vulvar skin conditions – Flashcards
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vulvar itching: common causes
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1. lichens 2. systemic dermatoses 3. eczemas 4. fungal vulvitis 5. VIN
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vulvar itching: lichens
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LS - lichen sclerosis (autoimmune) LSC - lichen limplex chronicus LS + LSC
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vulvar itching: systemic dermatoses
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psoriasis LP - lichen planus
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vulvar itching: eczema
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atopic dermatitis contact dermatitis (irritant, allergic)
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vulvar itching: fungal vulvitis
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candidasis tinea
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vulvar itching: VIN
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CA of vulva
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itching with psoriasis/eczema
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intense itch and scratch cycle of itch and scratch
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acute vulvar itching: how to manage
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sedate at night benedryl -help with itch (antihistamine) and sedate
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common complaints
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nature and duration previous trmt/response personal, fam hx -eczema, psoriasis other sites involved -mouth, eyes, elbow, scalp all meds applied to vulva -abx, hormones, steroids skin care -over cleaning: change the pH new sex partner/barrier contraceptives
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what lubrication is best
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coconut oil
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how to clean vulvar area
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warm water only for inside vulva mons and inner leg can use soap soap/scrub will change pH
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bechet's syndrome
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autoimmune
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vulvar dermatoses
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lichen sclerosis squamous cell hyperplasia other dermatoses VIN
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lichen sclerosis: prevalence
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most common vulvar dystrophy bimodal ages : young, old most common in caucasian women
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lichen sclerosis: cause
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unknown
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lichen sclerosis: presentation
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chronic, progressive, lifelong condition parchment like paper can affect non-vulvar areas
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lichen sclerosis: risk
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squamous cell carcinoma: 3-5% lifetime risk CA
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lichen sclerosis: dx
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biopsy
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lichen sclerosis: s/s
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itch, burn dyspareunia dysuria thin, white, parchment paper epithelium fissures ulcers bruises hemorrhage submucosal hemorrhage
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genital area: cream vs ointment
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ointment: -best choice cream: -ETOH base -but more easily absorbed -can use aquaphor as barrier then use cream
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genital area: fissures - use cream or ointment
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NO cream have to use ointment
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lichen sclerosis: with skin breakdown, but want to build up tissue
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cant get E cream onto tissue until get inflammation down
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lichen sclerosis: findings
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depigmented (white) or hyper pigmented in 'keyhole' distribution -vulva and anus introital stenosis loss of vulvar architecture reduced skin elasticity
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lichen sclerosis: to keep introitus open
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have sex if can or use dilators
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lichen sclerosis: trmt
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steroids testosterone ointment anti-pruritic perineoplasty
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lichen sclerosis: steroids
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Preferred: -clobetasol (temovate) 0.05% BID x2-3wks to QD (high potent steroid) -taper to med potency steroid 2-4x/mo for life
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lichen sclerosis: testosterone
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time honored but little evidence to support DONT USE
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lichen sclerosis: anti-pruritic
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atarax or benedryl PO -especially at night doxypin, HS or topically if not effective: amitriptyline PO (TCA)
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lichen sclerosis: perineoplasty
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surgical procedure may help dyspareunia, fissuring
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lichen sclerosis: f/u
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2-3x per year
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LCS: another name
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squamous cell hyperplasia
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LCS: causes
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irritant initiates scratch-itch cycle
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LCS: presentation
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ALWAYS itching burning pain tenderness thickened leathery red raised lesion
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LCS: scratch vs rub
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scratch -causes lesions, eroding rub: -causes thick leathery raised lesion
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LCS: trmt
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removal of irritant/allergen steroid - med potency anti-pruritic
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LCS: steroid
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medium potency triamcinolone acetonide (TAC) 0.1% ointment BID 4-6wk, then QD other mod strength steroid ointment intralesional TAC once every 3-6mo
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LS vs LCS: steroid choice
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LS -high potent LCS -moderate strength
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LCS: avoid irritant/allergen
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only aquaphor and water
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LCS: anti-pruritic
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hydroxyzine (atarax) 25-75mg, QHS doxepin 25-75 mg PO QHS doxepin (zonalon) 0.5% cream -start QD, titrate up benedryl
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LS + LCS:prevalence
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'mixed dystrophy' 15% all vulvar dystrophies
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LS + LCS: pathophys
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LS is irritant scratching cause LSC
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LS + LCS: differentials
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LS with plaque candida VIN
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LS + LCS: trmt
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clobetasol x12wks (high potent) -then steroid maintenance STOP THE ITCH - most important
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LS + LCS: f/u
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2x per year -r/t steroids thin skin -these pt have to use for long term -advise use til s/s resolve then stop(only use for flares)
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lichen planus : cause
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autoimmune
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lichen planus : classic form
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purple polygonal papules -genital skin and in mouth
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lichen planus : erosive form
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erosive ulcer originating on vestibule extends variably up vaginal canal
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lichen planus : forms
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classic form erosive form
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lichen planus : vulvo-vag-gingival syndrome
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involvement of vestibule, vag, mouth
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lichen planus : presentation
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purple, well demarcated, flat topped papules -oral and genital tissue involved erythematous erosive lesions on vestibule or in vag vulvar burning or pruritus
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lichen planus : differentials
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LS syphilis herpes chancroid behcet's
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lichen planus : dx
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biopsy
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lichen planus : trmt
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no one satisfactory trot emollients, vulvar care -treat superinfection vulva: clobetasol ointment, titrate down vag: anusol HC 25 mg supp. -1/2-1supp BID x 4wks then taper short course oral steroids if needed vag dilators to prevent scarring
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vulvar lesions open/eroded: dont use what
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steroids -will irritate, make worse
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psoriasis: presentation
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red, white, epithelial patches with scaly edge extensor skin beyond vulva -elbow, knee, scalp, nails -mons, vulva, crural folds
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psoriasis: cause
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30% have fam hx triggered by stress, drugs, infections, ETOH, cold
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psoriasis: s/s
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pruritis and soreness red/pink irregular patches elevated silver scales
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psoriasis: rx
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dovonex topical steroids -moderate potency
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vulvar 'eczema' : types
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atopic dermatitis contact dermatitis lichen simplex chronicus
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vulvar 'eczema' : contact dermatitis
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irritant contact dermatitis (ICD) allergic contact dermatitis (ACD)
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vulvar 'eczema' : LSC
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end stage eczema
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atopic dermatitis: prevalence
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10-15% if 2 parents with eczema - 80% risk to kids
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atopic dermatitis: presentation
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itch/scratch cycle
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atopic dermatitis vs contact derm
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atopic: endogenous contact derm: exogenous
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atopic dermatitis: criteria for dx
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exacerbations and remissions eczematoid lesions on vulva and elsewhere personal or family hx: -hay fever -asthma -rhinitis -other allergies clinical course longer than 6wks
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atopic dermatitis: trmt
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avoid scratching emollients topical steroids intralesional trimcinolone tacrolimus oral antihistamines or doxypin 5% cream
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atopic dermatitis: f/u
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frequently qmo until in remission
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contact dermatitis: types
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irritant alergic atopic, ICD, ACD
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HPV not cleared, persisting: risk
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VIN
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VIN: r/t
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infection with HPV 18 or LSC
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VIN: s/s
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itch burning ulceration
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VIN: 4 Ps
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papule formation pruritic "patriotic" - color changes parkeratosis on microscopy
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VIN: location
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vulvar
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VIN: risk
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precursor to vulvar cancer
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VIN: trmt
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wide local excision laser ablation
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VIN: recurrence
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common 48% at 15yrs
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vulvar melanoma: characteristics
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ABCD rule -asymmetry -border irregularities -color black or multicolored -diameter larger than 6mm
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vulvar melanoma: dx
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biopsy
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paget's disease: location
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occurs in milk line extramammary disease involves: -genital -perianal -axillary
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paget's disease: lesions
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brick red scaly velvety eczematoid plaque with sharp border
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paget's disease: s/s
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itch burn bleeding
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paget's disease: cause
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cellular origin unclear
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paget's disease: recurrence
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31-43%
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general vulvar care measures
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wear loose fitting clothing 100% cotton underwear -rinse underwear twice -low irritant soap; no use of fabric softener 100% cotton menstrual pads mild bathing soaps vulvar water rinse or very soft toilet paper use vaginal lubricants
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topical corticosteroids: groups
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superpotent (group I - II) moderately potent (group III - IV) mild potency (group V-VII)
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superpotent corticosteroids
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clobetasol 0.05% ointment (temovate) halobetasol 0.05% ointment (diprolene) flucinolone 0.05% ointment (lidex)
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moderate potent corticosteroids
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betamethasone valerate 0.1% (valisone) triamcinolone acetonide (TAC) 0.1%
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mild potency corticosteroids
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hydrocortisone 1-2% ointment
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chronic vulvar pain syndromes: list
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vulvodynia vaginismus
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vulvodynia: presentation
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vulvar discomfort -burning -pain -occur in ABSENCE of relevant visible findings or specific, identifiable disorder present 3-6mo before dx
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vulvodynia: prevalence
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highly prevalent women of all ethnicities onset highets age 18-25yo (lowest after age 35) 7x more likely to report difficulty and pain with first tampon use
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vulvar pain r/t
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infection inflammatory neoplastic neurologic
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vulvodynia: classifications
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generalized localized (provoked)
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vulvodynia - generalized: types
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provoked -sexual, nonsexual, both unprovoked mixed -provoked and unprovoked
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vulvodynia - generalized: referred to as
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hyperasthesia of vulva dysesthetic vulvodynia vulvar dysesthesia
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vulvodynia - localized: types
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provoked -sexual, nonsexual, both -provoked vestibulodynia (PVD) -vulvar vestibulitis syndrome (VVS) unprovoked mixed -provoked and unprovoked
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generalized vulvodynia: presentation
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chronic, unremitting vulvar burning -over entire surface of inner labia no significant, visible changes on physical exam seldom complaints dyspareunia erythema result of topical steroids
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OCP and dyspareunia
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binds free T (SHBG) and free E introitus becomes thin have to take off OCP and put on progestin only
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generalized vs localized/provoked vulvodynia
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generalized -main issue: BURN -itch is rare primary s/s -tactile stim - no pain localized/provoked -main issue: POINT TENDERNESS -tactile stim - pain
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generalized vulvodynia: pain
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neuropathic type pain -pudental nerve injury -straddle injury -vaginal hysterectomy -pelvic floor descent -soft tissue injury - episiotomy -sympathetic damage from surgery -pelvic floor myalgia
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generalized vulvodynia: contributing causes
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neuropathic type pain -allergies -calcium oxalate crystals
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generalized vulvodynia: trmt
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anticonvulsants and antidepressants antihistamines leukotriene receptor inhibitors guaifenesin AVOID salicylates transfer factor - promotes immune system pelvic floor therapy biofeedback manual pudental nerve release
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localized/provoked vestibulodynia: types
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primary PVD secondary PVD
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localized/provoked vestibulodynia: primary PVD
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vestibular pain -beginning during first attempt at vaginal penetration -1st tampon use, 1st sex, 1st speculum
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localized/provoked vestibulodynia: secondary PVD
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vestibular pain occurring after a period of pain free intercourse
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localized/provoked vestibulodynia: s/s
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most classic finding: POINT TENDERNESS 'burning' NOT constant -elicited by attempts to enter vag (sex, tampons) severe pain on vestibular touch or attempted vag entry erythema of various degrees
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localized/provoked vestibulodynia: common characteristics
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caucasian ages 20-40yo fair complexion premenopause acute onset s/s sex active for years prior to onset s/s pain associated w sex seen many MDs before correct dx numerous trmt failures prior to final dx nuliparous and multiparous women affected equally
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localized/provoked vestibulodynia: anatomy (vestibule)
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extends from hymenal ring laterally to Hart's line on the inner labia minor includes frenumum of clitoris includes posterior fourchette only genital tissue derived from endoderm major and minor vestibular glands
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localized vs generalized vulvodynia: q tip test
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wet tip of q tip with saline pt tell when feel it or painful touch on all hrs of clock LOCALIZED: intense pain with touch
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localized/provoked vestibulodynia: physical exam
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labia: -assess for pain with q tip test -start with least tender areas -Q tip test vestibule: -small amt redness posterior fourchette -site of intense pain (5-7 o'clock)
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localized/provoked vestibulodynia: risk factors
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vulvovaginal infection OCP physical, emotional, sexual abuse allergies early age first intercourse early age menarche nulliparity hx childhood enuresis difficulty/severe pain with tampon
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localized/provoked vestibulodynia: comorbid disorders
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interstitial cystitis/painful bladder syndrome IBS orofacial pain - TMJ fibromyalgia and chronic fatigue syndrome
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localized/provoked vestibulodynia: causes
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infectious inflammatory neoplastic neurologic
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diflucan: effective against what
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albicans
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localized/provoked vestibulodynia: trmt
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oral 'pain blocking' meds topical preparations nerve blocks neurostimulation pelvic floor therapy diet modification psychotherapy
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localized/provoked vestibulodynia: topical trmts
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ELA-max cream lidocaine 5% compounded in aquaphor or lipocream itching: -5% cromolyn in lipocream -estradiol -irritation associated with PO estrace TCA neurontin mixed with aquaphor elavil and neurontin lidocaine 5% protective coating to minimize contact with irritating discharge
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localized/provoked vestibulodynia: trmt
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perineoplasty -reserved for level III dyspareunia -efficacy, resume sex by 3mo interferon -reserved for biopsy proven for probe positive for HPB infection supportive psychotherapy
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localized/provoked vestibulodynia: immune therapy program
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disorder is systemic prob multidisciplinary approach diet test for insulin resistance stool eval allergy testing and desensitization attention to mind/body functioning
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localized/provoked vestibulodynia: surgery
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vestibulectomy -traditional surgery -recovery up to 1yr modified approach -laser ablation of periurethral and vestibular glands -small nerves vaporized
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vulvar skin care
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hypoallergenic soap/laundry detergent -All, dreft, baby products avoid fabric softeners rinse underwear multiple times take sitz baths several times a day rinse skin of vulva with squirt bottle apply aquaphor or lipocream avoid chlorinated swimming pool or hot tubs wear cotton underwear use white, unscented toilet paper AVOID personal or baby wipes 100mg calcium citrate daily cold packs
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100mg calcium citrate
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urinary oxalate irritate vulva med: moderates histamine release - itching
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vulvodynia: counseling issues
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attempt sex periodically to assess progress use lube provide support and encourage pt trmt requires effort improvement may not be evident 2-4mo
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generalized vulvodynia: summary
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pain CONSTANT lidocaine NOT effective NO erythema present caused by nerve sensation or allodynia
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localized vestibulodynia: summary
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pain response ONLY WITH TOUCH lidocaine/local anesthetic effective erythemic area usually sensitive inflammation
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vaginismus
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recurrent or persistent involuntary contraction/spasm of musculature of outer 1/3 vag may be cause or consequence of dyspareunia
