Essentials of vulvovaginal dermatology

Recognizing and appropriately managing frequent vulvar circumstances is crucial to protect affected person high quality of life and forestall irreversible architectural sequelae. Patients with vulvar dermatoses usually report a big delay from symptom onset to analysis. This delay is multifactorial and consists of affected person and supplier reluctance to debate vulvovaginal or different intimate signs. In addition, most girls don’t study their vulvas.

Results of a examine confirmed that solely 15% of contributors had been in a position to accurately sketch vulvar anatomy, 67% had not heard of vulvar self-examination, and 61% approached their genitalia with emotions of disgrace and embarrassment.1 It is necessary that suppliers be comfy initiating these conversations to forestall diagnostic delay and to offer sufferers correct info and well timed remedy.

Lichenoid circumstances

Using the right phrases permits suppliers to develop a large differential analysis (Figure 1). An necessary idea in vulvovaginal dermatology is lichenoid eruption, a various group of inflammatory pores and skin ailments sharing frequent morphology and/or histopathology. Distinguishing among the many numerous lichenoid circumstances of the genitalia, together with vulvar lichen sclerosus (VLS), vulvovaginal lichen planus (VLP), and vulvar lichen simplex chronicus (LSC), is necessary as a result of optimum remedies differ.

Although all 3 circumstances might current primarily with ache or pruritus, options reminiscent of anatomic involvement, danger elements, and associations might differ. VLS and VLP are major cutaneous problems, whereas vulvar LSC is a secondary pores and skin situation ensuing from one other underlying dermatosis, an infection, or psychological or neurologic situation. VLS primarily impacts exterior genitalia, whereas VLP might have an effect on each the vulva and vagina.

Vulvar lichen sclerosus

VLS is a power, usually progressive dermatologic situation that entails the anogenital area. The prevalence of VLS will not be properly established, although it’s possible an underrecognized and undermanaged situation. Results of enormous cohort examine confirmed an estimated prevalence within the United States of 0.05%, with 79% of diagnoses in ladies between the ages of 45 and 65 years however 16% of diagnoses in ladies between the ages of 18 and 44 years.2 Most sufferers current with vulvar ache, pruritus, or irritation, however sufferers could also be asymptomatic. Patients finally recognized with VLS might have yeast infections for years (Figure 2-1).

Early detection of VLS is important to stopping irreversible architectural sequelae and vulvar squamous cell carcinoma (SCC). Skin modifications that could be evident upon vulvar inspection embrace white, atrophic papules that will coalesce into plaques, usually affecting the labia minora or majora (Figure 2-2, Figure 2-3).

Early VLS might have a nonspecific presentation, so a excessive diploma of suspicion should be maintained. Varying levels of architectural change could also be current in later illness levels. It is necessary to notice indurations and small erosions, which could possibly be indicators of SCC, even in youthful sufferers. First-line remedy is early use of a superpotent topical corticosteroid with continued topical corticosteroid for upkeep remedy. Patient training emphasizing remedy adherence is important. In a examine that spanned 8 years, sufferers adherent to topical corticosteroid remedy didn’t develop SCC or precursor vulvar intraepithelial neoplasia (VIN), and adhesions and scarring developed in solely 3% of sufferers.3 Reports of symptomatic management additionally had been increased in adherent sufferers. In distinction, in sufferers solely partially adherent with remedy, 5% developed SCC or VIN and 40% developed adhesions
and scarring.3

Vulvovaginal lichen planus

VLP is an inflammatory situation and subtype of lichen planus (LP) that mostly impacts ladies between 50 and 60 years of age.4,5 Although the incidence and prevalence of VLP is unknown, most girls with LP have genital lesions.6 Most continuously, sufferers will current with soreness, pruritus, or genital burning.

Allergic and irritant contact dermatitis of the vulva

Allergic and irritant contact dermatitis (ACD/ICD) continuously happen concomitantly with different vulvar circumstances as preexisting dermatosis impairs pores and skin barrier perform. In sufferers with vulvar ACD, the most typical concomitant vulvar diagnoses are VLS adopted by LSC.10 This might complicate the medical image and result in diagnostic and administration delays. Therefore, vulvar ACD/ICD ought to be thought of when sufferers with vulvar illness usually are not bettering with customary remedy.

Vulvar ICD might happen acutely or, extra generally, chronically. Symptoms in vulvar ACD might turn into obvious 1 to 2 days after allergen publicity, however generally the publicity is unrecognized and will solely slowly produce signs and eruption. This continuously results in problem in figuring out the perpetrator allergen. Patients with ACD/ICD usually current with nonspecific vulvar pruritus or burning. Skin modifications in vulvar ACD/ICD are related and embrace erythema, edema, vesicles, bullae, and oozing. Thus, medical differentiation of vulvar ACD/ICD will not be dependable. The analysis of vulvar ICD is predicated on historical past and institution of a possible irritant, whereas vulvar ACD could also be established with patch testing.

Patients with vulvovaginal signs have usually tried numerous topicals for symptom decision earlier than searching for medical consideration. Common vulvar irritants embrace physique fluids, hygiene or private care merchandise, warmth, extreme bathing, drugs, soaps, and detergents.11 The mostly recognized allergens in ACD are fragrances, preservatives, and drugs together with neomycin and topical anesthetics.10,12,13 Patients might have an allergy to topical corticosteroids,10,14 that are an necessary first-line remedy for a lot of vulvar dermatoses (Figure 315).

ACD/ICD remedy consists of discontinuing potential irritants and allergens, utilizing petroleum on erosions, and educating sufferers. Patients ought to be endorsed on the significance of cleansing the vulva with lukewarm water with out harsh or fragranced soaps, cleansers, or detergents, and utilizing sitz baths for extra symptomatic aid. Topical corticosteroid ointments could also be utilized in extreme or power illness, and antihistamines could also be used for pruritus. Patients might profit from a dermatology referral for patch testing to establish attainable perpetrator allergens, which is a extra applicable testing modality to establish contact allergens than the pores and skin prick take a look at generally carried out by allergist physicians.

Lichen simplex chronicus

LSC is a reactive pores and skin dysfunction secondary to power pores and skin rubbing or scratching, usually in response to persistent pruritus or irritation, no matter major downside. It ends in secondary modifications of pores and skin together with thickening and lichenification (Figure 2-5), with a reasonably well-defined scaly plaque. Patients with different vulvar dermatoses usually develop LSC in response to power scratching. Patients with LSC can pose a diagnostic problem as major pores and skin circumstances can’t be appropriately recognized till there may be enchancment in LSC signs and cutaneous modifications. LSC is often a medical analysis, and administration facilities on disrupting the itch-scratch cycle, during which pruritus results in scratching, which perpetuates and worsens irritation. First-line medical remedy usually features a quick course of medium-potency topical corticosteroid to advertise lively lesion decision. Upon remedy of LSC, an underlying major vulvovaginal dermatosis could also be extra readily identifiable and addressed.

Genitourinary syndrome of menopause

Genitourinary syndrome of menopause (GSM), previously referred to as vulvovaginal atrophy or atrophic vaginitis, refers to a group of indicators and signs that happen in menopausal ladies secondary to decreased stimulation of estrogen-sensitive tissues, together with the vulva, vagina, urethra, and bladder. GSM is quite common. In reality, vulvovaginal signs happen in 39% to 51% of postmenopausal ladies, with the bulk having average to extreme signs, and one-third stopping sexual exercise due to their signs.16 Unfortunately, many ladies don’t acknowledge vulvovaginal atrophy and are reluctant to debate vaginal or sexual signs with well being care professionals.16 Most ladies with GSM imagine that their vaginal signs are a traditional a part of getting old.16 Symptoms seen in GSM embrace genital dryness, discomfort, burning, dyspareunia, dysuria, urinary incontinence, and recurrent urinary tract infections. Physical modifications might embrace a vaginal epithelium that could be a paler pink hue with decreased rugation, diminished pubic hair, decreased turgor and elasticity of the vulva, and minimization of the labia minora. GSM is a medical analysis. Women have a powerful want for well being care professionals to provoke conversations relating to GSM.16 First-line remedy consists of vaginal moisturizers, private lubricants, and low-dose vaginal estrogen. Of notice, a number of research have proven no enhance in danger of heart problems or most cancers with low-dose vaginal estrogen use.17,18 In addition, low-dose vaginal estrogen has minimal systemic absorption and doesn’t enhance plasma estradiol to premenopausal ranges, examine outcomes present.19 In circumstances of superior signs, pelvic bodily remedy could also be helpful, significantly for urinary incontinence
and dyspareunia.

Talking to a affected person about vulvovaginal issues

Before the clinic go to, consumption questionnaires present the affected person with house to reply delicate questions (Figure 420). During analysis, evaluate the affected person’s hygienic practices and product utilization. Patients ought to be requested whether or not they interact in a vulvar washing or cleansing apply. In our society, the place sufferers sadly are taught that their vulvas are unclean, sufferers might imagine that symptom decision is just a matter of washing extra totally or vigorously. Such aggressive cleansing can result in recalcitrant vulvar illness. Also notice any merchandise that sufferers could also be utilizing after toileting, reminiscent of moist wipes, that would result in vulvar ACD/ICD. In reviewing remedy and product utilization, doc the situation of genital software. This will be accomplished through the examination with direct affected person demonstrations by having the affected person apply plain petroleum jelly to herself as if it had been remedy. Frequently sufferers don’t immediately visualize the place they’re making use of merchandise or are utilizing inappropriate quantities of topical therapies, which can result in insufficient undertreatment of some areas or inappropriate overtreatment of others.

Prior to bodily examination, have a chaperone or assistant enter the room and acquire affected person verbal consent. Patient communication earlier than and through examination will increase participation and facilitates affected person management and autonomy. For new sufferers or these with notable vaginal discharge, get hold of moist and KOH preps to evaluate for an infection and diagnostic clues (reminiscent of parabasal cells in GSM). Using a hand mirror permits sufferers to see the place remedy ought to be utilized. The affected person’s place on the examination desk is essential to optimize their viewing of remedy software. The affected person might use petroleum jelly at this level to exhibit how they apply remedy, which supplies one other alternative for redirection or academic intervention if software is inaccurate.

A vulvar biopsy could also be wanted to diagnose circumstances when the medical analysis is unsure. Biopsy sort will depend on medical impression. Shave biopsy could also be used for suspected VLS or VLP, whereas punch biopsy ought to all the time be used for ulcerations or suspected malignancy. Get a biopsy for suspected VLS within the crinkly space, suspected VLP on the fringe of defect such that ordinary pores and skin is included, and suspected malignancy within the heart or border of the lesion.

During the administration portion of the clinic go to, affected person handouts and literature reinforce info lined through the clinic go to, and {a photograph} of the affected person’s genital space could also be obtained and annotated for affected person medical or private data after affected person consent. Reviewing this {photograph} with the affected person permits them to obviously see affected areas and visualize the place topical drugs ought to be utilized. The {photograph} could also be annotated to specify the situation, quantity, and frequency of topical remedy software (Figure 5).

After the clinic go to, give the affected person this annotated {photograph} to take residence to make use of as a information for remedy software. At future clinic visits, this preliminary {photograph} could also be reviewed to exhibit medical enchancment or modifications, and a brand new {photograph} could also be taken and annotated to assist talk any mandatory changes to areas of topical software.

At subsequent visits, the differential ought to be revisited, particularly if the affected person will not be bettering, as remedy failure could also be the results of missed diagnoses. A affected person might have greater than 1 situation concurrently affecting the vulva and vagina, which can be causal or solely related to each other. It is equally necessary to rediscuss exposures, hygiene, and drugs, as affected person habits might evolve and complicate circumstances or be misinterpreted as flares of major processes when as a substitute they symbolize a brand new secondary or concomitant course of, reminiscent of growth of recent ICD.

References

1.Preti M, Selk A, Stockdale C, et al. Knowledge of vulvar anatomy and self-examination in a pattern of Italian ladies. J Low Genit Tract Dis. 2021;25(2):166-171. doi:10.1097/LGT.0000000000000585

2.Melnick LE, Steuer AB, Bieber AK, Wong PW, Pomeranz MK. Lichen sclerosus amongst ladies within the United States. Int J Womens Dermatol. 2020;6(4):260-262. doi:10.1016/j.ijwd.2020.05.001

3.Lee A, Bradford J, Fischer G. Long-term administration of grownup vulvar lichen sclerosus: a potential cohort examine of 507 ladies. JAMA Dermatol. 2015;151(10):1061-1067. doi:10.1001/jamadermatol.2015.0643

4.Cooper SM, Wojnarowska F. Influence of remedy of erosive lichen planus of the vulva on its prognosis. Arch Dermatol. 2006;142(3):289-294. doi:10.1001/archderm.142.3.289

5.Kennedy CM, Galask RP. Erosive vulvar lichen planus: retrospective evaluate of traits and outcomes in 113 sufferers seen in a vulvar specialty clinic. J Reprod Med. 2007;52(1):43-47.

6.Lewis FM, Shah M, Harrington CI. Vulval involvement in lichen planus: a examine of 37 ladies. Br J Dermatol. 1996;135(1):89-91.

7.Zendell Ok, Edwards L. Lichen sclerosus with vaginal involvement: report of two circumstances and evaluate of the literature. JAMA Dermatol. 2013;149(10):1199-1202. doi:10.1001/jamadermatol.2013.4885

8.Bradford J, Fischer G. Management of vulvovaginal lichen planus: a brand new method. J Low Genit Tract Dis. 2013;17(1):28-32. doi:10.1097/LGT.0b013e318258bf5b

9.Fairchild PS, Haefner HK. Surgical administration of vulvovaginal agglutination attributable to lichen planus. Am J Obstet Gynecol. 2016;214(2):289.e1-289.e2. doi:10.1016/j.ajog.2015.08.070

10.Trivedi MK, Woodruff CM, Kornik R, Botto N. Patch testing in vulvar allergic contact dermatitis. Dermatitis. 2018;29(2):95-96. doi:10.1097/DER.0000000000000345

11.Schlosser BJ. Contact dermatitis of the vulva. Dermatol Clin. 2010;28(4):697-706. doi:10.1016/j.det.2010.08.006

12.Warshaw EM, Furda LM, Maibach HI, et al. Anogenital dermatitis in sufferers referred for patch testing: retrospective evaluation of cross-sectional information from the North American Contact Dermatitis Group, 1994-2004. Arch Dermatol. 2008;144(6):749-755. doi:10.1001/archderm.144.6.749

13.Lewis FM, Shah M, Gawkrodger DJ. Contact sensitivity in pruritus vulvae: patch take a look at outcomes and medical end result. Am J Contact Dermat. 1997;8(3):137-140.

14.Dumycz Ok, Osinka Ok, Feleszko W. Contact allergens in topical corticosteroid autos: evaluation of product composition. Contact Dermatitis. 2017;76(4):254-255. doi:10.1111/cod.12693

15.Haefner H. The gynecologist’s information to steroid use. February 27, 2015. Accessed July 11, 2022. https://dokumen.tips/documents/gynecologists-guide-steroid-useppt-2242015-2-steroids-a-manage-not-cure-dermatologic.html

16.Krychman M, Graham S, Bernick B, Mirkin S, Kingsberg SA. The Women’s EMPOWER survey: ladies’s information and consciousness of remedy choices for vulvar and vaginal atrophy stays insufficient. J Sex Med. 2017;14(3):425-433. doi:10.1016/j.jsxm.2017.01.011

17.Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Vaginal estrogen use and power illness danger within the Nurses’ Health Study. Menopause. 2018;26(6):603-610. doi:10.1097/GME.0000000000001284

18.Crandall CJ, Hovey KM, Andrews CA, et al. Breast most cancers, endometrial most cancers, and cardiovascular occasions in contributors who used vaginal estrogen within the Women’s Health Initiative Observational Study. Menopause. 2018;25(1):11-20. doi:10.1097/GME.0000000000000956

19.Santen RJ. Vaginal administration of estradiol: results of dose, preparation and timing on plasma estradiol ranges. Climacteric. 2015;18(2):121-134. doi:10.3109/13697137.2014.947254

20.Edwards L. Patient info packet. Mid-Charlotte Dermatology and Research Southeast Vulvar Clinic. Accessed July 11, 2022. https://nebula.wsimg.com/70af598099d980b624b0e104369f19c6?AccessKeyId=B78439C8610A1092E451&disposition=0&alloworigin=1

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