Vulval abnormalities

Question 1

Vulval dermatoses - def

Answer 1

Range of benign skin conditions which generally cause white thickening of vulval skin - lichen sclerosus, lichen planus, vulval dermatitis, vulval psoriasis

Question 2

Lichen sclerosus - definition

Answer 2

benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by symptoms of pruritus and pain. Usually develops in anogenital region but can occur on any skin surface

Question 3

Lichen ssclerosus - background

Answer 3

1. Chronic inflammatory condition (lymphocyte-mediated). Associated with other autoimmune disease - e.g. thyroid disease, diabetes, vitiligo, pernicious anaemia
2. May be hereditary - association with HLA-DQ7
3. Incidence: 1 in 300 to 1 in 1000 women
4. Normally in peri-menopausal women, but can occur in young girls (2/3 improve at puberty, may be misdiagnosed as signs of abuse)
5. Long-term risk of vulval squamous cell carcinoma, so need long-term observation, follow-up and biopsy of suspicious lesions

Question 4

Lichen sclerosus - presentation

Answer 4

1. Burning pain or itch, occasionally asymptomatic
2. Figure of 8 appearance around vulva and anus
3. White, shiny, wrinkly, atrophic appearance ‘like tissue paper’. May have white patches, purpura or telangiectasia
4. Hyperkeratosis and lichenification if chronic scratching
5. Over time, can develop loss and fusion of labia minora, narrowing of introitus, resulting in problems with intercourse and micturition

Question 5

Lichen sclerosus - ix/mx

Answer 5

1. Potent corticosteroids - clobetasol propionate 0.05% bd initially once a night for 4 weeks, alternate nights for 4 weeks, once or twice weekly for 4 weeks, then as required for flares (shiny appearance will remain)
2. Follow-up at 3mo to check response
3. Biopsy for dx, if not responding to tx. Also biopsy suspicious lesions (risk of vulval cancer)
4. Check ferritin levels and tx if low. Screen for autoimmune conditions, if suggesteive symptoms (FBE, TFTs, glucose, serum iron, autoimmune antibodies, intrinsic factor, vitamin B12)
5. Annual review with GP and advise urgent contact if ulcers, bleeding or suspicious lesions. Referral to specialit unit for tacrolimus if symptoms not responding

Question 6

Vulval dermatitis (i.e. eczema) - overview (3)

Answer 6

1. Associated with other atopic illnesses (asthma, hay fever or eczema)
2. If scratched so that there is skin thickening -> lichen simplex chronicus
3. Common irritants = soaps, shower gels, condoms, deodorants, creams

Question 7

Vulval dermatitis - presentation (3)

Answer 7

1. Itch - burning and pain secondary to scratching
2. Erythema +/- scaling of skin
3. No loss or fusion of labia

Question 8

Vulval dermatitis - mx

Answer 8

1. Avoid irritants and apply general vulval skin care
2. Low vaginal swabs for secondary infection (e.g. Candida)
3. Severe disease - treat with steroid cream - clobetasol propionate or betamethasone valerate, if less severe. Use bd initially, reduce to od, then twice weekly, as condition improves
4. Consider sedating antihistamine (e.g. chlorphenamine 4mg) at night to prevent scratching
5. Referral to dermatology for patch testing

Question 9

Lichen planus - definition

Answer 9

Lichen planus is an uncommon disorder of unknown cause that most commonly affects middle-aged adults. Lichen planus may affect the skin (cutaneous lichen planus), oral cavity (oral lichen planus), genitalia (penile or vulvar lichen planus), scalp (lichen planopilaris), nails, or esophagus.

Question 10

Lichen planus - presentation

Answer 10

1. Purplish papules and plaques, may have white streaks on top (‘Wickham’s striae’)
2. May cause painful, red, ulcerated areas around introitus
3. Itch
4. Post-coital bleeding
5. Discharge

Question 11

Lichen planus - mx

Answer 11

1. Follow up and biopsy suspicious lesions bc increased risk of vulval cancer
2. Avoid irritant and apply general vulval skin care
3. Low vaginal swabs for secondary infection (e.g. Candida)
4. Severe disease - treat with steroid cream - clobetasol propionate or betamethasone valerate, if less severe. Use bd initially, reduce to od, then twice weekly, as condition improves
5. Consider sedating antihistamine (e.g. chlorphenamine 4mg) at night to prevent scratching

Question 12

Vulval psoriasis - presentation (2)

Answer 12

1. Classically well-defined erythematous patches

2. May have scaling on pubic area, but not necessarily on vulval skin

Question 13

Vulval psoriasis - mx

Answer 13

1. Good vulval skin care
2. Bland emollients
3. Mild topical steroids
   (Note - other psoriatic medications often too harsh for vulval skin)

Question 14

Pruritus vulvae - background

Answer 14

1. Vulval itch
2. Common - 1 in 10 women
3. Persistent itch, often worse at night and may disturb sleep

Question 15

Pruritus vulvae - causes

Answer 15

1. Infection - e.g. candidiasis, threadworms, genital lice (Phthirus pubis), scabies (Sarcoptes scabiei)
2. Vulval dermatoses (lichen sclerosus, vulval dermatitis, lichen planus, vulval psoriasis)
3. Vulval intraepithelial neoplasia or vulval carcinoma
4. Urinary incontinence
5. Systemic conditions - liver failure, uraemia

Question 16

Pruritus vulvae - mx

Answer 16

1. Identify cause and tx appropriately
2. Ix - may need swabs, skin scrapings, skin biopsy, UEC, LFTs
3. General vulval skin care and bland emollients
4. Short course of weak steroid cream (hydrocortisone 1-2 weeks)
5. Sedating antihistamine at night (e.g. chlorphenamine 4mg) - to break itch/scratch cycle`

Question 17

Vulvodynia/vestibulodynia - definition

Answer 17

Dysaesthesia/pain in vulva or around introitus in the absence of a specific cause

Question 18

Vulvodynia/vestibulodynia - presentation (3)

Answer 18

1. Burning, stinging or raw discomfort
2. Typically worse when sitting down
3. May occur as sequelae to inflammatory vulval condition (e.g. lichen sclerosus)

Question 19

Vulvodynia/vestibulodynia - ix/mx

Answer 19

1. Investigate and exclude other causes (?)
2. General vulval skin care
3. Topical local anaesthetic gel
4. Amitriptyline - start on low dose (10mg) 3h before bed and increase as tolerated/required up to 80mg, reduce gradually after 3mo
5. Antiepileptics (used rarely and with specialist referral, e.g. chronic pain service) - gabapentin and pregabalin