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DipGUM > Vulval conditions > Flashcards

Vulval conditions Flashcards

1
Q

General advice for vulval conditions

A

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

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2
Q

Lichen sclerosus - pathophysiology

A

Inflammatory dermatosis
possible autoimmune
autoantibodies to extracellular matrix protein 1

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3
Q

Lichen sclerosus - describe association with autoimmune conditions

A

Increased frequency of other autoimmune disorders in females

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4
Q

Lichen sclerosus - symptoms

A 
Itch
Sorenss
Dyspareunia (introital narrowing)
Urinary symptoms
Constipation (if perianal involvement)
Asymptomatic
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5
Q

Lichen sclerosus - signs

A 
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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6
Q

Lichen sclerosus - complications

A

SCC
clitoral pseudocyst
sexual dysfunction
dysaesthesia

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7
Q

Risk of SCC in Lichen sclerosus?

A

<5%

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8
Q

Lichen sclerosus - histopathology?

A

epidermal atrophy
hyperkeratosis
sub epidermal hyalinisation of collagen and lichenoid infiltrate

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9
Q

When is biopsy indicated for Lichen sclerosus?

A

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

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10
Q

What other investigation is important for Lichen sclerosus?

A

Thyroid function

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11
Q

Lichen sclerosus - treatment regimen

A

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

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12
Q

Why is ointment based steroid better for anogenital skin?

A

reduced need for preservatives in ointment

less risk of irritation/contact allergy

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13
Q

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

A

severe recalcitrant disease

Severely teratogenic - avoid pregnancy for TWO years AFTER treatment completed

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14
Q

When is surgery indicated in lichen sclerosus?

A

Co-existent VIN/SCC ONLY

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15
Q

lichen sclerosus - follow up

A

Annual

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16
Q

Lichen Planus - pathophysiology

A

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

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17
Q

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

A

Classical
Hypertrophic
Erosive

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18
Q

Lichen planus - describe classical signs

A

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

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19
Q

Lichen planus - describe hypertrophic signs

A

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

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20
Q

Lichen planus - describe erosive signs

A

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

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21
Q

Erosive Lichen planus disease - complications and why?

A

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

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22
Q

Which clinical subtype of Lichen planus most commonly causes symptoms?

A

Erosive disease

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23
Q

Lichen planus - complication

A

Scarring

SCC

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24
Q

Risk of SCC in Lichen planus?

A

3%

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25
Q

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

A

Mucous membrane involvement specifically involvement of vagina

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26
Q

Lichen planus - histopathology?

A

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

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27
Q

When is biopsy indicated for lichen planus?

A

If diagnosis uncertain
Atypical features
immunobullous disorder considered in differential

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28
Q

Lichen planus - recommended regimen?

A

Ultra-potent steroid

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29
Q

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

A

Oral ciclosporin
Retinoids
Oral steroids

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30
Q

Vulval eczema - 3 types/classification?

A

Atopic
Allergic
Irritant

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31
Q

Vulval eczema - signs

A 
erythema
lichenification
excoriation
fissuring
pallor
hyperpigmentation
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32
Q

Vulval eczema - complication

A

Secondary infection

33
Q

Vulval eczema - what investiations may be useful?

A

Patch testing

Biopsy - atypical or no response to treatment

34
Q

Vulval eczema - treatment

A

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

35
Q

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

A

Aqueous cream

risk of irritant effects

36
Q

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

A

Hydromol

37
Q

Lichen simplex - what are the 4 main groups

A

Underlying dermatoses
Systemic conditions causing pruritus
Environmental factors
Psychiatric disorders

38
Q

Lichen simplex - what systemic conditions may cause pruritus?

A 
Renal failure
Obstructive biliary disease (PBC or PSC)
Hodkins lymphoma
Hyper/hypothyroidism
Polycythaemia rubra vera
39
Q

Lichen simplex - what environmental factors may cause pruritus?

A

heat
sweat
rubbing of clothing
harsh skincare products

40
Q

Lichen simplex - what psychiatric factors are associated?

A

anxiety
depression
obsessive compulsive disorder
dissociative experiences

41
Q

What is lichen simplex?

A

chronic lichenified eczema/dermatitis caused by repetitive scratching and rubbing

42
Q

Lichen simplex - signs

A 
Lichenification
- thickened
- slightly scaly
- pale or earthy-coloured skin
- accentuated markings
Erosions/fissures
excoriation
Pubic hair may be lost
43
Q

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

A

Mental state examination

44
Q

What investigations may be indicated for Lichen simplex?

A

Screen for secondary infection
Patch testing
Ferritin
Biopsy

45
Q

Lichen simplex - management

A 
Avoid precipitating factor
Emollient
Topical steroid
Mild anxiolytic antihistamine at night
Consider CBT if co-exisiting mental health issues
46
Q

When might potent steroid be indicated for Lichen simplex?

A

if lichenified areas

47
Q

Vulval psoriasis - pathophysiology?

A

Chronic inflammatory epidermal skin disease

Typically presents as part of plaque or flexural psoriasis

48
Q

Vulval psoriasis - signs?

A

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

49
Q

Vulval psoriasis - what may worsen it?

A

Irritation from:
urine
tight fitting clothes
sexual intercourse

50
Q

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

A

Punch biopsy

51
Q

Vulval psoriasis - management?

A

Avoid precipitating factor
Emollient
Topical steroid

52
Q

What potency of steroid should be used in vulval psoriasis?

A

mild to moderate

53
Q

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

A

Weak coal-tar
Vitamin D analogues
Cause irritation!

54
Q

Vulval intraepithelial neoplasia - what is it?

A

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

55
Q

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

A

Differentiated type

56
Q

Which HPV is mainly associated with VIN?

A

HPV 16

57
Q

What factors increase risk of VIN?

A

Immunocompromise

Smoking history

58
Q

VIN - symptoms

A

lumps
erosions
burning/itch/irritation
asymptomatic

59
Q

VIN - signs

A

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

60
Q

What are pigmented VIN less also known as?

A

BOwenoid papulosis

61
Q

What proportion of VIN develops SCC?

A

9-18%

62
Q

How common is recurrent of VIN following treatment?

A

Common

63
Q

VIN - histopathology

A

loss of organisation of squamous epithelium

cytological atypia - differentiated or undifferentiated

64
Q

What should be considered when performing biopsy for VIN

A

need MULTIPLE biopsies

risk of missing invasive disease

65
Q

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

A

association between CIN and VIN

66
Q

Vulval intraepithelial neoplasia - treatment

A

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

67
Q

What is the limitation of vulvectomy for VIN?

A

recurrence may occur

impaired function/cosmesis

68
Q

VIN - follow up

A

Close

Resolution of VIN may occur

69
Q

Vulval pain/Vulvodynia - define

A

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

70
Q

How can vulvodynia be categorised?

A

Generalised or localised

Provoked or unprovoked (or mixture of both)

71
Q

Localised provoked vulvodynia - cause?

A

Multifactorial

history of vulvovaginal candidiasis

72
Q

Localised provoked vulvodynia - symptoms?

A

vulval pain at Introitus during sexual intercourse or tampon use

73
Q

Localised provoked vulvodynia - signs?

A

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

74
Q

Vulvodynia - complications?

A

Sexual dysfunction

Psychological morbidity

75
Q

Localised provoked vulvodynia - management?

A 
Avoid irritation factors
Emollient soap substitute
topical local anaesthetic 15-20min before sex
pelvic floor feedback
vaginal TENS
vaginal trainers
CBT or psychosexual counseling
76
Q

What benefit are oral medication for vulvodynia?

A

Benefit not clear

consider TCA such as amitriptyline

77
Q

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

A

Patients who have responded to topical lidocaine

78
Q

Unprovoked vulvodynia - clinical features?

A

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

79
Q

Unprovoked vulvodynia - management?

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

DipGUM (39 decks)

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