1 / 18

Vulval Skin Disorders

Vulval Skin Disorders. Max Brinsmead PhD FRANZCOG April 2011. 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

coligny
Download Presentation

Vulval Skin Disorders

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Vulval Skin Disorders Max Brinsmead PhD FRANZCOG April 2011

  2. 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

  3. 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

  4. 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.

  5. 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

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

  7. 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

  8. Lichen sclerosis & atrophicus

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

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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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 (Melaleucaalterniflora) 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

More Related