13) Gynaecological Problems - Vulval Disorders Flashcards
Autoantibody in lichen sclerosus
Extracellular matrix protein 1
Percentage of patients with lichen sclerosis with another autoimmune condition
40%
Clinical features of lichen sclerosus
Pale atrophic areas Purpura (ecchyosis) Fissuring Erosions "figure of 8" around perianal area Loss of architecture
Risk of squamous cell cancer with lichen sclerosus
4%
Histological findings with lichen sclerosus
Epidermal atrophy, hyperkeratosis with sub-epidermal hyalinisation of collagen and lichenoid infiltrate
Investigations in lichen sclerosus
Biopsy if uncertain of diagnosis.
Investigation for other autoimmune conditions.
Treatment of lichen sclerosus
- 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.
Where does lichen planus affect?
Skin, genital and oral mucous membranes (can rarely affect lacrimal duct, oesophagus and external auditory meatus)
Antibodies in lichen planus
Basement membrane zone antibodies
Types of lichen planus
- Classical
- Papules on keratinised anogenital skin + striae on inner vulva - Hypertrophic (rare) - thickened warty plaques
- Erosive
- Most common subtype to cause vulval symptoms
- Mucosal surface eroded and purple network (Wickhams striae) at edges of erosion
Risk of SCC with lichen planus
3%
Which condition if the vagina is involved?
Lichen planus
Management of lichen planus
Ultra-potent topical steroids
Vaginal corticosteroids
Combined antimicrobial/steroid preparations
Systemic treatment (no evidence base):
- Oral ciclosporin
- Retinoids
- Oral steroids
- Biological agents
Treatment of vulval eczema
- If mild, 1% hydrocortisone
- If severe or lichenified - betamethasone 0.025% or clobetasol propionate 0.05%
What is lichen simplex?
Response to skin being repeated scratched over a long period of time
Signs of lichen simplex
Lichenification (thickened, slightly scaly, pale or earthy-coloured skin)
Erosions or fissuring
Excoriations
Pubic hair lost in area of scratching
Investigations for lichen simplex
Screen for infection
Patch testing
Ferritin
Biopsy
Management of lichen simplex
“Usual” advice
Topical corticosteroid
Mild anxiolytic antihistamine e.g. hydroxyzine/doxepin
Percentage of general population with psoriasis
2%
Appearance of vulval psoriasis
Well demarcated brightly erythematous plaques which are symmetrical and affect natal cleft
Treatment for vulval psoriasis
As for other vulval dermatoses
+ Coal tar preparations
+ Vit D analogues
Risk of developing vulval cancer from VIN
9-19%
HPV usually associated with low grade VIN (classical/usual/undifferentiated)
16
What is differentiated VIN associated with?
Lichen sclerosus/lichen planus
Which type of VIN is more likely to progress?
Differentiated
What is localised provoked vulvodynia?
Superficial dyspareunia and focal tenderness.
No signs of inflammatory process.
Treatment for localised provoked vulvodynia
Topical LA (wash off before sex) Pelvic floor muscle biofeedback Vaginal TENS Vaginal trainers CBT Psychosexual counselling Amitryptiline Surgical: Modified vestibulectomy
Mangement of unprovoked vulvodynia?
As a chronic pain syndrome Use of emollients Neuropathic meds Topical LA CBT Acupuncture
What is Hart’s line
Junction between vestibule and inner labia which marks change in epithelium from non-keratinised to keratinised
When to do vulval biopsy?
All areas of vulval melanosis + new/changing pigmented lesions.
Persistently eroded areas.
Indurated + suspicious ulcerated areas.
Poor response to treatment.
How to do vulval biopsy?
4mm Keyes punch biopsy (need 2 if requiring immunofluorescence for bullous disease) from edge of lesion to include some normal tissue
How does atopic vulval eczema appear?
Symmetrically inflamed, erythematous, weepy skin. No loss of anatomy. May be satellite lesions and have poorly defined edges.
How to differentiate irritant contact dermatitis from allergic contact dermatitis?
Irritant - erythema where irritant applied.
Allergic - erythema spreads outside of that area.
Treatment of contact dermatitis
Moderate (clobetasone BUTYRATE) or potent (mometasone) steroids and avoid trigger.
How does seborrhoea eczema appear?
Glazed skin in intralabial sulci.
Treatment for seborrhoea eczema?
Moderate (clobetasone BUTYRATE) or potent (mometasone) steroids and emollients.
