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
Major complaints: Pruritus? Pain? What are exacerbating factors?
Hygienic practices: daily use of panty liners, feminine products, baby wipes?
Occlusive clothing: lycra garments? Confining undergarments, such as non-cotton underwear or thongs?
Medications applied to the vulva or intravaginally, such as anti-fungal therapy, or other agents, such as contraceptives, perfumed or deodorized soap, to the vulva?
Personal and/or family history of eczema, allergies, or hay fever? Any history of diabetes, malignancy, or autoimmune disease?

4. Physical Examination & Diagnostics
Inspect the entire vulvar and perianal area with good lighting
Inspect the mouth
Swabs for microbiology
Skin biopsy
Patch testing
Take note of even trivial skin changes, such as small tears, which can produce severe symptoms
Inspection of as well to ensure lichen planus is not missedmouth to rule out lichen planus (common to have concurrent oral and vulvar involvement)
Biopsy for definitive diagnosis and to rule out dysplasia if suspected
Patch testing in cases of contact dermatitis

6. Exogenous (Contact) Dermatitis
Vulvar dermatitis (eczema) – the most common vulvar dermatosis
Two types of contact dermatitis
Allergic (20% of cases)
Irritant (80% of cases)
Endogenous dermatitis refers to atopic dermatitis, which can affect the vulva but will not be discussed in this presentation
Vulvar dermatitis: accounts for one-third to one-half of vulvar complaints
Allergic: the allergen induces an immune response
Irritant: the trigger/irritant itself directly damages the skin
Can be difficult to distinguish from each other and can occur together

7. 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
Thus, vulvar tissue more vulnerable and susceptible to contact dermatitis than other regions
Allergens – Products used for months to years can create allergic reactions
The body creates antibodies to allergens and symptoms occur upon the second or third exposure
Delayed reactions with allergens as the body must first build an immune response

8. 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
Fissures in the skin around the vestibule
Generalized pruritis: may occur with true allergic episodesmay occur with true allergic episodes

9. Contact Dermatitis

10. 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
Propylene glycol: commonly used in topical and oral preparations, causes an irritant or allergic reaction in 12.5% of patients. When ingested, a recurrence of vulvar dermatitis seen in nearly 50% of patch test positive cases
Metronizadole (Flagyl) is a drug that is a common irritant

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

12. 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
Identification -- Can confirm with patch testing
Moisturzing local preparations, such as hydrophilic (water-holding) agents
Soaks: several times daily
Ice packs, such as frozen peas!
Xylocaine for anesthetic purposes

13. Contact Dermatitis
Patch testing

14. 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
Long-continued trauma to the skin over numerous months
Lichenification = thickening
Excoriations = scratch marks
hyperpigmentation

15. LSC
Note the accentuation of normal skin markings and leathery texture

16. 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
Goal: break the habitual itch-scratch cycle
Medium to lower topical steroids as lesions resolve
Occlusion – Cordran tape
Unna boot: for complete occlusion. May break itch-scratch cycle in severe cases

17. 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”))
20% of patients have at least one autoimmune disease (vitiligo, alopecia areata, or thyroid disease)
SCC: Lifetime risk for women being followed < 5%
HPV not found in majority of cancers arising in genitalia

18. 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 *
Atrophy: wrinkling of skin, parchment-like
Fissures: secondary to scratching or intercourse

19. 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
Thickened areas: LSC from scratching and rubbing

20. LS&A
Note the figure-eight or hourglass configuration of the vulva and perineum

21. LS&A
Complete obliteration of the vulvar architecture with loss of labia minora and clitoral hood in the third slide on the far-right

22. LS&A Symptoms – mean duration 99 months Intense pruritus Soreness
Burning
Dyspareunia
Symptoms: mean duration of 99 months if left untreated
Intense pruritus: 96% of patients
15% of patients have vulvodynia symptoms at initial presentation
Vulvodynia symptoms: burning and soreness instead of the typical pruritus associated with LS&A

23. LS&A Management Biopsy Clobetasol ointment = drug of choice
Effective in 90% of patients with reversal of epidermal atrophy
Biopsy: for diagnostic confirmation or to r/o SCC
Biopsy: white color or atrophic surface most fruitful areas
Clobetasol: “super-potent,” group I category
Clobetasol: apply BID for one month, then daily for two weeks, then PRN or change to lower-strength steroids for maintenance

24. LS&A Refractory/Severe Cases Cortisone injections
Oral retinoid therapy and topical tretinoin
Maintenance with testosterone ointment and progesterone cream
Surgery rarely indicated
Retinoids: may be helpful in some cases
Testosterone and progesterone: have less efficacy than bland emollient
Surgery: rare indications, except for excision of dysplasia or correction of adhesions

25. 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
Mucous membranes: 90% of such cases involve buccal mucosa; >50% gingiva; 40% tongue

26. 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
This syndrome is present in five percent of patients who present with yellow-sticky discharge

27. 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
Flat-topped papules occur on the flexor surfaces of upper extremities or on penile shaft

28. Lichen Planus Vulvovaginal symptoms
Pruritus on hair-bearing vulvar skin
Severe burning pain in the vestibule or vagina
Vestibule or vagina: dyspareunia (painful intercourse)

29. 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
Vaginal obliteration occurs in long-standing, untreated cases
Adhesions form in the absence of sexual activity or regular vaginal dilation
Erosive cases are pre-malignant given their increased risk for SCC. Biopsy suspicious areas!

30. Lichen Planus
Classic violaceous, flat-topped papules on the extremities

31. Lichen Planus
Buccal mucosa with Wickham’s striae (white, lace-like pattern)
White ulcerative lesion in second slide

32. Lichen Planus
Erythematous erosions on gums and ulcer on the tongue

33. Lichen Planus
Severely erythematous erosions with narrow rims of white, whereas we saw white patches surrounded by rims of erythema or violaceous halos in LS&A
Total obliteration of vulvar architecture with absence of labia minora and clitoral hood in all 4 slides

34. Lichen Planus
Fixed vulvar lesion that warrants a biopsy to rule out SCC

35. Lichen Planus Management
Biopsy: histological evaluation superior to direct immunofluorescence
Topical and/or intravaginal steroid = first-line therapy
Biopsy: Rim of white reticulation around eroded lesion most fruitful area
For diagnostic confirmation and to rule out SCC if fixed erosive lesions
Difficult condition to treat!

36. 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
Clobetasol: if marked erosions have occurred
Protopic and Elidel: may burn, especially on raw areas
Oral medications in severe cases
Typical methotrexate dose: 5 to 10 mg PO or SC weekly

37. Lichen Planus Vaginal management Anusol hydrocortisone suppositories
Vaginal dilation
Surgery
Anusol suppositories: for pain relief and to keep vagina open by reducing inflammation. Use BID for 2 months, then daily for 2 months, then 1-3 times weekly for maintenance
Vaginal dilation: to keep vagina open
Surgery: done in severe cases to open the vestibule or uncover the clitoris from under adhesions