13) Gynaecological Problems - Vulval Disorders

Question 1

Autoantibody in lichen sclerosus

Answer 1

Extracellular matrix protein 1

Question 2

Percentage of patients with lichen sclerosis with another autoimmune condition

Answer 2

40%

Question 3

Clinical features of lichen sclerosus

Answer 3

Pale atrophic areas
Purpura (ecchyosis)
Fissuring
Erosions
"figure of 8" around perianal area
Loss of architecture

Question 4

Risk of squamous cell cancer with lichen sclerosus

Answer 4

4%

Question 5

Histological findings with lichen sclerosus

Answer 5

Epidermal atrophy, hyperkeratosis with sub-epidermal hyalinisation of collagen and lichenoid infiltrate

Question 6

Investigations in lichen sclerosus

Answer 6

Biopsy if uncertain of diagnosis.

Investigation for other autoimmune conditions.

Question 7

Treatment of lichen sclerosus

Answer 7

• Ultra-potent topical steroids (e.g. clobetasol propionate)
  (Apply daily for 1/12, alternate days for 1/12, twice weekly for 1/12 and then RV 3/12).
• If concern re: secondary infection then combined preparation for short period e.g. clobetasol with neomycin and nystatin, or fucibet
• Second line options (unlicensed):
  Topical calcineurin inhibitors e.g. tacrolimus, oral retinoids, UVA1 phototherapy.

Question 8

Where does lichen planus affect?

Answer 8

Skin, genital and oral mucous membranes (can rarely affect lacrimal duct, oesophagus and external auditory meatus)

Question 9

Antibodies in lichen planus

Answer 9

Basement membrane zone antibodies

Question 10

Types of lichen planus

Answer 10

1. Classical
   - Papules on keratinised anogenital skin + striae on inner vulva
2. Hypertrophic (rare) - thickened warty plaques
3. Erosive
   - Most common subtype to cause vulval symptoms
   - Mucosal surface eroded and purple network (Wickhams striae) at edges of erosion

Question 11

Risk of SCC with lichen planus

Answer 11

3%

Question 12

Which condition if the vagina is involved?

Answer 12

Lichen planus

Question 13

Management of lichen planus

Answer 13

Ultra-potent topical steroids
Vaginal corticosteroids
Combined antimicrobial/steroid preparations

Systemic treatment (no evidence base):

• Oral ciclosporin
• Retinoids
• Oral steroids
• Biological agents

Question 14

Treatment of vulval eczema

Answer 14

• If mild, 1% hydrocortisone

- If severe or lichenified - betamethasone 0.025% or clobetasol propionate 0.05%

Question 15

What is lichen simplex?

Answer 15

Response to skin being repeated scratched over a long period of time

Question 16

Signs of lichen simplex

Answer 16

Lichenification (thickened, slightly scaly, pale or earthy-coloured skin)
Erosions or fissuring
Excoriations
Pubic hair lost in area of scratching

Question 17

Investigations for lichen simplex

Answer 17

Screen for infection
Patch testing
Ferritin
Biopsy

Question 18

Management of lichen simplex

Answer 18

“Usual” advice
Topical corticosteroid
Mild anxiolytic antihistamine e.g. hydroxyzine/doxepin

Question 19

Percentage of general population with psoriasis

Answer 19

2%

Question 20

Appearance of vulval psoriasis

Answer 20

Well demarcated brightly erythematous plaques which are symmetrical and affect natal cleft

Question 21

Treatment for vulval psoriasis

Answer 21

As for other vulval dermatoses
+ Coal tar preparations
+ Vit D analogues

Question 22

Risk of developing vulval cancer from VIN

Answer 22

9-19%

Question 23

HPV usually associated with low grade VIN (classical/usual/undifferentiated)

Answer 23

16

Question 24

What is differentiated VIN associated with?

Answer 24

Lichen sclerosus/lichen planus

Question 25

Which type of VIN is more likely to progress?

Answer 25

Differentiated

Question 26

What is localised provoked vulvodynia?

Answer 26

Superficial dyspareunia and focal tenderness.

No signs of inflammatory process.

Question 27

Treatment for localised provoked vulvodynia

Answer 27

Topical LA (wash off before sex)
Pelvic floor muscle biofeedback
Vaginal TENS
Vaginal trainers
CBT
Psychosexual counselling
Amitryptiline
Surgical: Modified vestibulectomy

Question 28

Mangement of unprovoked vulvodynia?

Answer 28

As a chronic pain syndrome
Use of emollients
Neuropathic meds
Topical LA
CBT
Acupuncture

Question 29

What is Hart’s line

Answer 29

Junction between vestibule and inner labia which marks change in epithelium from non-keratinised to keratinised

Question 30

When to do vulval biopsy?

Answer 30

All areas of vulval melanosis + new/changing pigmented lesions.
Persistently eroded areas.
Indurated + suspicious ulcerated areas.
Poor response to treatment.

Question 31

How to do vulval biopsy?

Answer 31

4mm Keyes punch biopsy (need 2 if requiring immunofluorescence for bullous disease) from edge of lesion to include some normal tissue

Question 32

How does atopic vulval eczema appear?

Answer 32

Symmetrically inflamed, erythematous, weepy skin. No loss of anatomy. May be satellite lesions and have poorly defined edges.

Question 33

How to differentiate irritant contact dermatitis from allergic contact dermatitis?

Answer 33

Irritant - erythema where irritant applied.

Allergic - erythema spreads outside of that area.

Question 34

Treatment of contact dermatitis

Answer 34

Moderate (clobetasone BUTYRATE) or potent (mometasone) steroids and avoid trigger.

Question 35

How does seborrhoea eczema appear?

Answer 35

Glazed skin in intralabial sulci.

Question 36

Treatment for seborrhoea eczema?

Answer 36

Moderate (clobetasone BUTYRATE) or potent (mometasone) steroids and emollients.