BASHH - Management of Vulval Disorders

Question 1

What is the aetiology of lichen sclerosus?

Answer 1

Inflammatory dermatosis of unknown aetiology
Autoantibodies to extracellular matrix protein 1
See increase in other autoimmune conditions also

Question 2

Name the condition: 
Pale white atrophic areas involving the vulva (may be figure of 8 - perianal)
Purpura (ecchymosis)
Can have hyperkeratosis
Blistering is rare
Loss of architecture
Not involving vaginal mucosa

Answer 2

Lichen sclerosus

Question 3

What are the complications of lichen sclerosus?

Answer 3

Malignancy SCC (<5%)
Clitoral pseudo cyst
Sexual dysfunction
Dysaesthesia

Question 4

Name the condition from histology:

Thinned epidermis with sub-epidermal hyalinization and deeper inflammatory infiltrate

Answer 4

Lichen sclerosus

Question 5

What is the treatment for lichen sclerosus?

Answer 5

Ultrapotent topical steroids (Clobetasol) - ideally ointment (less preservative and therefore contact dermatitis)
OD for 1/12
Alt days for 1/12
BW 1/12
Review at 3/12 then PRN
Yearly r/v (with GP if stable disease)

Add in neomycin/nystatin or fucidin if 2dry infection a concern

Question 6

What are the unlicenced treatments for lichen sclerosus?

Answer 6

• Topical calcineurin inhibitors (tacrolimus)
• Oral retinoids in severe recalcitrant dis (derm only)
• UVA phototherapy

Question 7

What is the aetiology of vulval lichen planus?

Answer 7

Inflammatory disorder affecting skin, genital and oral mucous membranes
Rarely; lacrimal duct, oesophagus, ext auditory meatus
?T cell activated response
Weak circulating basement membrane zone antibodies in 60%

Question 8

What are the 3 subtypes of lichen planus?

Answer 8

1. Classical
2. Hypertrophic
3. Erosive (most common vulval)

Question 9

Name the condition:
Eroded mucosal surfaces
At the edges is a mauve and pale network (Wickham’s striae)
May have vaginal erosions with telangiectasia and patchy erythema

Answer 9

Erosive lichen planus

Question 10

What are the complications of lichen planus?

Answer 10

Scarring including vaginal synechiae

SCC up to 3%

Question 11

Name the condition from histology:
Irregular saw-toothed acanthosis
Increased granular layer and basal cell liquefaction
Band-like dermal infiltrate mainly lymphocytic

Answer 11

Lichen planus

Question 12

What is the treatment of lichen planus?

Answer 12

• Ultrapotent topical steroids e.g. clobetasol - only 9% show resolution of inflammation
• Vaginal steroids - enema foam

F/U: 2-3/12 to monitor response
Erosive - longterm specialised follow up

Question 13

What are the 3 types of vulval eczema?

Answer 13

1. Atopic
2. Allergic contact
3. Irritant contact

Question 14

Name the conditon:
Erythema
Lichenification
Excoriation
Fissuring

Answer 14

Vulval eczema

Question 15

What is the treatment of vulval eczema?

Answer 15

Avoid precipitating factor
Emollient soap
Steroids titrated to severity of symptoms

Question 16

What are the 4 groups of lichen simplex?

Answer 16

1. Underlying dermatoses (e.g. fungal infection)
2. Systemic conditions causing pruritis
   
   • e.g. biliary obstruction, Hodgkin’s lymphoma, thyroid
     disease, polycythaemia rubra vera
3. Environmental factors (heat, sweat, rubbing clothing)
4. Psychiatric disorders

Question 17

Name the condition:
Thickened, slightly scaly pale or earthy coloured skin with accentuated marking
Erosions and fissuring
Excoriations
Pubic hair lost over area of scratching

Answer 17

Lichen simplex

Question 18

What are the complications of lichen simplex?

Answer 18

Secondary infection

Question 19

What is the treatment of lichen simplex?

Answer 19

Avoid precipitating factor
Emollient
Toplical steroids - potent when lichenified; combined with antibiotic
Mildly anxiolytic antihistamine at night
CBT if mental health issues

F/U: Mild - PRN
Severe - 1/12 then PRN

Question 20

What is the aetiology of psoriasis?

Answer 20

Chronic inflammatory epidermal disease affecting 2% of general population
Rarely vulva may be the only presenting area

Question 21

Name the condition:
Well demarcated brightly erythematous plaques
Often symmetrical, affect natal cleft
Usually no scaling due to maceration
Fissuring

Answer 21

Psoriasis

Question 22

What are the complications of psoriasis?

Answer 22

May be worsened by Koebner effect by irritation from urine, tight clothes, sex

Question 23

What is the treatment of psoriasis?

Answer 23

• Topical weak/moderate steroid - may need short course of potent
• Coal tar preparations (can cause irritation/foliculitis)
• Vitamin D analogues
• May need systemic Rx if extensive and severe

F/U: PRN; 1/12 if on potent steroids

Question 24

What are the risk factors for VIN?

Answer 24

HPV 16
Differentiated type - lichen sclerosus and planus
Immunocompromised women
Smoking

Question 25

Name the condition:
Raised white, erythematous or pigmented lesions
May be warty, moist or eroded
Commonly multifocal

Answer 25

VIN

Question 26

What are the complications of VIN?

Answer 26

SCC in 9-18%
Recurrence common
Psychosexual consequences especially after surgery

Question 27

Name the condition by histology:
Loss of organisation of squamous epithelium
variable degree of cytological atypia - graded differentiated or undifferentiated and by depth

Answer 27

VIN

Question 28

What are the further investigations with VIN?

Answer 28

Ensure smear up to date
Colposcopy
Anoscopy if peri-anal lesions seen

Question 29

What is the treatment of VIN?

Answer 29

Local excision - Rx of choice for small discrete lesions
5% imiquimod cream (unlicensed), not in preg
Vulvectomy
F/U until 5 years of resolution

Question 30

What are the alternative treatments for VIN?

Answer 30

Local destruction e.g. CO2 laser, cryo
5 fluorouracil cream, not in preg
Supervision