Vulval Conditions Flashcards
What are the differentials of vulval itch?
Candidiasis, trichomoniasis, pubic lice, scabies, vulval intra-epithelial neoplasia, atrophic vulvovaginitis, dermatitis, psoriasis, lichen sclerosis/planus/simplex chronicus
What is lichen sclerosis?
Inflammatory scarring dermatoses of ano-genital skin
Who tends to suffer from lichen sclerosis?
6-10x more common in women
2 peaks = prepubertal girls and postmenopausal women
What tends to be the clinical course of lichen sclerosis?
Usually resolves in children but tends to be more chronic and relapsing in adults
What are the symptoms of lichen sclerosis?
Itch = worse at night
Pain, dyspareunia, constipation (especially children)
What are some red flag signs for vulval cancer?
Persistent ulcer, lump, weight loss
What are some risk factors for lichen sclerosis?
21% linked with other autoimmune diseases (especially thyroid)
Smoking carries higher risk of developing complications
Can lichen sclerosis have a psychosocial impact?
Yes
What are the examination signs of lichen sclerosis?
White papules and plaques = figure 8 pattern on vulval and perineal skin, vagina not involved
Ecchymosis, erosions, fissures, architectural change
How common is extra-genital skin involvement in lichen sclerosis?
Occurs in 10% of women with vulval disease
What is the main differential of lichen sclerosis?
Lichen planus
What are some features of lichen planus?
Affects genital skin and mucous membranes
Usually patients aged 50-60
Associated with autoimmune disease
What are the symptoms of lichen planus?
Itch, pain, dyspareunia, discharge
May be oral, nail or hair involvement
What are the other differentials of lichen sclerosis?
Vitiligo, mucous membrane pemphigoid, morphoea
What is the main complication of lichen sclerosis?
Squamous cell carcinoma = up to 5% risk
What is some general skin care advice for patients with vulval itch?
Wash gently once daily with soap substitute and try to avoid scratching/irritants
Apply emollients to relieve dryness and itching, and to act as barrier = Epimax is first line
What is the treatment of lichen sclerosis?
General skin care
Super potent topical steroid = clobetasol propionate 0.05% (dermovate), 1/2 fingertip amount, 12 week regime
What initial investigations are done for vulval itch?
High vaginal swab for infection and STI screen
What are the symptoms of atrophic vulvovaginitis?
Itch, pain, mild thin white discharge, vaginal dryness, dyspareunia
What are the signs of the atrophic vulvovaginitis?
Atrophy of labia, narrowing of vaginal opening, petechial haemorrhage
What is atrophic vulvovaginitis associated with?
Low levels of oestrogen = tends to occur in postmenopausal women
What are the symptoms of the genitourinary syndrome of the menopause?
Narrowing of the vaginal opening, labial atrophy, decrease in vaginal length, thinning of vaginal wall, urinary symptoms
How is atrophic vulvovaginitis treated?
Vaginal oestrogen = can be taken with HRT
Perineal massage, lubricants, vibrator
How can vaginal oestrogen be delivered?
Cream, oestring implant (lasts 3 months), pessary
What are the benefits of vaginal oestrogen?
Doesn’t cause endometrial hyperplasia/cancer with long term use and has little systemic absorption
What may women with atrophic vaginitis develop?
Secondary vaginismus = body anticipates pain and tenses, increasing pain during sex further