Vulvar and Vaginal Disorders


Chapter 170

Vulvar and Vaginal Disorders



Heidi Collins Fantasia



Vulvar Disorders


Definition and Epidemiology


Benign vulvar disorders, which encompass a broad range of dermatologic conditions, account for significant patient concern. Women may delay seeking treatment owing to fear, embarrassment, or confusion over which health care provider would best understand their condition. Therefore, symptoms may be present for some time before women seek care. Signs and symptoms of benign vulvar disorders can include pruritus, pain, burning, irritation, and a mass and/or growth. Women have often tried nonprescription remedies before coming to a provider.1


Pruritus is often the chief patient complaint for most vulvar disorders, and skin breakdown is common from scratching. Vulvar pruritus is a nonspecific vulvar symptom that may be unrelated to vaginitis, sexually transmitted infections (STIs), Bartholin duct cysts, or neoplasms. Proper treatment of vulvar pruritus depends on an accurate diagnosis. Women with vulvar pruritus often receive multiple treatments in the absence of a correct diagnosis; women are commonly prescribed therapy over the phone without ever having been examined, even if symptoms have been recurrent.2


In examining women with vulvar pruritus, the provider is advised to ask about and to inspect other areas of the body; many conditions affecting other organ systems, including tuberculosis, Crohn disease, and endometriosis, can have vulvar manifestations. For example, vulvar psoriasis may have an unusual presentation, but more typical psoriatic lesions are often seen simultaneously elsewhere on the body and may provide a diagnostic clue. Even with an experienced clinician, several visits may be needed to diagnose and to improve certain vulvovaginal conditions.


The visual inspection is essential in identifying vulvar changes. A hand-held microscope, or in some cases a colposcope, may allow more detailed inspection. Vaginitis, cervicitis, and other STIs should be excluded. Some of the common vulvar conditions causing pruritus are presented in this chapter.



Lichen Sclerosus


Pathophysiology


Lichen sclerosus (LS) is a chronic condition with an unclear cause. Multiple factors are most likely involved in the development of this disorder. LS can have an autoimmune component, and women with LS may also develop other autoimmune diseases such as thyroid disorders, anemia, vitiligo, and alopecia areata. It has also been postulated that LS may be triggered by an infectious process, a genetic predisposition, and decreased estrogen levels.3


LS is primarily seen in perimenopausal and postmenopausal women, and the incidence increases with age. Although LS can occur in females of all ages, postmenopausal women are affected more frequently than women of other age groups. Approximately 1 in 30 older women has LS, and it is especially common in women with psoriasis.4 It also affects males but at rates much lower than in females. LS is primarily found in the anogenital region, but it can be seen elsewhere on the body, such as the neck and shoulders.



Clinical Presentation and Physical Examination


Although it is sometimes asymptomatic, LS often results in severe vulvar pruritus and/or dyspareunia. Affected areas include the labia minora, vulvar vestibule, perineum, and clitoris; the vagina is usually spared. Early LS can be particularly difficult to diagnose. Early in the disease process, women may report vague vulvar burning and generalized irritation or itching that is difficult for them to localize and quantify. On examination, white papules can be seen, and the epithelium may appear normal or thin, resembling parchment.5 Typically, tissue elasticity is decreased and edema may be present, depending on the disease stage. Fissures and secondary infections may develop, especially with sexual activity or scratching, which may make diagnosis especially difficult. With disease progression, papules develop into large, hypopigmented, symmetric plaques, often hourglass or keyhole shaped, on the labia minora, vulva, and anal area, which can resemble hyperplasia.6 If these are not treated, there is eventual loss of vulvar architecture such that the labia minora are no longer seen, and introital stenosis may develop, resulting in dyspareunia, ecchymosis, fissures, and telangiectasis.



Diagnostics






Management


imageSpecialist referral is indicated for biopsy results that indicate hyperplasia or atypia. Surgical consultation is warranted if there is evidence of severe architectural changes or scarring. Women with LS have a slightly increased risk of developing squamous cell carcinoma. If there is evidence of severe architectural changes and/or vaginal, urethral, or anal stenosis, a surgical consultation is warranted.


The primary goals of treatment are symptom relief and prevention of disease progression.



1. Superpotent corticosteroids currently provide the best outcomes. However, treatment with ultropotent steroids is recommended for only 4 to 6 weeks.7


2. Clobetasol, halobetasol, or betamethasone dipropionate augmented 0.05% in an ointment base is recommended.


3. A typical regimen is a thin layer of steroid applied to the affected area once or twice daily for 2 to 4 weeks, then tapered to three times per week for maintenance therapy.8 Long-term sequelae of potent topical corticosteroids (atrophy and thinning of skin and subcutaneous tissues) have not been clinically significant in this disorder because the vulvar skin is steroid resistant and can tolerate long-term application of superpotent steroids.9 Contact dermatitis is a rare but reported side effect of this medication.


4. Subsequent LS recurrences are managed by reinstating the corticosteroid therapy.9 It may be appropriate to switch to a milder corticosteroid such as betamethasone valerate 1% (high potency) or triamcinolone ointment 0.1% or fluocinolone acetonide ointment 0.025% (moderate potency) for long-term management.10


5. Topical antibiotic ointment can use used to treat signs of mild infection caused by scratching and excoriation.


6. Prescription (e.g., hydroxyzine, 25 to 50 mg) and over-the-counter (OTC) (e.g., diphenhydramine, 25 to 50 mg) antihistamines given at bedtime may also help relieve pruritus associated with LS.


7. Topical tacrolimus or systemic acitretin or etretinate may be beneficial


8. Application of topical estrogen cream can improve symptoms if LS exists in the presence of menopausal vulvovaginal atrophy.


9. Other relief measures to consider include the application of cool compresses and cool soaks and wearing loose-fitting clothing.



Life Span Considerations


LS is more common among menopausal women and may exist in the presence of atrophy related to estrogen deficiency. In addition, skin changes associated with aging predispose skin to trauma owing to thinning and decreased elasticity.



Complications


Thin, nonelastic tissue associated with LS can cause stenosis of the vaginal opening and result in painful intercourse (dyspareunia). This can often be corrected with topical steroids and/or estrogen therapy. A more serious complication is permanent scarring; surgery may be required to lyse adhesions and restore vulvovaginal functioning.



Indications for Referral or Hospitalization


If there is indication of atypia, hyperplasia, or a mixed diagnosis on biopsy, a gynecologic referral is indicated, especially in older women.


LS is often seen in combination with hyperplasia and requires closer follow-up monitoring.5 Women with LS have a slightly increased risk of developing squamous cell carcinoma.


If there is evidence of severe architectural changes and/or vaginal, urethral, or anal stenosis, a surgical consultation is warranted. The role of surgery is defined in LS and should be limited to repair of introital stenosis or confirmed malignant disease.11


Patients who do not respond to a course of topical, high-potency steroids or who report ongoing pain should be referred to a gynecologic dermatology specialist. Other treatment modalities can include oral tricyclic antidepressants (amitriptyline, desipramine, and nortriptyline) and steroid injections.



Patient and Family Education


LS requires a long-term treatment plan that will span the lifetime. Women should be educated that this condition is chronic and episodes of symptom control will be interwoven with disease exacerbations. Each woman will respond differently to steroid treatment and it may take some time and different dosing regimens to discover the best treatment plan. Women who are sexually active will need guidance on methods to reduce dyspareunia. Because women with LS have a slightly higher risk of squamous cell carcinoma, the importance of yearly skin checks should be stressed. General patient education information for all women with vaginal and vulvar complaints is listed in Box 170-1.




Lichen Planus


Pathophysiology


Lichen planus (LP) is an acute or chronic inflammatory dermatosis affecting the skin, scalp, and the mucous membranes of the mouth, vulva, and vagina. The frequency of LP varies according to the population studied, but there is an estimated prevalence of 1% to 2% in the United States.12 LP affects middle-aged people most often, although childhood LP has been described in the literature. Women are affected as often as men.12 The cause is uncertain, but evidence suggests that it may have an autoimmune component, and inflammation precedes the appearance of lesions. Other possible triggers for LP can include infection with the hepatitis C virus and exposure to certain metals and chemicals.



Clinical Presentation and Physical Examination


In the genital area, there are two presentations of LP: classic or erosive. The appearance of classic LP includes well-defined delicate, white, reticulated papules. Erosive LP involves the presence of erythematous, erosive lesions and a desquamating process. Large denuded areas may lead to profuse leukorrhea or can become adherent, causing stenosis of the vaginal introitus.


Physical examination findings can vary with vulvar LP. Erythema is possible, as well as erosions and a lacy appearance on the skin. As with LS, the examination may reveal architectural changes that include loss of genital features, scarring of the vulva and anus, and urethral and vaginal stenosis. Women with LP often complain of a variety of vulvar symptoms, including pain, pruritus, burning, dyspareunia, and dysuria.





Management


imageSpecialist referral is indicated for biopsy results that indicate hyperplasia or atypia. Surgical consultation is warranted if there is evidence of severe architectural changes or scarring.


The primary goals of treatment are symptom relief and prevention of disease progression. LP requires lifelong management and treatment that is similar to that for LS.



1. Superpotent corticosteroids are the first-line treatment.


2. Clobetasol, halobetasol, or betamethasone dipropionate augmented 0.05% in an ointment base is recommended. A typical regimen is a thin layer of steroid applied to the affected area once or twice daily for 2 to 4 weeks, then tapered to three times per week for maintenance therapy.8 Long-term sequelae of potent topical corticosteroids (atrophy and thinning of skin and subcutaneous tissues) have not been clinically significant in this disorder because the vulvar skin is steroid resistant and can tolerate long-term application of superpotent steroids.9 Contact dermatitis is a rare but reported side effect of this medication.


3. The frequency of maintenance applications of topical steroids will vary depending on individual response and extent of the disease. Lifelong management is necessary to decrease pain and scarring.


4. Topical antibiotic ointment can be used to treat signs of mild infection caused by scratching and excoriation.


5. Prescription (e.g., hydroxyzine, 25 to 50 mg) and OTC (e.g., diphenhydramine, 25 to 50 mg) antihistamines given at bedtime may also help relieve pruritus associated with LP.


6. Application of topical estrogen cream can improve symptoms if LP exists in the presence of menopausal vulvovaginal atrophy.


7. Petrolatum ointment may be applied as a barrier for sensitive skin.


8. Other relief measures to consider include the application of cool compresses, cool soaks, and use of loose-fitting clothing.



Life Span Considerations


LP often manifests at midlife. For women this often coincides with the perimenopausal and postmenopausal years. LP may exist in the presence of atrophy related to estrogen deficiency, which can further increase discomfort. In addition, skin changes associated with aging predispose skin to trauma as a result of thinning, decreased elasticity, and a decreased ability to act as a first-line protection against injury.



Complications


Severe LP can cause significant pain, decreased quality of life, and interference with daily activities. Thin, nonelastic tissue associated with classic LP can cause stenosis of the vaginal opening and result in painful intercourse. This can often be corrected with topical steroids and/or estrogen therapy. A more serious complication is permanent scarring; surgery may be required to lyse adhesions and restore vulvovaginal functioning. Erosive LP can cause chronic pain, sexual dysfunction, and dysuria.




Patient and Family Education


Similar to LS, LP is a chronic condition that requires treatment over the life span. Symptoms and subsequent treatment will vary depending on whether the woman has classic or erosive LP. Pain is common with LP and can significantly affect a woman’s quality of life and sexual functioning. Symptom management may involve a multidisciplinary approach that includes gynecologists, dermatologists, pain specialists, and pelvic floor physical therapy. The use of vaginal dilators may be necessary to prevent scarring and stenosis of the vaginal introitus. Women with LP should receive education on general vulvar care, including loose-fitting clothing; mild soaps; gentle patting of the vulvar area to dry; mild laundry detergent; cotton underwear; and sleeping without underwear or pajama bottoms. See Box 170-1.



Lichen Simplex Chronicus


Pathophysiology


Lichen simplex chronicus (LSC), or squamous cell hyperplasia, is the result of repetitive surface trauma from irritants that cause scratching or rubbing—a perpetual itch-scratch cycle. LSC is characterized histologically by epithelial thickening, lichenification, hyperkeratosis, and eczematous inflammation. It manifests, as do most of the non-neoplastic epithelial disorders, as pruritus, which may be secondary to degeneration and inflammation of terminal nerve fibers. The cause is not completely known, but atopic dermatitis is a common finding in women affected by LSC.







Life Span Considerations


Although LSC can occur in children, it most often occurs after age 30 and can coincide with the menopausal transition. This is a chronic condition that women will need to manage throughout the midlife and older adult years. Aging skin is more susceptible to trauma from scratching, and advising patients to wear soft cotton gloves to bed may help reduce skin breakdown from scratching. As women age, urinary incontinence is more common, and wet skin from exposure to urine increases the risk of excoriation and infection. LSC in the presence of atrophy from estrogen deficiency of menopause may need to be treated with topical estrogen therapy.



Complications


LSC can cause skin changes such as hypopigmentation or hyperpigmentation that may be permanent. The severe pruritus that is a hallmark symptom of LSC can cause sleep disturbances, fatigue, and decreased quality of life. Skin breakdown places patients at risk for superimposed bacterial and fungal infections that can be painful. Decreased sexual function from pruritus and pain is possible.




Patient and Family Education


Similar to LS and LP, LSC is a chronic condition that requires treatment over the life span. Tricyclic antidepressants at bedtime are often prescribed to help control itching and scratching symptoms and not to control depressive symptoms. Women need education regarding their treatment plan and the multifaceted approach to the management of this disorder.



Contact Dermatitis


Pathophysiology


Contact dermatitis of the vulvovaginal area results when the area comes in contact with an allergen or irritant. This causes localized inflammation and edema. Pruritus is common. Contact dermatitis occurs when there is an immediate irritation of the area after exposure to an offending substance. Allergic responses, on the other hand, develop several days after exposure.10



Clinical Presentation and Physical Examination


Women with vulvar contact dermatitis often report a recent onset of vulvar irritation, pruritus, burning, soreness, or discomfort. These symptoms often worsen with friction or if skin is wet. Dysuria may result when acidic urine passes over inflamed or excoriated skin. On examination, erythema is typically present, and excoriation can result from scratching. Skin may be thickened if contact with the irritant or allergen has occurred over an extended period of time. Vaginal discharge is not common.





Management



The goal of management is identifying the triggering substance and eliminating it.


The list of possible irritants is extensive (Box 170-2). Women should be asked about treatments to the vulva (either prescribed or OTC medications) and use of feminine hygiene products (such as douches, sprays, and deodorants), tampons or pads, condoms, spermicides, lubricants, laundry detergents, soaps, and shampoos.


Oct 12, 2016 | Posted by in CRITICAL CARE | Comments Off on Vulvar and Vaginal Disorders
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