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Gaby’s Green Top Guidelines > 2023 Vulval Skin Conditions (2011 Swap) > Flashcards

2023 Vulval Skin Conditions (2011 Swap) Flashcards

1
Q

What is the most common vulval dermatosis & what is its incidence?

A

Lichen sclerosus
1.6-3%

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2
Q

What are the symptoms of lichen sclerosus?

A
  1. Itch
  2. Soreness
  3. Dyspareunia
  4. Urinary Sx due to fusion of labia minora
  5. Constipation if perianal involvement
  6. Rarely, asymptomatic
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3
Q

What are the signs of lichen sclerosus?

A
  1. Pallor, often atrophic but atypically, hyperkeratotic
  2. Purpura, common, pathognomonic
  3. Loss of architecture
  4. Erosions
  5. Lichenification atypically
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4
Q

What is the distribution of lichen sclerosus?

A
  1. Labia majora
  2. Labia minora
  3. Clitoral hood
  4. Perianal skin
  5. Not vagina
  6. Localised or in figure of 8 distribution
  7. Extra-genital lesions in up to 10%
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5
Q

What are the complications of lichen sclerosus?

A
  1. Squamous cell carcinoma: <5%
  2. Clitoral pseudocyst if hood seals
  3. Sexual dysfunction
  4. Urinary Sx
  5. Vulvodynia
  6. Reactivation of HSV or HPV
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6
Q

What are the histological features of lichen sclerosus?

A
  1. Epidermal atrophy
  2. Sub-epidermal hyalinisation
  3. Lymphocytic dermal infiltrate
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7
Q

With clinical diagnosis of lichen sclerosus, in which circumstances is a biopsy essential?

A
  1. Diagnosis uncertain
  2. Atypical features
  3. Suspicion of dVIN or SCC
  4. Failure to respond to 1st line Tx
  5. Development of atypical pigmented areas
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8
Q

What is the treatment for lichen sclerosus?

A
  1. Ultrapotent topical steroid
    eg clobetasol propionate,
    mometasone fuorate
    1m daily, 1m alternates, 1m twice wk
  2. Review at 3 months
  3. Oral retinoids if severe hyperkeratosis
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9
Q

What are the pregnancy & breastfeeding considerations with lichen sclerosus?

A
  1. LS tends to improve in pregnancy
  2. No contraindication to NVB
  3. Can continue topical steroids
  4. Oral retinoids highly teratogenic, must be stopped 2 years prior to TTC
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10
Q

What is the likely pathophysiology of lichen sclerosus?

A

Inflammatory
Autoimmune
Antibodies to ECM protein 1

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11
Q

What are the symptoms of lichen planus?

A
  1. Itch
  2. Soreness
  3. Dyspareunia
  4. Urinary Sx
  5. Vaginal discharge
  6. Can be asymptomatic
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12
Q

What are the 3 classifications of lichen planus?

A
  1. Classical
  2. Hypertrophic
  3. Erosive
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13
Q

What are the signs of classical lichen planus?

A
  1. Papules
  2. Keratinised anogenital skin
  3. Striae on inner aspect of vulva
  4. Hyperpigmentation
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14
Q

What are the signs of hypertrophic lichen planus?

A
  1. Thickened warty plaques
  2. May become ulcerated, infected & painful
  3. Involvement of vagina excludes LS
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15
Q

What are the signs of erosive lichen planus?

A
  1. Eroded mucosal surfaces
  2. Wickham’s striae: purple lacy network
  3. Can lead to scarring & complete stenosis
  4. Friable telangiectasia & patchy erythema
  5. Serosanguinous discharge
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16
Q

What are the complications of lichen planus?

A
  1. Scarring, inc vulval & vaginal adhesions
  2. SCC, mainly linked to hypertrophic type
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17
Q

What are the histopathological findings in lichen planus?

A
  1. Saw-toothed acanthosis
  2. Increased granular layer
  3. Basal cell liquefaction
  4. Band-like lymphocytic dermal infiltrate
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18
Q

What is the treatment for lichen planus?

A
  1. Ultra-potent topical steroid
    eg clobetasol propionate
  2. Oral steroids for severe flares
  3. Topical calcineurin inhibitors eg tacrolimus
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19
Q

What are the treatments for vulval eczema?

A
  1. Emollients & soap substitutes
  2. Mild to moderate topical steroids
  3. If significant inflammation or lichenification, potent/ultrapotent steroid
  4. Sedating antihistamine if severe itch disrupting sleep
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20
Q

What are the treatments for vulval psoriasis?

A
  1. Weak to moderately potent steroids
  2. Vitamin D analogues
  3. Weak coal tar preparations
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21
Q

What are the treatments for HSIL: high-grade intraepithelial lesions?

A
  1. Local excision
  2. Imiquimod cream, especially if multifocal disease
  3. Refer all to vulval clinic
  4. Cidofovir as alternative to imiquimod
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22
Q

What are the treatments for dVIN?

A
  1. Local excision
  2. MDT advice
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23
Q

What are the treatments for NSAGU: non-sexually-acquired genital ulcers?

A
  1. Topical local anaesthetic
  2. NSAIDs
  3. Aciclovir until HSV excluded
  4. Clobetasol propionate OD
  5. Systemic steroids under specialist
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24
Q

What are the treatments for provoked vulvodynia?

A
  1. 5% lidocaine ointment or 2% lidocaine gel
  2. Pelvic floor physio
  3. Psychosexual services
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25
Q

What are the treatments for unprovoked vulvodynia?

A
  1. Pain modifiers eg amitriptyline
  2. Topical local anaesthetic
  3. Pain clinic referral
  4. Duloxetine, pregabalin or gabapentin
26
Q

What are the types of eczema, which can also present vulvally?

A
  1. Atopic
  2. Contact
  3. Seborrhoeic
27
Q

What proportion of the population is affected by atopic eczema?

A

15-20%

28
Q

What is the pathophysiology of eczema?

A
  1. Gene mutation affecting structural epidermal barrier
  2. Environmental triggers
  3. Chronic inflammation
29
Q

What is the pathophysiology of seborrhoeic eczema?

A

Overexubetant inflammatory response to non-pathogenic yeast: malassezia

30
Q

What are some precipitating factors for lichen simplex?

A
  1. Underlying dermatoses
  2. Systemic conditions causing itch
  3. Environmental factors
  4. Psychiatric disorders
31
Q

What are the signs & symptoms of vulval eczema?

A
  1. Itch
  2. Erythematous inflammation
  3. Poorly demarcated margins
  4. Fissuring
  5. Xerosis (dry skin)
  6. Lichenification if chronic
  7. Weeping, blisters & erosions if severe allergic contact dermatitis
32
Q

How does seborrhoeic eczema present?

A
  1. Mildly pink
  2. Glazed
  3. Poorly defined patches
  4. Slightly greasy scale
  5. Pubic region, groin flexures, natal cleft
33
Q

What proportion of the population have psoriasis?

A

2%

34
Q

What proportion of patients with psoriasis have genital involvement at some stage?

A

60%

35
Q

What are the symptoms of genital psoriasis?

A
  1. Itch
  2. Soreness
  3. Dyspareunia
36
Q

What are the signs of genital psoriasis?

A
  1. Well-demarcated brightly erythematous plaques
  2. Symmetrical, on labia majora & mons pubis
  3. May extend into inguinal folds, perianal skin & natal cleft
  4. Rarely scales as moist
  5. Fissuring
37
Q

What are the complications of vulval psoriasis?

A
  1. Secondary candidiasis
  2. Streptococcal infection
38
Q

How is VIN now classified?

A
  1. LSIL: low-grade squamous intraepithelial lesions
  2. HSIL: high-grade squamous intraepithelial lesions
  3. differentiated VIN
39
Q

What are the rates of HSIL?

A

3 per 100,000

40
Q

What proportion of VIN cases are HSIL?

A

95%

41
Q

What is the cause of LSIL & HSIL?

A

High-risk HPV, predominantly 16

42
Q

What is the epidemiology of HSIL?

A
  1. Peak age 35-49
  2. Smokers
  3. Immunocompromised
43
Q

What is the aetiology of dVIN?

A
  1. Older age group
  2. Lichen sclerosus & occasionally planus
44
Q

What are the symptoms of VIN?

A
  1. Burning
  2. Itch
  3. Lump or thickening
  4. Asymptomatic
45
Q

What are the signs of HSIL?

A
  1. White, erythematous or pigmented
  2. Warty
  3. Multifocal
46
Q

What are the signs of dVIN?

A
  1. Treatment-resistant lichen sclerosus
  2. Hyperkeratotic, erosive or ulcerated
  3. At vestibule, in & around clitoris, labia minora & introitus, perineum, perianal skin
47
Q

What are the complications of VIN?

A
  1. Progression to SCC
  2. Multifocal disease
  3. Recurrent disease
  4. Psychosexual issues
48
Q

What is the rate of progression to SCC of a) HSIL, b) dVIN

A

a) 10%
b) 50%

49
Q

What are the histological findings in HSIL?

A
  1. Disruption of architecture
  2. High nuclear to cytoplasmic ratio
  3. Hyperchromasia
  4. Pleomorphism
  5. Cytological atypia
  6. Mitoses
  7. Basal layer atypia
  8. P16 block patterning
50
Q

What are the histological findings in dVIN?

A
  1. Difficult to interpret
  2. Acanthosis
  3. Parakeratosis
  4. Irregular elongation
  5. Anastomoses of rete ridges
  6. Basal layer atypia
  7. p53 staining
51
Q

What are the infective causes of acute genital ulceration?

A
  1. HSV
  2. Zoster
  3. Syphilis
  4. Monkey pox
  5. Lipschutz
52
Q

What are the inflammatory causes of acute genital ulceration?

A
  1. Pyoderma gangrenosum
  2. Immuno-bullous disease
  3. SLE
53
Q

What are the other non-infective/non-inflammatory causes of acute genital ulceration?

A
  1. Fissuring
  2. Burns
  3. Stevens-Johnson syndrome
  4. Toxic epidermal necrolysis
54
Q

What are the infective causes of chronic genital ulceration?

A
  1. TB
  2. LGV
  3. Chancroid
  4. Hypertrophic HSV
  5. Amoebiasis
  6. Schistosomiasis
  7. Leishmaniasis
55
Q

What are the inflammatory causes of chronic genital ulceration?

A
  1. Crohn’s disease
  2. Behcet’s syndrome
  3. Hidradenitis suppurativa
56
Q

What are the malignant causes of chronic genital ulceration?

A
  1. HSIL
  2. SCC
  3. Extra-mammary Paget’s
  4. Cutaneous lymphoma
57
Q

What infections are linked with NSAGU?

A
  1. EBV
  2. CMV
  3. COVID-19
58
Q

How should NSAGUs be investigated?

A
  1. Screening to exclude STIs
  2. Consider PCR for haemophilias ducreyi
  3. Test for monkey pox if clinical hx
  4. Bacterial culture
  5. Infection serology
59
Q

Which specific disorders are linked with vulval pain?

A
  1. Infectious: CA, HSV, HPV
  2. Inflammatory: LS, LP, immunobullous disorders
  3. Neoplastic: Paget’s, SCC
  4. Neurological: postherpetic neuralgia, nerve compression, neuroma
  5. Trauma
  6. Iatrogenic
  7. Hormone deficiency
60
Q

What factors can be associated with vulvodynia?

A
  1. Other pain syndromes
  2. Gene polymorphisms
  3. Hormones
  4. Inflammation
  5. Musculoskeletal
  6. Neurological
  7. Psychosocial
  8. Structural defects

Gaby’s Green Top Guidelines (51 decks)

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