Vulvar disorders Flashcards
What are the etiologies of Lichen Sclerosis? Explain
Autoimmune
Genetic
Environmental
*You have an autoimmune predisposing factor and then you have an environmental factor -> leading to this condition
What are the environmental factors that contribute to causing Lichen Sclerosis?
- incontinence
- infection
- contact dermatitis
- trauma –> Koebner’s phenomenon
Who is Lichen Sclerosis MC in?
postmenopausal women
What are the common presenting sx of Lichen Sclerosis?
Pruritus= MC
Pain
- dysuria
- dyspareunia
- anal discomfort
What area does Lichen Sclerosis involve?
diffuse involvement of vulva
usu. begins periclitorally, spreads to perineal
Describe the appearance of lichen sclerosis
sharply, well-demarcated, white plaques
“cellophane paper”
waxy
What is the hallmark of disease w/ lichen sclerosis?
fragility
-purpura, erosions, fissures
Severe cases of lichen sclerosis can cause what?
loss of normal anatomic landmarks
What are the RFs for squamous cell carcinoma from lichen sclerosis?
*hyperkeratotic lesions (pigment change)
elderly
How do you dx lichen sclerosis?
punch biopsy
How do you tx lichen sclerosis?
Topical super-high potency steroid ointment
=1st line if clobetasol (Temovate) 0.05% ointment
apply 2x daily, then 1-3x /week for maintenance once texture is normal
Is lichen sclerosis curable?
no :(
What are factors that contribute to causing Lichen simplex chronicus?
- Hx of atopy
- Emotional tensions (w/ hx of anxiety/depression)
- Environmental triggers (sweating, excessive hygiene, panty-liners, topical meds, tight clothing)
What is the cycle of Lichen simplex chronicus?
- Inflammatory cell infiltrate increases sensitivity
- itching
- scratching/rubbing
- mechanical irritation
- epidural thickening
REPEAT
What is the clinical presentation of Lichen simplex chronicus?
progressive vulvlar pruritus &/or burning x weeks-months
“itch that scratches”
Describe the PE findings for Lichen simplex chronicus?
poorly marginated
red
scaling papules & plaques
Initial signs of Lichen simplex chronicus?
Chronic signs?
Initial: weeping, excoriations, crusting
Chronic: Lichenification, hypo pigmentation w/ moisture
How do you dx Lichen simplex chronicus?
clinically
vulvar punch biopsy= definitive dx
Tx for Lichen simplex chronicus?
Identify underlying triggers (looser clothing, no panty liners, decrease stress)
-baths
-topical steroid cream (hydrocortisone 1-2%)
-antihistamine
SSRI
Who is lichen planes MC in?
women 50-60
Presentation of lichen planus?
Introital irritation= superficial dyspareunia
burning (less commonly pruritus)
vaginal discharge
What will be seen on PE with lichen planus?
- disruption of vulvar anatomy
- can be seen on mucosal and/or keritonized surface
- Non-erosive disease= lacy, white fern-like
- Erosive disease= deep vaginal redness, vulvar erosions
Tx for lichen planus?
1st line= topical steroid creams
Hydrocortisone acetate 25mg suppository if extends into vagina
What is VIN?
Vulvar intraepithelial neoplasia=
neoplastic cells contained to squamous epithelium
Which classes of VIN are precursors to vulvar cancer?
2 and 3
What strains of HPV is VINu a/w and who is it MC seen in?
HPV 16, 18, 31
younger women
RFs of VINu?
same are CIN
= smoking, immunosuppression, multiple sex partners
Sx of VINu
- asymptomatic
- vulvar burning in about 50%
What diagnostic things must be done in VINu?
colposcopy/Pap smear
What is the standard of care for VINu?
Surgical tx
CO2 laser vaporization, local wide exicsion, vulvectomy
Is VINd related to HPV? Who is it seen in?
NO unrelated
women >70
Does VINd involve the upper and lower epithelium?
No
only the lower 1/3
An older women with untreated squamous cell hyperplasia (lichen sclerosis) is at risk of?
VINd
Tx of VINd
surgical excision
Women with VINu should receive what vaccine?
Gardasil
What are common comorbidities a/w vulvar CA?
obesity, HTN
Type II DM
What age is a/w vulvar CA?
bimodal peak
20-40 (VINu)
60-70 (VINd)
Presentation of vulvar CA?
Asymptomatic
Pruritis= MC sx
vulvar bleeding
vulvar pain
Tx of vulvar CA?
complete surgical removal of tumor w/ inguinal node dissection
What is Bahcet’s disease and how is it caused?
autoimmune
Exposure to agent trimmest disease in pt w/ predisposition (bacterial/viral agents, heavy metals, chemicals)
Clinical presentation of Bahcet’s disease?
oral ulcerations
urogenital lesions
skin lesions
ocular disease- uveitis
Criteria to dx Behcets?
Recurrent oral aphthae at least 3x in 1 year \+ 2 of below: -recurrent genital ulcers -uveitis -skin lesions - (+) Pathergy test
what is the pathergy test
needle insertion in the skin -> 2mm papule at injection site w/in 48 hrs
1st line tx for Bahcet’s
Temovate 0.05% ointment
Clinical presentation of Bartholin cyst/absess
- acute, painful unilateral labial swelling
- dyspareunia
- pain w/ sitting or walking
- drainage
What is tx for Bartholin cyst/absess?
I&D w/ insertion of Word catheter
cultural purulent material
+/- empirical abx therapy
Abx options for Bartholin cyst/absess
- Bactrim
- Augmentin
- 2nd/3rd gen Cephalosporin + Doxy
What are some potential causes of vulvodynia?
- low estrogen (onset around menopause)
- pelvic floor dysfunction
- psych factors (mood/anxiety disorders 4x as likely)
- neurologic sensitization
MC complaint w/ vulvodynia?
what is seen on PE?
Vulvar BURNING
Absent clinical findings
When you do an exam for vulvodynia, where should the pain be when palpating w/ a q-tip
pain limited to the vestibule
Non-pharmacologic options for vulvodynia
Non-pharmacologic:
- avoid scented products, tight clothing, panty liners
- Sitz bath followed by petroleum jelly
- couple counseling
- pelvic floor therapy
pharmacologic tx options for vulvodynia
- topical lidocaine ointment
- topical vaginal estrogen w/ testosterone
- Amitriptyline or nortriptyline
- SNRIs
- Gabapentin
