Lesions of the Vulva

Pediculosis pubis – Phthirus pubis – Body louse – Obtained from Close contact – Towels, beddings Located near the hair shaft of hair – Can lodge in the vulva, eyelids – Eggs deposited in the base of the hair follicles – Constant itching of the perineal area – Incubation period: 30 days – Nourished by human blood

– Diagnostics: Scratch skin papule adjacent to hair shaft and place under a drop of mineral oil (Eggs, lice, pepper-grain feces) – Treatment : Must kill both the adult parasite and egg: Permethrin 1% (Kwell) shampoo (Don’t let it enter the eyes!) Apply for 5 minutes then wash off thoroughly Avoid eyelids

Scabies – Sarcoptes scabiei – Close contact – Widespread doesn’t spare the vulva – Adult female digs a burrow underneath the skin – Travels about 2.5 cm/min – Severe but intermittent itching exacerbated at night – Papules, vesicles, or burrows – The great dermatologic imitator because aside from itching, it can produce other skin problems – Treatment same as Pediculosis Permethrin cream 5% Applied to all areas of the body, from neck down, wash off after 8-14 hours Household contacts: Treat patient and the rest of the household because you can get it from bedding, fomites or close contact. This should include treating house help. Decontaminate beddings and clothing by hot washing.

Molluscum contangiosum – Pox virus – Papules with umbilicated center – Characteristic crater in the middle. – 1-5 mm (Not very big) – 1 to 20 solitary lesions randomly distributed over the vulvar skin.

– new nodules will persist from several months to years. – Skin-to-skin contact – Incubation: 2-7 weeks – Self-limiting, mildly contagious in immunocompetent persons – Replicates in cytoplasm

Condyloma acuminatum Condyloma Acuminatum – Genital, venereal, or anogenital warts, – Human Papilloma Virus – Most common viral STD of the vulva, vagina, rectum and cervix – >70 HPV subtypes – pinhead-sized papules to large cauliflower-like masses. – usually asymptomatic – Some are symptomatic: pain, itching, tendency to bleed when friable – Associated with other infections – Type 6, 11: Associated with benign genital tract lesions – Types 16, 18: Associated with pre-malignant or malignant lesions

– Predisposing factors: Immunosuppression Diabetes Pregnancy Trauma – Treatment: Depends on size, location and pregnancy If only a few lesions: chemical, electrocautery, immunotherapy

Chemical – Patient administered: Imiquimod 5% cream (Aldara) » Immune enhancer » Daily, at bedtime, up to 16 weeks » Wash 6-10 minutes » Another option is Interferon. However, this is very expensive and is only available in western countries. » Provider-administered: – Cryotherapy – Electocautery – Podophyllin (weekly): applied by physician – Trichloroacetic Acid (TCA) weekly

Syndromic management of STIs Public health approach Prevention and promotion take precedence Population perspective Cost-effectiveness

Estimated New Cases of Curable STIs among Adults, 1999

Estimates of HIV/AIDS Prevalence throughout the World, 2005

Syndromic Management of STIs Case and point: Puerto Galera – Hospitality industry – Not all use condoms – MHO sends midwives to check on women weekly – Checkup necessary to renew “hospitality permit” – 2 MHOs for the whole town; undermanned – Expenses are out-of-pocket

Approaches to STI diagnosis Etiological diagnosis Clinical diagnosis Syndromic case management

Syndromic approach Steps: – history-taking and examination – diagnosis and treatment, using flowcharts – counseling and education on safer sex, including condom promotion and provision – partner management – data gathering (recording)

Syndromic approach problem-oriented (patient’s symptoms) highly sensitive and does not miss mixed infections treats the patient at the first visit makes STI care more accessible (primary care level) uses flowcharts provides opportunity and time for education and counseling

Syndromes

Criticisms Unscientific – Similar diagnostic accuracy as clinical diagnosis Too simple for physicians – Should be simple enough to be used by a primary healthcare worker – More time for education and behavior change Fails to make sure of clinician’s skills and experience – Clinicians using own clinical judgement misdiagnose 50% of the time

Treating for most common cause then treat for second cause if symptoms don’t improve – Most patients don’t return to health center – Patient will continue to transmit STI Waste of drugs because of overtreatment – Studies show that syndromic approach is less expensive

Algorithm examples