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1 Vulvar Cases 2 nd PANHELLANIC CONGRESS on Lower Genital Tract Disorders December Grand Hyatt Athens Lynette J. Margesson MD FRCPC Assistant Professor of Obstetrics & Gynecology and Surgery(Dermatology) Geisel School of Medicine at Dartmouth Lebanon, NH, USA Conflicts of interest None 1

2 Objectives Recognize and discuss vulvar contact dermatitis Recognize and discuss the vulvar lichen sclerosus and lichen planus 59 year old lady has sudden onset of vulvar burning and dysuria. She has had vulvar psoriasis for years and often feels dirty. She is living on a hot sail boat and having problems trying to keep clean. 2

3 3

4 A Psoriasis B Severe Candidiasis C Cellulitis D Contact Dermatitis Your diagnosis is? Severe Irritant Contact Dermatitis from Witch hazel a plant used in creams for inflammation 4

5 What statement is correct? A The vulva need scrubbing to be clean B Use Patch Testing to diagnose irritant contact dermatitis C Soaps and cleansers do not cause vulvar contact dermatitis D Irritant vulvar contact dermatitis is very common Irritant Dermatitis 20% Benzocaine Cleansers & Wipes 5

6 Vulvar Patients are desperate! with Itch, burn, pain They will try anything for relief! Soaps, cleansers, wipes, anesthetics, yeast Rx etc. Misleading labels give a false sense of safety Ask at every visit what exactly they use 36 year old lady has a very itchy vulvar rash for 4 years. The rash flares with heat, friction. The rash does not respond to topical steroids. She is always scratching, even at work. She scratches at night and keeps her husband awake. 6

7 Your Diagnosis Is? A. Lichen Sclerosus B. Lichen Simplex Chronicus C. Contact Dermatitis D. Lichen Planus 7

8 Lichen Simplex Chronicus Lichen Simplex Chronicus Look Carefully Touch to feel thick skin 8

9 Lichen Simplex Chronicus (LSC) End stage of the cycle Itch Scratch Itch Worse with heat, humidity, stress and irritants Scratching feels very good Which conditions are associated with LSC, one or more? A. Lichen Sclerosus B. Atopic Dermatitis C. Psoriasis D. Contact Dermatitis 9

10 Look for more than one problem Contact +/- Infection +/- Dermatosis Treatment of LSC includes all except - A. Topical Corticosteroid Ointment - clobetasol B. Patch Testing for allergic Contact Dermatitis C. Azathioprine D. Systemic Corticosteroids 10

11 Treatment LSC Confirm diagnosis biopsy as needed Control infection bacteria and candida - Stop irritants - Educate patient - Send for Patch Testing if not responding Stop Itch Scratch Itch cycle - Cool sitz baths / gel packs - Sedate at night - Topical superpotent steroids - clobetasol 0.05% ointment bid x 2 wks, OD x2 wks, MWF x 2 wks - Severe systemic steroids prednisone or IM triamcinolone Look for more than one cause A 72 year old lady has vulvar itching for several months. She uses incontinence pads and sits all day. A biopsy showed lichen simplex chronicus. She has failed treatment for eczema. 11

12 Your two diagnoses are? A Contact Dermatitis B Lichen Sclerosus C Psoriasis D Lichen Planus 12

13 Lichen Sclerosus Irritant Contact Pads and sitting Secondary infection in fissures Lichen Sclerosus 13

14 The following statement about Lichen Sclerosus is correct: A. Lichen Sclerosus seldom scars B. Lichen Sclerosus clears at puberty C. Lichen Sclerosus is the commonest cause of chronic vulvar disease D. Asymptomatic Lichen Sclerosus needs no treatment The following statement about Lichen Sclerosus is incorrect: A. Superpotent corticosteroids are first line treatment B. Calcineurin inhibitors, tacrolimus and pimecrolimus, are second line treatments C. All irritating hygiene habits must stop D. Treatment is limited to 12 to 16 weeks 14

15 Two ladies 56 and 59 years old have similar problems. They have vulvar burning, sexual dysfunction with no penetration for over a year. They cannot tolerance any topicals as all burn on application. 15

16 12/26/2018 Do they have the same condition? 1 YES 2 NO LS How to stop topical treatment burning? LP Start with systemic steroids and control infection and any irritating contact 16

17 Which is lichen sclerosus? A B C Benign Mucous Membrane Pemphigoid B Lichen Sclerosus C Lichen Planus A 17

18 Treatment of Vulvar LS includes usually all but: A. Mycophenolate mofetil B. Education C. Clobetasol or halobetasol 0.05% oint daily for 12 weeks then 1-3X/week D. Regular reassessment every 6-12 months Pearls of Lichen Sclerosus Treatment Maintenance Rx is forever to prevent scarring and cancer Consider intralesional Triamcinolone Do not only treat according to symptoms If not responding, reassess, rebiopsy to R/O SCC Make sure they know how to do treatment Make sure still doing Rx often quit! Severe not responding - get help (systemic steroids, methotrexate) 18

19 69 year old lady has had an mildly itchy vulva since the onset of menopause. Now she has a burning vulva with dysuria that has been getting worse for 1-2 years. Estrogen cream and antiyeast creams burn and do not help. She cannot have penetration. 19

20 A Lichen Planus B Scarred vulvitis C Lichen Sclerosus D Lichen Sclerosus and Lichen Planus Your Diagnosis is? LS and LP are seen together and Sheets LS papules Bx LS Eroded Scarred vulva Bx LP often missed 20

21 12/26/2018 Comorbid Vulvar Lichen Planus and Lichen Sclerosus. Day T, Moore S, Bohl TG, Scurry J. J Low Genit Tract Dis Jul;21(3): LS LP 21

22 12/26/2018 LOOK CAREFULLY What 2 skin conditions / rashes do you see? LOOK CAREFULLY Psoriasis LS 22

23 A 52 year old lady has an itchy, burning vulva. She was given topical imidazole cream, and oral fluconazole with no response. The burning is getting worse. 23

24 Your Diagnosis Is? A. Lichen Planus B. Candidiasis C. Contact Dermatitis D. Lichen Sclerosus Lichen Planus 24

25 Lichen Planus A destructive skin hypersensitivity reaction 10 times less common than lichen sclerosus Erosive 85% Lacy 10% Hypertrophic 4% Can have normal vulva and active vaginal LP Which statement about lichen planus is incorrect? A. Histopathology commonly inconclusive B. Usually affects postmenopausal women C. Is easily confused with Lichen Sclerosus D. Commonly onsets in childhood 25

26 Which statement about lichen planus is incorrect? A. LP causes an erosive Inflammatory vaginitis B. LP responds easily to simple treatment C % patients have oral LP and vulvovaginal LP D. On vulva LP typically is non specific with erosions with burning, irritation and sexual dysfunction Lichen Planus On vulva, vagina, mouth often erosive On vulva typically non descript erosions with itching, burning, irritation and sexual dysfunction 26

27 What Factors are Important to diagnose Lichen Planus one or all? A. Morphology B. Onset C. Pathology D. Location Lichen Planus Treatment Confirm diagnosis biopsy - Stop irritants - Educate patient - Stop scratching - Control infection Control inflammation - clobetasol or halobetasol 0.05% oint - intralesional, vaginal or systemic corticosteroids - topical tacrolimus (Protopic ) 0.03%, 0.1% oint - burns 27

28 Difficult Lichen Planus Systemic Corticosteroids: Triamcinolone 1 mg/kg (Kenalog 40 ) IM q4wks x 3 Prednisone mg PO OD, decreasing dose Intravaginal corticosteroids and dilators may be needed Systemic Treatment Mycophenolate mofetil, Methotrexate, Acitretin or Cyclosporine Get Help 28

29 29

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