Vulval conditions Flashcards by Yvonne McFarlane

General advice for vulval conditions

Avoid contact with soap, shampoo, bubble baths
Soap substitute
Avoid tight fitting garments
avoid spermicide

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Lichen sclerosus - pathophysiology

Inflammatory dermatosis
possible autoimmune
autoantibodies to extracellular matrix protein 1

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Lichen sclerosus - describe association with autoimmune conditions

Increased frequency of other autoimmune disorders in females

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Lichen sclerosus - symptoms

Itch
Sorenss
Dyspareunia (introital narrowing)
Urinary symptoms
Constipation (if perianal involvement)
Asymptomatic

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Lichen sclerosus - signs

Pale atrophic areas on vulva
purpura (ecchymosis)
fissuring
erosions (blisters rare)
hyperkeratosis
Loss of architecture
- loss of labia minora
- midline fusion with introital stenosis
- clitoral hood sealed over

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Lichen sclerosus - complications

SCC
clitoral pseudocyst
sexual dysfunction
dysaesthesia

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Risk of SCC in Lichen sclerosus?

<5%

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Lichen sclerosus - histopathology?

epidermal atrophy
hyperkeratosis
sub epidermal hyalinisation of collagen and lichenoid infiltrate

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When is biopsy indicated for Lichen sclerosus?

If diagnosis uncertain
Atypical features
Not responding to first course of steroid

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What other investigation is important for Lichen sclerosus?

Thyroid function

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Lichen sclerosus - treatment regimen

Ultra-potent steroid (eg clobetasol propionate)
Daily 1 month, then alternate days 1 month, then twice weekly
Review 3 months

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Why is ointment based steroid better for anogenital skin?

reduced need for preservatives in ointment

less risk of irritation/contact allergy

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When is oral retinoid therapy used for lichen sclerosus? What important caution must be given?

severe recalcitrant disease

Severely teratogenic - avoid pregnancy for TWO years AFTER treatment completed

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When is surgery indicated in lichen sclerosus?

Co-existent VIN/SCC ONLY

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lichen sclerosus - follow up

Annual

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Lichen Planus - pathophysiology

Inflammatory disorder
Skin, genital and oral mucous membrane
Rare to affect oesophagus, lacrimal duct or external auditory meatus
unknown pathogenesis

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Lichen Planus maybe divided into three main groups - what are they?

Classical
Hypertrophic
Erosive

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Lichen planus - describe classical signs

papules on keratinised anogenital skin
+/- striae inner aspect vulva
hyperpigmentation following

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Lichen planus - describe hypertrophic signs

Rare
Perineum and perianal area
thickened warty plaques can ulcerate/painful
mimic malignancy

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Lichen planus - describe erosive signs

mucosal surfaces eroded
edge of erosion - mauve/grey and a pale network (Wickham’s striae)
friable telangiectasia
patchy erythema

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Erosive Lichen planus disease - complications and why?

scarring and complete stenosis (healing of erosions/delayed treatment)
post coital bleed (telangiectasia)

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Which clinical subtype of Lichen planus most commonly causes symptoms?

Erosive disease

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Lichen planus - complication

Scarring

SCC

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Risk of SCC in Lichen planus?

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What feature of lichen planus differentiates it most from lichen sclerosus?

Mucous membrane involvement specifically involvement of vagina

Lichen planus - histopathology?

irregular saw-toothed acanthuses increased granular layer and basal cell liquefaction band-like dermal infiltrate

When is biopsy indicated for lichen planus?

If diagnosis uncertain Atypical features immunobullous disorder considered in differential

Lichen planus - recommended regimen?

Ultra-potent steroid

What alternative regimens may be consider in complex or recalcitrant lichen planus?

Oral ciclosporin Retinoids Oral steroids

Vulval eczema - 3 types/classification?

Atopic Allergic Irritant

Vulval eczema - signs

``` erythema lichenification excoriation fissuring pallor hyperpigmentation ```

Vulval eczema - complication

Secondary infection

Vulval eczema - what investiations may be useful?

Patch testing | Biopsy - atypical or no response to treatment

Vulval eczema - treatment

Avoid precipitating factor Emollient soap substitute Topical steroid - potency dependent in severity

Which emollient should not be applied as a moisturiser in Vulval eczema? Why?

Aqueous cream | risk of irritant effects

What is a preferred/useful emollient for moisturising in Vulval eczema?

Hydromol

Lichen simplex - what are the 4 main groups

Underlying dermatoses Systemic conditions causing pruritus Environmental factors Psychiatric disorders

Lichen simplex - what systemic conditions may cause pruritus?

``` Renal failure Obstructive biliary disease (PBC or PSC) Hodkins lymphoma Hyper/hypothyroidism Polycythaemia rubra vera ```

Lichen simplex - what environmental factors may cause pruritus?

heat sweat rubbing of clothing harsh skincare products

Lichen simplex - what psychiatric factors are associated?

anxiety depression obsessive compulsive disorder dissociative experiences

What is lichen simplex?

chronic lichenified eczema/dermatitis caused by repetitive scratching and rubbing

Lichen simplex - signs

``` Lichenification - thickened - slightly scaly - pale or earthy-coloured skin - accentuated markings Erosions/fissures excoriation Pubic hair may be lost ```

In addition to history of symptoms for Lichen simplex what other aspect of history may be important?

Mental state examination

What investigations may be indicated for Lichen simplex?

Screen for secondary infection Patch testing Ferritin Biopsy

Lichen simplex - management

``` Avoid precipitating factor Emollient Topical steroid Mild anxiolytic antihistamine at night Consider CBT if co-exisiting mental health issues ```

When might potent steroid be indicated for Lichen simplex?

if lichenified areas

Vulval psoriasis - pathophysiology?

Chronic inflammatory epidermal skin disease | Typically presents as part of plaque or flexural psoriasis

Vulval psoriasis - signs?

Well-demarcated brightly erythematous plaques symmetrical frequently affects natal cleft no scaling fissures involves the sites - scalp, umbilicus, flexors

Vulval psoriasis - what may worsen it?

Irritation from: urine tight fitting clothes sexual intercourse

If required, what type of biopsy should be performed if considering vulval psoriasis?

Punch biopsy

Vulval psoriasis - management?

Avoid precipitating factor Emollient Topical steroid

What potency of steroid should be used in vulval psoriasis?

mild to moderate

What other topical treatments may be consider for vulval psoriasis? What are their limitations?

Weak coal-tar Vitamin D analogues Cause irritation!

Vulval intraepithelial neoplasia - what is it?

Vulval skin condition that may become cancerous low grade change - associated with HPV Differentiated type - associated with lichen sclerosur or planus

Risk of progression to SCC is greatest with which type of VIN? Low grade or differentiated?

Differentiated type

Which HPV is mainly associated with VIN?

HPV 16

What factors increase risk of VIN?

Immunocompromise | Smoking history

VIN - symptoms

lumps erosions burning/itch/irritation asymptomatic

VIN - signs

raised white, erythematous or pigmented lesions Warty, moist or eroded Multifocal lesions common

What are pigmented VIN less also known as?

BOwenoid papulosis

What proportion of VIN develops SCC?

9-18%

How common is recurrent of VIN following treatment?

Common

VIN - histopathology

loss of organisation of squamous epithelium | cytological atypia - differentiated or undifferentiated

What should be considered when performing biopsy for VIN

need MULTIPLE biopsies | risk of missing invasive disease

Why is it important to check cervical cytology up to date in VIN?

association between CIN and VIN

Vulval intraepithelial neoplasia - treatment

Local excision - if small well circumscribed Imiquimod cream 5% Vulvectomy

What is the limitation of vulvectomy for VIN?

recurrence may occur | impaired function/cosmesis

VIN - follow up

Close | Resolution of VIN may occur

Vulval pain/Vulvodynia - define

vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder

How can vulvodynia be categorised?

Generalised or localised | Provoked or unprovoked (or mixture of both)

Localised provoked vulvodynia - cause?

Multifactorial | history of vulvovaginal candidiasis

Localised provoked vulvodynia - symptoms?

vulval pain at Introitus during sexual intercourse or tampon use

Localised provoked vulvodynia - signs?

focal tenderness with cotton tip at Introitus or around clitoris no signs acute inflammatory process

Vulvodynia - complications?

Sexual dysfunction | Psychological morbidity

Localised provoked vulvodynia - management?

``` Avoid irritation factors Emollient soap substitute topical local anaesthetic 15-20min before sex pelvic floor feedback vaginal TENS vaginal trainers CBT or psychosexual counseling ```

What benefit are oral medication for vulvodynia?

Benefit not clear | consider TCA such as amitriptyline

Who is most likely to get benefit from surgery for vulvodynia?

Patients who have responded to topical lidocaine

Unprovoked vulvodynia - clinical features?

pain is longstanding and unexplained may be associated with urinary symptoms, IBS or fibromyalgia Vulva appears normal

Unprovoked vulvodynia - management?

``` MDT approach Combination of therapies Emollient soap substitute Pain modifiers as used in chronic pain topical local anaesthetic CBT acupunture physiotherapy ```