Vulvar disorders Flashcards
What is Lichen Sclerosis
autoimmune disease where autoAbs attack extracellular matrix and basement membrane, affecting all levels of the skin
Lichen sclerosis is associated with
thyroid disorders (esp. hypothyroid) HLA
The two predicted etiologies of lichen sclerosis are
Genetic (22% have positive FHx)
Environmental (incontinence, infx, contact dermatitis, trauma- koebner phenomenon)
What age women does Lichen Sclerosis affect
mostly POST-menopausal
What are the MC symptoms of lichen sclerosis
**Pruritis!
Dysuria, dyspareunia, anal discomfort
What does lichen sclerosis look like oh physical exam
Sharp, well demarcated white plaques (cellophane paper*) that start around the clitoral area and spread to the perineum
Can look waxy, or hyperkeratotic
Classic: white figure 8 sign
What is the hallmark of lichen sclerosis
purpura
erosions
fissures
Bad cases of lichen sclerosis can present like this
loss (or fusion) of normal anatomical landmarks
Is lichen sclerosis associated with cancer
5% of cases progress to squamous cell carcinoma- RF are elderly and hyperkeratotic lesions
A few cases of atypical nevi and melanoma have been reported (take pigmented lesions SERIOUSLY)
How do you diagnose lichen sclerosis
Full thickness vulvar punch biopsy
How do you treat lichen sclerosis
Topical VERY HIGH potency steroid OINTMENT- Clobetasol 0.5%, apply BID until nl texture, then 1-3x week to maintian
ADE of clobetasol high potency (lichen sclerosis) are
atrophy
dermatitis
rosacea
-SO, when applying make sure it is only to the affected area
Can you cure lichen sclerosis
No, it is autoimmune so it does not go away
need long term follow up!
Squamous cell carcinoma visit after 1 year
What causes lichen simplex chronicus
unknown!
environmental trigger (sweating, excessive hygiene, panty ilners, topical meds, tight clothing)
Emotional tensions induce pruritis
Hx of atopy (eczema) are more prone
What cycle is associated with lichen simplex chronicus
itch-scratch cycle!
itch= scratch= irritate= epidural thickening= inflammatory cells increase sensitivity= itch and REPEAT
How does lichen simplex chronicus present
vulvar pruritis/ BURNING, relieved when scratching
“the itch that rashes”
Patients with lichen simplex chronicus often have underlying
depression or anxiety
On physical exam, lichen simplex chronicus presents as
poorly marginated, red, scaling papules and plaques
initial: weeping, excoriations, crusting
chronic: lichenification, hypopigmentation w/ moisture (anogenital macerated look)
How do you diagnose lichen simplex chronicus
clinically (PE)
can also do a confirmation vulvar punch biopsy
How do you treat lichen simplex chronicus
Remove underlying trigger (wear loose clothing, no panty liners, less aggressive hygiene, decrease stree)
Bath tub soaks
lubricant
low potency steroid cream (hydrocortisone 1-2%, triamcinalone acetonide, betamethasone valerate)
Anti-histamine QHS to Tx pruritis
SSRI daily
What is lichen planus
autoimmune d/o more common in extra-genital areas that occurs mostly in women 50-60
Lichen planus presents with
introital irritation (SF dyspareunia) burning vaginal discharge
On PE for lichen planus you note
Disruption of vulvar anatomy (agglutination of labia minora, introital narrowing) on mucosal or keratinized surface
Non-erosive: lacy, white epithelium (fern like), white striae
Erosive: deep vaginal redness, vulvar erosions, purulent vaginal secretions
How do you treat lichen planus
Low potency topical steroids (like simplex chronicus)- hydrocortisone acetate 25mg suppository QHS
2 line: topical tacrolimus ointment BID, or systemic corticosteroids
vaginal estrogens
vaginal dilators (if you have narrowing of introitus)
Is lichen planus curable
It responds well to Tx, but has a high rate of recurrence
What is vulvar intraepithelial neoplasia
neoplastic cells confined to squamous epithelium
classified as VIN 1, 2, or 3
What are each classification of VIN associated with
VIN1: genital warts
VIN2-3: true precursor to cancer
VIN 2-3 are further classified as
VINu: usual, high risk for HPV
VINd: differentiated
VINu is associated with
HPV 16, 18, 31
younger women
RF for VINu include
smoking*
immunosuppression
multiple sex partners
How does VINu present
ASx
vulvar burning and pruritis
How do you diagnose VINu
colposcopy/ pap smear (bc it is associated w/ high grade CIN)
must biopsy ALL pigmented lesions
How do you do a vulvar colposcopy
stain w/ 3-5% acetic acid, let sit 3-5 min (tissue turns white over lesions)
-DO NOT use acetic acid over inflamed or broken skin
lesions can be raised or flat, turn gray/white or even red/black
How do you treat VINu
No gauranteed cure, but you can try these OFF-label meds (30-50% recurrence rate):
5FU (Efudex) cream
Interferon (Intron A)
Imiquimod (Aldara) 5% cream
Standard of care treatment for VINu is
surgery;
CO2 laser vaporization (destroy entire thickness)
local wide excision (must for VIN3)
vulvectomy
do NOT preform CO2 laser vaporization to Tx VINu if
invasion is suspected
VINd occurs in
older women (>70)
LOWER 1/3 of vagina (upper 2/3 have no abn cells)
-unrelated to HPV
VINd is associated with
squamous cell hyperplasia (Lichen Sclerosis)
unidentified carcinogens + chronic irritated skin
-many have associated untreated lichen sclerosis, lichen simplex chronicus, or squamous hyperplasia
How can you prevent VINd
treat underlying condition!
if lichen sclerosus, high potency Clobetasol ointment
How do you treat VINd
surgical excision
ACOG/ASCCP recommend
Vaccinate (Gardasil)
F/u post Tx w/ colposcopic vulvar inspection at 6-12 months, and annually after that
ACOG/ASCCP state
women with a Hx of VIN are considered at risk for recurrence throughout their lifetime
What is the 4th MC malignancy of the female genital tract
vulvar cancer!
Occurs more in women w/ T2DM, obese, or hypertensive
What is the incidence of vulvar cancer
bimodal peaks;
VINu in women 20-40 (HPV related)
VINd in women 60-70 (chronic irritation)
How does vulvar cancer present
ASx!! so always inspect the vulva!
*Pruritis
vulvar bleeding and pain
On PE what are different findings associated with vulvar cancer
SCC: large, cauliflower lesion - small, ulcerative lesion w/ surrounding hyperkeratosis
Malignant melanoma: raised, dark lesion MC at labia majora and clitoris
BCC: raised lesion w/ ulcerated center and rolled border
What is vulvar cancer staging based on
FIGO
How do you treat vulvar cancer
Primary: complete surgical removal w/ inguinal node resection
Radiotherapy if w/ lymph node spread
What is Behcet’s disease
Autoimmune d/o triggered by exposure in susceptible individuals (bacterial/viral antigens, heavy metals, chemicals)
How does Behcet’s disease present
- Oral ulcers (aphthous ulcers)
- Urogenital lesions (ulcers)
- Skin lesions (erythema nodosum, SF thrombophlebitis, palpable purpura, papulopustular lesions
- Ocular disease (uveitis)
What is the criteria needed to Dx Behcet’s disease
recurrent aphthous ulcers 3x in 1 year PLUS 2 of following:
recurrent genital ulcers
uveitis
skin lesions
+ pathergy test (2mm papule at injection site w/in 48 hrs)
How do you treat Behcet’s disease
Temovate (clobetasol) 0.05% ointment (high potency)
Intralesional triamcinolone
systemic corticosteroids if refractory
Where are bartholin glands found and what do they do
at 4 and 8 o’clock position w/in labia minora
they open into vestibule adjacent to introitus
they secrete mucus like material to maintain moisture of vaginal mucosa
What is a bartholin cyst
ductal obstruction 2/2 trauma or non-specific inflammation
1-3cm large
can develop an abscess from an infected cyst or primary gland infection (STI)
How do bartholin cysts present
acute, painful unilateral labial swelling (less pain if only a cyst)
dyspareunia
pain with sitting or walking
drainage
On PE, a bartholin cyst will look like
tender, fluctuant labial mass w/ surrounding erythema and edema
cellulitis
abscess formation
fever
How do you treat a bartholin cyst
I%D w/ wood catheter to occupy space and prevent recurrence
Culture purulent material
+/- Abx (bactrim, augmentin, 2/3 gen Ceph+Doxy)
Sitz bath 2-3 days 2/p I&D
No intercourse until catheter is removed
What bacterial likely will be found on bartholin cyst culture
polymicrobial; E. coli, MRSA, or STI
In order to prevent recurrence, what can you do for a bartholin cyst
Marsupialization after draining!
What is Vulvodynia
Unexplaines pain and burning in the vulvar area
What causes Vulvodynia
unknown! Suspected causes include: Drop in estrogen (menopause) pelvic floor dysfunction Mood/anxiety d/o (4x more likely) poor allostasis Neuro sensitization 2/2 chronic inflammation (increased epithelial nerve endings and SF blood flow= more sensitive)
How does vulvodynia present
Burning
stinging, irritated, sore, raw, or stabbing
absent clinical findings
no underlying pathology
Introital pain w/ intercourse (avoid coitus!)
What are categories of vulvodynia
generalized vs localized
provoked vs non-provoked
non-sexual, sexual, or both
On PE for vulvodynia you will find
pain limited to vestibule (use Q-tip to palpate vestiule, labia majora, perineum, and interlabial folds)
spasm or ttp on single digit exam
non-specific vestibular erythema
How do you treat vulvodynia (non-pharm)
avoid scented products, tight clothes, vigorous exercise, panty liners
Sitz baths BID w/ thin film of petroleum jelly
couples counseling
pelvic floor PT
How do you Tx vulvodynia (pharm)
topical lidocaine ointment
topical vaginal estrogen w/ testosterone
Amitriptyline/Nortriptyline QHS (start at 10mg, titrate to 50)
SNRI
Gabapentin TID (start at 100, titrate to 1200)
