Planus

Slide31

Lichen Planus

Slide32

Lichen Planus

Slide33

Lichen Planus

Slide34

Lichen Planus

Slide35

Lichen Planus

Management

Biopsy: histological evaluation superior to direct immunofluorescence

Topical and/or

intravaginal

steroid = first-line therapy

Slide36

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

Slide37

Lichen Planus

Vaginal management

Anusol

hydrocortisone

suppositories

Vaginal

dilation

Surgery

Slide38

Slide39

Slide40

Slide41