#93 Diagnosis and Management of Vulvar Skin Disorders Flashcards
What are the two most common symptoms of vulvar disorders?
Pruritis and pain
What are common causes of acute vulvar pruritis?
Candidia Tinea cruris Contact dermatitis Trichomoniasis Molluscum Scabies (infestations)
Common causes of chronic vulvar pruritis?
Atopic or contact dermatitis Lichen sclerosis, lichen planus, lichen simplex chronicus Psoriasis Genital atrophy VIN or VAIN pager disease HPV infection Crohn’s disease
What is vulvar lichen simplex chronicus
Vulvar lichen simplex chronicus is a chronic eczematous disease characterized by scaling and lichenified plaque with intense and unrelenting itching, which may result in sleep disruption.
What do you see on physical exam for lichen simplex chronicus?
In long-standing disease, the skin appears thickened and leathery, and areas of hyperpigmentation and hypopigmentation may be present. Erosions and ulcers also can develop, most commonly from chronic scratching.
Does lichen simplex chronicus result in sleep disruption?
It may
What %tage of patients with lichen simplex chronicus will report a history of atopic disease?
65-75%
what causes lichen simplex chronicus?
End stage response to a lot of possible initiating factors. environmental factors (eg, heat, excessive sweating, and irritation from clothing or topically applied products) and dermatologic disease (eg, candidiasis, lichen sclerosus)
What is the mean age of onset of lichen sclerosis?
50s-60s
What are the most common symptoms of lichen sclerosis?
pruritus, followed by irritation, burning, dyspareunia, and tearing
What does lichen sclerosis look like on exam?
porcelain-white papules and plaques, often with areas of ecchymosis or purpura. The skin commonly appears thinned, whitened, and crinkling (leading to the description “cigarette paper”). Perianal involvement can create the classic “figure of eight” or hourglass shape. Other findings include fusion of the labia minora, phimosis of the clitoral hood, and fissures
What is the most common form of lichen planus?
Errosive form
What is the classic presentation of lichen planus on mucous membranes?
white, reticulate, lacy, or fernlike striae (Wickham striae)
What is the appearance of lichen planus on genital skin?
Papules are found on the genital skin, they appear dusky pink in color, without an apparent scale, and less well demarcated.
How does errosive lichen planus present in the vulva?
Deep, painful, erythematous erosions appear in the posterior vestibule and often extend to the labia minora, resulting in agglutination and resorption of the labial architecture. The vaginal epithelium can become erythematous, eroded, acutely inflamed, and denuded of epithelium. Erosive patches, if present, are extremely friable. Over time, these eroded surfaces may adhere, resulting in synechiae and, eventually, complete obliteration of the vaginal space
What %tage of postmenopausal women experience vulvovaginal irritation, soreness, and dryness, lower urinary tract problems, and dyspareunia?
50%
Does VIN usually an isolated diagnosis?
Up to 50% of women with VIN will have antecedent or concomitant lower genital tract neoplasia, usually cervical or vaginal intraepithelial neoplasia
What is steroid rosacea?
Withdrawal from use of a moderate- to high-potency topical steroid can result in rebound vasodilation, accompanied by burning and irritation.
When should vulvar bx be performed?
Low threshold except in pediatric population. Tthickening, pebbling, hypopigmentation, or thinning of the epithelium: biopsy will aid in diagnosis and management. Biopsy of hyperpigmented or exophytic lesions, lesions with changes in vascular patterns, or unresolving lesions is particularly important and should be performed in order to rule out carcinoma.
How can you decrease discomfort with local anesthesia administration for vulvar biopsies?
Apply topical anesthetic - combination lidocaine and prilocaine cream or 4% liposomal lidocaine cream (30-60 mins onset of action)
8.4% sodium bicarbonate can be added to the lidocaine (1:10 ratio)
For which vulvar lesions should you use a punch biopsy?
inflammatory diseases, ulcers, pigmented lesions, or suspected tumors. Want to know depth of involvement
For small lesions of vulva what should you biopsy?
Excise entire lesion
For large hyperpigmented lesions on vulva which area should you biposy?
Thickest portion of lesion
What area of an ulcerated vulvar lesion should be biopsied?
The edge
How should you manage labial adhesions?
Observation, unless symptomatic
What is first line therapy for labial adhesions?
Estrogen cream
