Max Brinsmead MB BS PhD May 2015 Vulval Skin Disorders Max Brinsmead MB BS PhD May 2015

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

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

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.

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

Investigations Exclude diabetes, hypothyroidism & iron deficiency Gram stain and culture for Candida Tests for STDs when clinically indicated Autoimmune tests after 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

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

Lichen sclerosis & atrophicus

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

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

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

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

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

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

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

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

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

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 (Melaleuca alterniflora) 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

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