Disclosures/Conflicts of Interest

Transcription

Disclosures/Conflicts of Interest
Your Diagnosis Is?
Test Your Knowledge of Various
Vulvovaginal Conditions
Chicago
October , 2013
Hope K. Haefner, MD
Disclosures/Conflicts of Interest
Hope K. Haefner, MD
Advisory Board of Merck, Co. Inc.
Off label us of multiple medications discussed
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Written Information Available:
University of Michigan
Center for Vulvar Diseases (Google)
http://obgyn.med.umich.edu/patient-care/
womens-health-library/vulvar-diseases
Then, click on Information on Vulvar Diseases
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Course Objectives
At the end of this course,
the participant should be able to:
• Identify the clinical features of various
vulvovaginal conditions
• Become familiar with a variety of treatments for
skin diseases
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Gross and histologic images
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Test Format
The image shown represents
which vulvar condition?
Test Format
The image shown represents
which vulvar condition?
A

B

C

D

Vulvar intraepithelial neoplasia
Melanoma
Molluscum contagiosum
None of the above
d
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A 20 year old G0 is referred to you with
papillary projections on her vestibule
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Your diagnosis is? (Part 1)
A

B

C

D

Fordyce spots
Micropapillomatosis
Condyloma
Inclusion cysts
Your treatment is? (Part 2)
A

B

C

D

No treatment needed
Laser
Sharp excision
Trichloroacetic acid
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A 64 y.o. G4P4 was recently
diagnosed with lichen sclerosus
(no biopsy performed). She was
started on clobetasol propionate.
She calls complaining of vulvar
pain.
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Your diagnosis is?
A. Lichen planus
B. Pemphigoid
C. Lichen sclerosus with herpes infection
D. Invasive squamous cell carcinoma
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How many different types
of herpes exist that affect
humans with disease?
A.
B.
C.
D.
2
4
6
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http://en.wikipedia.org/wiki/Herpesviridae
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What percent of people with HSV-2
are unaware that they are infected?
A.
B.
C.
D.
10-20%
21 – 40%
50- 70%
Over 80%
61-year-old G3P3 presents with
constant vulvar drainage
*
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If you could only look at one other area of
her body, where would you look?
A.
B.
C.
D.
Eyes
Colon
Axilla
Mouth
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What is this?
A.
B.
C.
D.
Squamous cell carcinoma
Epithelial inclusion cyst
Pyogenic granuloma
Paget’s disease
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What is the staging system used for
Hidradenitis Suppurativa?
A.
B.
C.
D.
WHHS (World Health Hidradenitis
Staging)
Clark’s Staging
Breslow’s Staging
Hurley’s Staging
Hurley’s Criteria for HS Staging
Stage I: abscess formation, single or multiple,
without sinus tracts and cicatrization.
Stage II: recurrent abscesses with tract formation and
cicatrization. Single or multiple, widely separated
lesions.
Stage III: diffuse or near- diffuse involvement,
or multiple interconnected tracts and abscesses across
entire area.
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HS Clinical Features

Chronic lesions
“Tombstone comedones” – open twin
or multi-headed comedones
Chronic draining, malodorous sinuses
Dense fibrous scars
Pitted and pocked acne-like scars
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4 months post op from skin grafts
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2 years after surgery
A 79 y.o. G1P1 is referred
for vulvar lesions
These have been present for years.
Rare itching—none currently
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Your diagnosis is?
A. Epithelial inclusion
cysts
B. Invasive squamous
cell carcinoma
C. Fordyce spots
D. Hidradenitis
suppurativa
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She is not bothered by them;
Your treatment is?
A.
B.
C.
D.
Wide local excision
Radical vulvectomy
No treatment needed
Baby shampoo to
cysts
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Another condition associated with a
“cheesy substance” is?
A. Necrotizing fasciitis
B. Bartholin duct cyst
C. Vulvar intraepithelial
neoplasia
D. Molluscum
contagiosum
*
27 y.o. with 1 1/2 year history of
vulvar irritation. History of genital
herpes. PMH significant for
hypothyroidism.
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She had tried multiple agents for
her condition including topical
steroids, Vagisil, antibiotics, and
Diflucan.
She used oral steroids but
developed knee pain. Protopic
has not helped.
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MICROSCOPIC DIAGNOSIS:
1. Vulva, biopsy: Hyperkeratosis consistent
with lichen simplex chronicus.
2. Right labium majus, biopsy: Scar with
overlying and adjacent lichen simplex
chronicus.
3. Vulva, left bottom, biopsy: Excoriation
with lichen simplex chronicus.
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Skin biopsy: Site: Vulva; Lesional
status: Lesional: No evidence for
pemphigus/pemphigoid. Occasional
cytoid bodies suggestive of lichen
planus.
Your diagnosis is?
A

B

C

D

Lichen planus
Pemphigoid
Molluscum
Severe contact
dermatitis
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Which agent has she reacted to?
A

B

C

D

Diflucan
Topical steroids
Vagisil
Antibiotics
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VULVAR FISSURES
• Two main varieties
• Posterior fourchette fissures
which occur with intercourse
• Skin fold fissures which patients
describe as “paper cuts”
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Treatment
• Rule out candida, lichen sclerosus, atrophy,
herpes, Crohn disease
• Reduce friction
– Ample lubricants (water, silicone, oil based)
– Position changes
• Treat atrophic vaginitis with local estrogen and dilator
• Treat vestibulodynia and vaginismus
• Surgical excision as last resort
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Treat with Dilators
Splash White Bottle Drying
Rack
by Skip Hop
More Thoughts on Drying Racks
Munchkin Sprout
Drying Rack
Handmade!
Target
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Treat with Dilators…
If cost is an issue
Surgical Therapy for Fissures
• Close anterior to
posterior
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A 56 y.o. G3P3 presents with
vulvar irritation.
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D. Birenbaum MD collection
What is your diagnosis?
A

B

C

D

Candidiasis
Bacterial vaginosis
Trichomoniasis
Desquamative inflammatory
vaginitis
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Atrophic Vaginitis
Desquamative Inflammatory
Vaginitis (DIV)
Etiology is unknown; theories
• Lichen planus
• Nonspecific term for any erosive mucosal
disease (LP, pemphigus vulgaris, cicatricial
pemphigoid)
• Group B streptococcal infection
• Specific sterile inflammatory vaginitis,
probably autoimmune
• Common picture of several uncharacterized
diseases
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DIV
Therapy
- Intravaginal clindamycin cream
- If that fails, clindamycin cream and
hydrocortisone suppositories
- If no response, compound a high dose
intravaginal corticosteroid and 2%
clindamycin
15-year-old girl who had sudden onset
of dysuria and severe vulvar burning.
-She was feeling tired.
-She has a cough, a low-grade
fever and malaise.
-Her doctor diagnosed acute HSV
and started her on acyclovir and
sent her to be seen. This is day 3.
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Your Diagnosis Is?
A.
B.
C.
D.
Aphthous Ulcers
Atypical Herpes Simplex Virus
Drug Rash
Trauma – Abuse?
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Aphthous
Ulcers
Vulvar Aphthous Ulcers
Canker sores on the vulva
Acute painful ulcer(s) of sudden onset
Common as acute reactive ulcers
in younger patients - often missed
Synonyms:
 Ulcus vulvae acutum
 Lipschütz ulcers
 Reactive nonsexually related acute genital ulcers*
* Lehman JS et al. J Am Acad Dermatol; 2010;63:44-51
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Aphthous Ulcers: Pathogenesis




Cause is unknown - Idiopathic -90%
Secondary 10%
Genetic factors: positive family history in some cases
Infections may trigger aphthae; but most likely do not
directly cause the lesions
Hypothesis: microbial antigens, by way of molecular
mimicry, induce an autoreactive (autoimmune) process
Vulvar Aphthous Ulcers
“Canker Sores” on the Vulva
•
•
•
•
•
•
•
•
•
Average age is 14 (9-19) yrs
Sudden onset
Usually multiple, painful, well demarcated punched-out ulcers
Size: most <1cm; can be 1-3 cm
Prodrome - flu-like with mild fever, headache, malaise
Duration 1-3 weeks, can last months
One episode, less common recurrent
Past history of oral aphthae – canker sores
Rarely Behcet’s in North America
Huppert JS Lipschutz ulcers: evaluation and management of
acute genital ulcers in women. Dermatol Ther. 2010 Sep-Oct;23(5):533-40
Lai K, Lambert E, Mercurio MG. Aphthous vulvar ulcers in adolescent girls: case report
and review of the literature. J Cutan Med Surg. 2010 Jan-Feb;14(1):33-7. Review.
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Aphthae from Mycoplasma pneumoniae
APHTHAE
Acute (more common)
– usually a prodrome - fever, headache, malaise, GI upset
- EBV, Mycoplasma pneumoniae, viral upper respiratory infection
or gastroenteritis, influenza, Strep, CMV
Recurrent /Complex (recurrent oral and genital aphthae)
Inflammatory Bowel disease - Crohn’s, Ulcerative colitis, Celiac disease
Behcet’s disease
Medications – cytotoxic, NSAIDs
Myeloproliferative disease, cyclic neutropenia, lymphopenia
HIV
Syndromes – rare
PFAPA – periodic fever, aphthae, pharyngitis, adenitis
MAGIC – mouth and genital ulcers with inflamed cartilage
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Aphthous
Ulcers
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Evaluation Vulvar Aphthae
Thorough history and physical – eye, oral, genital
Lab tests –
CBC, diff
Serology for HSV, HIV, EBV, syphilis, CMV,
Mycoplasma pneumoniae
Influenza – swab PCR
HSV - swab for PCR
For Strep -throat swab and antistreptolysin O titre
Tests as indicated for – RARE- paratyphoid and typhoid (stool, blood
culture), TB enterocolitis, Yersinia
GI investigations –
for inflammatory bowel disease and celiac disease
Diagnosis of exclusion – etiology often not found
Vulvar Aphthae – Therapy
Pain control – topical, systemic
Prednisone 40 – 60 mg each morning until pain resolves
(3-5 days, then ½ dose 3-5 days )
- ultrapotent corticosteroid
Educate -Most often a one-time event, can recur
If not controlled:
Intralesional triamcinolone (Kenalog 10) 5-10 mg/ml
colchicine 0.6 mg bid-tid if tolerated
dapsone 50-150 mg per day
dapsone + colchicine
pentoxyfylline 400 mg tid
cyclosporine 100 mg 1-3/d
thalidomide 100-150 mg per day
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Summary
When patients do not respond to therapy
–Reconsider the diagnosis
–Check for infection - fungal, bacterial,
HSV
–Consider contact dermatitis to a
medication, over washing, etc.
–Evaluate for carcinoma
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Great Job!
Questions and Answers
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