Benign Vulvar Disease

Mary Lou Baxter MD FRCPC
Sept 23 , 2011
Dermatology
VULVOVAGINAL
DISEASE
Family
Medicine
Gynecology
Lichen Sclerosus*
Vulvodynia
Lichen Simplex Chronicus*
Lichen Planus*
Psoriasis*
OTHER*
* May have extragenital involvement
22%
15%
7%
7%
5%
44%
Lichen Sclerosus (LS)
 Chronic inflammatory disease
 Presents most frequently in postmenopausal women
 Mean age of onset 35-40
 10-15% of cases occur in children
 More common in women, Caucasian population
 15-20% have extragenital lesions (less symptomatic)
 Shoulders, back, chest
Lichen Sclerosus - Appearance




White, thin, fragile patches or shiny plaques
+/-telangiectasiae, hemorrhage
+/-erosions, ulceration
+/-hyperpigmentation
 Bilateral, symmetrical changes
 Loss of normal architecture
 “Figure of 8”,
Lichen Sclerosus - Symptoms
 longstanding pruritus of vulva and perianal area
 +/- pain, bleeding
 +/- dyspareunia, dysuria
 may be asymptomatic
Lichen Sclerosus - Diagnosis
 History and Physical
 Not all loss of labia is Lichen sclerosus
 Doesn’t involve vagina or oral mucosa
 Confirmed by Biopsy
 Except in young and fragile
Lichen Sclerosus - Etiology
 ?Autoimmune
 Thyroid disease, vitiligo
 Familial, genetic
 HLA typing
 Local factors (skin grafts)
Lichen Sclerosus - ?Cancer
 4 –5% risk of vulvar SCC in women with LS (Meffert et
al. 1995)
 In women with vulvar SCC, 25-61% of cases have
adjacent LS (Liebowitch et al. 1990)
 Association but ?premalignant
 Not clear if treatment alters risk
Lichen Sclerosus - Treatment
INITIAL: Topical corticosteroid
 Clobetasol (Dermovate®) 0.05% ointment



BID x 1-2 months, then OD x 1-2 months, reassess
1-3 x per week maintenance, reassess 4-6 mos. OR
taper to less potent steroid od
95 % will have complete or partial symptom relief
Lichen Sclerosus - Treatment
 Oral antihistamines for pruritus (eg hydroxyzine 10-25 mg
qid, cetirizine 10 mg qhs)
 Intralesional triamcinolone 3 mg/ml
 Barrier ointments: petrolatum, zinc oxide or silicone based
(Prevex)
 Patient education: manage expectations
vulvar skin care
maintenance treatment/ followup
literature
Lichen Sclerosus - Treatment
 Testosterone/progesterone creams ineffective
 +/-Estrogen replacement (local/systemic)
 Amitriptyline (low dose) if pain is significant
 Vaginal dilators may be necessary
 (avoid surgery to correct scarring)
Lichen Sclerosus Maintenance Treatment
 Medium or low potency topical corticosteroid
ointment od or clobetasol 0.05% ung 2 – 3 x/wk
 Alternate: tacrolimus ointment (Protopic 0.03 -0.1%)
 Long term followup q 6 -12 mos
 Re-biopsy if suspicious for SCC
LSC - Appearance
 Red/pink patches and plaques
 Lichenification
 Not typically symmetrical
 +/- hyper or hypopigmentation
 +/-erosions, crusts, fissures
 Non-scarring  vulvar architecture maintained
Lichen Simplex Chronicus (LSC)
 Also called squamous hyperplasia, hyperplastic dystrophy
 ?trigger factors + increased cutaneous sensory nerve
activity itch  scratch  itch repetitive trauma,
altered skin barrier and benign epidermal hyperplasia
 May be the end result of chronic dermatitis or any other
pruritic vulvar disease
LSC - Treatment
 Rule out other conditions
 Identify irritants / vulvar skin care
 Topical corticosteroid ointment: medium potency
(eg betamethasone valerate, Prevex B) tapered to
low potency (hydrocortisone 1%, Prevex HC) bid
 Control itch: oral antihistamines, cold, ¼%
menthol added to topical corticosteroid, xylocaine
5% ointment; avoid benzocaine-containing agents
LICHEN PLANUS
Lichen Planus
Highest incidence between age 30-60
 Many mucosal and non-mucosal variants
 Most common is oral LP (1% all women)
 Of this group 50% will have genital involvement
 Etiology unknown ?autoimmune T-cell disorder


70% of vulvar have vaginal involvement
Lichen Planus
Irritating vaginal discharge and/or vulvar pain
 +/- intense pruritus, burning and dyspareunia
 May have vaginal obliteration/stenosis
 Rarely asymptomatic

Lichen Planus Clinical Variants
Papulosquamous (classic)
 Itchy papules and plaques with white lacy pattern on vulvar introitus
Erosive (Vulvo-vaginal-gingival
(VVG) syndrome)
 erosions/ulcers/scarring
 glassy red areas with white borders called Wickham’s striae
 Sterile yellow/green alkaline vaginal discharge
Hypertrophic
 Least common, very itchy
 Often confused with LS or LSC and can look like SCC
Lichen Planus - Treatment

Vulvar involvement
 Clobetasol 0.05% ointment bid x 1 – 3 months
 Medium-potency topical steroid for maintenance (e.g.
betamethasone valerate ointment bid)
 Tacrolimus 0.1% ointment bid (maintenance)
Lichen Planus - Treatment
Vaginal Involvement
 Halobetasol or Clobetasol 0.05% cream 2g
intravaginally qhs (premarin applicator/tampon)
 Cortifoam 1 unit PV qhs (80 mg hydrocortisone)
 Proctotofoam (3.75 mg hydrocortisone/dose)
 Anusol HC suppository (10 mg)
 +/- intravaginal estrogen
Lichen Planus - Treatment

Systemic treatment rarely needed
 Prednisone 40 mg daily orally; taper
 Triamcinolone IM 1mg/kg q4weeks
 Intralesional triamcinolone 3 mg/ml
 Antimalarials, methotrexate, azathioprine, etanercept,
mycophenolate mofitil
Typical psoriasis; well demarcated plaque
with heavy, silvery scale
Vulvar Psoriasis
 pruritus main symptom
 symmetrical, well-demarcated smooth red plaques labia
majora, mons
 fissured, red patches in intergluteal fold
 look for psoriasis in other sites: scalp, nails, extremities
 + family history
 Under-diagnosed
Vulvar Psoriasis - Treatment
 Low-medium potency topical steroid ointment
 +/- tar (3% LCD), ¼% menthol prn itch
 Tacrolimus (Protopic 0.1%) ointment
 Calcipotriol (Dovonex) ointment
 Intralesional triamcinolone 3 mg/ml
 Oral antihistamines prn itch
 Responds to systemic antipsoriatic therapy if indicated (mtx, retinoids,
biologics)
 Minimize trauma, vulvar skin care
Vulvar Dermatitis
 Atopic
 Seborrheic
 Contact : irritant
allergic
 Plasma Cell Vulvitis (Zoon’s)
Irritant contact
dermatitis to
Lysol
Vulvar Dermatitis
 pruritus +/- tenderness, dyspareunia
 ill-defined, red scaling patches labia majora, mons,
perianal, folds
 +/- erosions, LSC if longstanding
Vulvar Dermatitis - Treatment
 General measures:
 minimize moisture
 reduce overzealous washing
 tampons vs pads with menses
 replace pantiliners with incontinence pads
 avoid fragranced or deodorant soaps
 “soak & seal”
Vulvar Dermatitis - Treatment
 medium to low potency topical steroid ointment bid
 barrier ointment (petrolatum, silicone, zinc oxide) prn
 ¼% menthol +/- oral antihistamines prn itch
 oral antifungal prn secondary candidiasis
Zoon’s Plasma Cell Vulvitis
 Deep red-brown +/- petechial glistening patches
 Vestibule, periurethral, labia minora
 Burning/tenderness/dyspareunia
 DDx: LP/VIN 3/fixed drug eruption
 Path: dense band-like infiltrate/ >50% plasma cells
 Tx: potent topical +/intralesional corticosteroids
Topical Steroid Potency
 Classification by steroid molecule (cream base)
Weak – e.g. hydrocortisone 0.05%, 1% , hydrocortisone valerate
(Hydroval)
Moderately potent - e.g. betamethasone valerate (Celestoderm),
mometasone (Elocom), triamcinolone(Aristocort-R)
Potent – e.g. desoximetasone 0.25% (Topicort), fluocinonide
(Lyderm), betamethasone diproprionate( Diprolene, Lotriderm)
Very potent - e.g. clobetasol (Dermovate),
halobetasol proprionate (Ultravate)
Topical corticosteroids
Choice of vehicle affects potency and tolerability
Ointments: less likely to cause irritant or allergic
contact dermatitis
- more potent relative to same steroid in
cream, lotion or gel base
Limit amount and strength for long term use
Educate patient re: correct application
Striae from topical corticosteroid
Secondary
candidiasis
 Treatment: 1% hydrocortisone
powder in clotrimazole cream
bid
 +/- oral fluconazole 150 mg
 And if all else fails:
“If it’s dry, wet it,
if it’s wet, dry it,
and no grease in the creases”
(or ask your local Dermatologist)
References
 Black, Martin ed. Obstetric and Gynecologic
Dermatology, 3rd ed. Elsevier; 2008
 Edwards, Libby and Lynch PJ, Genital Dermatology
Atlas, 2nd ed. Philadelphia: Lippincott Williams &
Wilkins; 2011