Vulval conditions Flashcards
General advice for vulval conditions
Avoid contact with soap, shampoo, bubble baths
Soap substitute
Avoid tight fitting garments
avoid spermicide
Lichen sclerosus - pathophysiology
Inflammatory dermatosis
possible autoimmune
autoantibodies to extracellular matrix protein 1
Lichen sclerosus - describe association with autoimmune conditions
Increased frequency of other autoimmune disorders in females
Lichen sclerosus - symptoms
Itch Sorenss Dyspareunia (introital narrowing) Urinary symptoms Constipation (if perianal involvement) Asymptomatic
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
Lichen sclerosus - complications
SCC
clitoral pseudocyst
sexual dysfunction
dysaesthesia
Risk of SCC in Lichen sclerosus?
<5%
Lichen sclerosus - histopathology?
epidermal atrophy
hyperkeratosis
sub epidermal hyalinisation of collagen and lichenoid infiltrate
When is biopsy indicated for Lichen sclerosus?
If diagnosis uncertain
Atypical features
Not responding to first course of steroid
What other investigation is important for Lichen sclerosus?
Thyroid function
Lichen sclerosus - treatment regimen
Ultra-potent steroid (eg clobetasol propionate)
Daily 1 month, then alternate days 1 month, then twice weekly
Review 3 months
Why is ointment based steroid better for anogenital skin?
reduced need for preservatives in ointment
less risk of irritation/contact allergy
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
When is surgery indicated in lichen sclerosus?
Co-existent VIN/SCC ONLY
lichen sclerosus - follow up
Annual
Lichen Planus - pathophysiology
Inflammatory disorder
Skin, genital and oral mucous membrane
Rare to affect oesophagus, lacrimal duct or external auditory meatus
unknown pathogenesis
Lichen Planus maybe divided into three main groups - what are they?
Classical
Hypertrophic
Erosive
Lichen planus - describe classical signs
papules on keratinised anogenital skin
+/- striae inner aspect vulva
hyperpigmentation following
Lichen planus - describe hypertrophic signs
Rare
Perineum and perianal area
thickened warty plaques can ulcerate/painful
mimic malignancy
Lichen planus - describe erosive signs
mucosal surfaces eroded
edge of erosion - mauve/grey and a pale network (Wickham’s striae)
friable telangiectasia
patchy erythema
Erosive Lichen planus disease - complications and why?
scarring and complete stenosis (healing of erosions/delayed treatment)
post coital bleed (telangiectasia)
Which clinical subtype of Lichen planus most commonly causes symptoms?
Erosive disease
Lichen planus - complication
Scarring
SCC
Risk of SCC in Lichen planus?
3%
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
