Vulvar

Question 1

Definition of bacterial vaginosis

Answer 1

Clinical criteria plus positive cultures from affirm, microscopy, a culture.

Clinical criteria: Thin white discharge, pH of vaginal fluid greater than 4.5, wiff test

Question 2

Normal pH of the vagina

Answer 2

3.8-4.5 reproductive

>4.7 pre/post reproductive

Question 3

Treatment of Contact Vulvitis

Answer 3

Remove All Potential Irritants
 Baking Soda Soaks
 Daily Skin Protectant
Zinc oxide ointment / petroleum / Aquaphilic /
Veg. oil
 Low to Medium Potency Steroid Ointment
Triamcinolone – nystatin (Mycolog II)
• Triamcinolone (Kenalog)
• Hydrocortisone butyrate (Locoid)
• Hydrocortisone valerate (Westcort)

Question 4

Lichen Simplex

Answer 4

Eczema
Characterized by lichenified plaque with
intense and unrelenting itching (+/- scaling)
 Sleep disruption
 Occurs primarily in mid- to late adult life
 Up to 75% have history of atopic disease
 Diagnosis is clinical

Improve Skin Barrier Function
 Stop Excessive Hygiene
 Avoid irritants (perfumes, dyes)
 Tepid Soaks
 Soothing, promotes circulation, cleans
 Daily Skin Protection
 “Band-Aid” effect (zinc, Vaseline, veg. oil)

(control nocturnal scratching)
 Tricyclic antidepressant; e.g. amitriptyline
 Antihistamine; e.g. hydroxyzine
 Steroid
BID x 2 weeks
 HS x 2 weeks
 M-W-F HS x 2 weeks
 Return 6-8 weeks
 With or without antipruritic (scabicide)
 Pramoxine

Question 5

LIchen Sclerosus

Answer 5

Fusion of labia minora
Phimosis of the citerol hood
Thin, white skin, localized to the labia minor and /
or labia major
 Vagina is NOT involved
5% association with Vulvar Squamous Cell CA
 Most common cause of chronic vulvar disease
- Remove Irritants / Comfort Care / Tepid Soaks
 Topical steroid application – OINTMENT
 Clobetasol (Temovate 0.05%)
 Betamethasone (Valisone 0.1%)
 Lowest potency for maintenance!

Question 6

Lichen Planus

Answer 6

Likely related to cell-mediated immunity
-Approximately 1% of population has oral
 Of women with oral disease, 20-25% have genital
- reticulated, white
flat-topped papules and plaques (lichenification)
-Topical and systemic corticosteroids
 topical calcineurin inhibitors (tacrolimus)
 oral cyclosporine
 Hydroxychloroquine (Plaquenil)
 Oral retinoid
 Methotrexate
 Azathioprine (Imuran)
 Cyclophosphamide

Question 7

Lichens (sclerosus, Planus, Simplex)

Answer 7

Sclerosis–itching or burning\scars\not in the vagina
Lichen planus–burning\scars\in the vagina and mouth
Lichen simplex–itching\no scars\not in the vagina

Question 8

Vulvodynia

Answer 8

Comfort Care / Remove Irritants
• Cool packs for burning
• Diet (low oxalate / Ca++) ? 1 in 44!
Topical – lidocaine / compounded formulations
 Injections- Botulinum toxin, Enoxaparin, Blocks
 Systemic (neuropathic mechanism)
 Tricyclics – amitriptyline (low dose- start
10mg)
 Other antidepressants – duloxetine,
venlafaxine, SSRI
 Antiepileptics – gabapentin, pregabalin,
topiramate