Genital Derm Flashcards
Lichen Simplex Chronicus
Chronic intense pruritus results in repetitive scratching and rubbing so that the skin becomes thickened in a typical lichenified pattern.
Cause: not known, probably genetic…Heat, sweat triggers
Secondary LSC of the vulvar skin can occur with associated conditions:
- Infections: Candida, Tinea cruris
- Dermatoses: Lichen sclerosus, Atopic dermatitis, Psoriasis, Contact dermatitis, Lichen planus
- Neoplasia: Vulvar intraepithelial neoplasia
- Metabolic conditions: Diabetes, Iron deficiency
Diagnosis: from clinical findings. Rule out causes!
-Histologically, eczema, dermatitis, atopic dermatitis, and lichen simplex chronicus appear the same
Biopsy: not helpful
Consider:
Wet mounts: rule out candidiasis
KOH: for dermatophyte fungi (tineas)
Biopsy helpful if there is loss of architectural landmarks (labia minora) to rule out lichen sclerosis
Mgmt: Will resolve, won’t lose vaginal structure hopefully
- Reduce triggers in local environment
- Restore normal barrier layer function
- Reduce inflammation
- Stop itch-scratch cycle
- Breathable fabrics
- Weight loss
- Manage fecal, urinary, vaginal secretions
- Stop excessive bathing
- Lubricant/barrier
- Topical steroids (ointment, high potency) for a month or until clinical improvement
- Antihistamines
Things that Itch
Lichen Simplex Chronicus Intertigo Candidiasis Tinea Erythrasma Psoriasus Lichen Planus Plasma Cell Mucositis Paget's Disease Intraepithlial Neoplasia
Red Papules
Bites/Infestations (Bed bugs, scabies) Cherry Angiomas Prurigo Nodularis (Picker's nodules) Pyogenic Granuloma Urethral Caruncle (and prolapse) Vulvar Endometriosis Hematomas Karposi Sarcoma Crohn's Disease
Pustular Lesions
Folliculitis Furuncles Carbuncles Hidradenitis suppurativa Appear pustular but are solid= Epidermal cysts & Molluscum
Erosive & Vesicular Lesions
Herpes Impetigo Pemphigus Hailey-Hailey Disease Bullous erythema multiforme Fixed drug eruptions Trauma/artifact Erosive malignant (Basal and *Squamous cell carcinomas*) Syphilis Chancroid Aphthous Ulcer
White Lesions
Vitiligo Post0inflamatory hypopigmentation Lichen sclerosis Lichen planus Lichen simplex chronicus White sponge nevus Intraepithelial neoplasia Epidermal cysts Molluscum contagiosum
Skin-colored lesions
Warts Condyloma latum Molluscum Skin tah Intradermal nevi Lipomas Basal & Squamous cell carcinomas
Pigmented Lesions
Seborrheic keratoses Pigmented warts Intraepithelial neoplasia Kaposi sarcoma Genital melanosis Pigmented nevus Melanoma
Seborrheic Ketatoses
Located on trunk, genitals, or lower limbs. Seen a lot on old men.
Scaley, Waxy feel.
Look similar to warts, but darker than flesh tone and flatter. Look like you could scrape them off.
Unknown cause.
Biopsy to rule out malignancy
Intraepithelial Neoplasia
CIN= Cervical VIN= Vulvar VAIN= Vaginal PIN= Penial
Tan/Brown/Black non-symmetric discoloration.
Biopsy for Dx!
Not a cancer b/c it doesn’t penetrate the BM, but need to biopsy and remove so it doesn’t progress
Genital Melanosis
Hyperpigmented asymmetrical spot(s). Flat, dark, smooth. More common on mucosa. More common in middle-older age. Biopsy
Pigmented Nevus
No Biopsy:
-Common nevus (tan/brown, even in color -~90%)
Biopsy:
-Dysplastic nevi (Brown, asymmetrical, speckled color with red/white/blue)
- Atypical nevi (look like a common nevi but larger aka >6mm)
- Nevi associated with Lichen Sclerosis (black, smooth, macule/papule/patch)
Melanoma
Rare, occurs in older age group (50-80)
Black exophytic mass (DDX atypical nevus).
Located on labia, clit, glans, prepuce, shaft, or anus.
May be nodular or ulcerated.
50% are localized disease, 20% multifocal
More common in caucasians
Squamous Cell Carcinoma
Lichen Sclerosis is a precursor
-90% of genitial cancers
-occurs at sites of chronic inflammation or HPV
-more common >65
-red or skin colored plaques that erode
-may have lymphadenopathy
Dx: biopsy
Tx: surgical removal
HPV-Related: Variegated appearance (Pink, Red, Brown, Black, Skin-colored) Longer stage from in-situ to invasive Younger men Multiple lesions Shaft, perianal
Non-HPV Related: Less variegated (Red, White, Skin-colored) More rapid progression from in-situ to invasive Older men Solitary lesions Glans, corona, prepuce Association with lichen sclerosis
Lichen Sclerosis
Autoimmune disorder?
T Lymphocyte-mediated inflammation.
Keyhole presentation around the vagina and anus. Does NOT effect the actual vagina!
Usually in childhood or post-meno.
First presents with severe itching… Labia disappear, skin becomes shiny, vag introits can scar and become smaller/close.
Skin gets thin, crinkly, like tissue paper.
4% chance for SCC if untreated
Biopsy: the tissue paper skin
Tx: Ultra-potent steroid (clobetasol) and taper off to 1-2x/week if well controlled, want to get to stop scratching. Tx for life.
Basal Cell Carcinoma
-5% of genital cancers
-increased incidence in fair skinned, older people
-itchy
-rolled edges, elevated
-local invasion and necrosis
-rare metasteses
Dx: biopsy
Tx: surgical removal
Extramammary Paget’s Disease
primary or secondary forms
Could initially present with itching.
Well demarcated red plaque, rough, scaling with moist surface, white thickened islands, erosions.
Onset usually >50yrs
More common in women
Needs Biopsy! 10-20% correlation with an underlying GU/GI malignancy.
Lichen Planus
Autoimmune disorder, cell-mediated.
Usually self-limiting, resolves in a few years. Can reoccur, painful.
May present with white lacy pattern or erosive, look all over body (mouth, wrists, vulvar area)
Dx via biopsy
Tx: Erosive form is very hard to treat! Hypertrophic and papulosqualmous respond well to tx.
topical Ultra-potent steroid (clobetasol) and taper off to 1-2x/week if well controlled.
Some drugs induce lichen planus–like (lichenoid) eruptions anywhere on the body, including in the vulvar area. These include beta blockers, hydrochlorthiazide, methyldopa, penicillamine, quinidine, non-steroidal anti-inflammatories (NSAIDs), angiotenein converting enzyme (ACE) inhibitors, sulfonylurea agents, carbamezepine, gold, lithium, and quinine.
Erythrasma
Looks like Tinea, but no central clearing.
Caused by Corynebacterium minutissimum
Located proximal/medial thigh, crural crease.
Spares the scrotum, vulva, and penis usually.
Dx: neg Wood’s light, neg KOH
Tx: Erythro 500mg BID 1-2weeks
Seborrheic Dermatitis/Intertrigo
Red patches and scales with indistinct margins located where moisture is retained (skin folds- axillae, umbilicus, crural folds).
May have superimposed candida infection.
Tx: reduce heat and moisture, topical steroid (hydrocor 1-2.5%, triamcinolone 0.1%)
