An All Too Familiar Story

Transcription

1 All that itches is not yeast Michele Ambor Hutz NP An All Too Familiar Story A patient presents to her provider complaining of frequent yeast infections. The provider prescribes treatment without an exam assuming the patient s self diagnosis is correct. The patient explains that she has tried numerous OTC preparations without any relief. The patient is tested for HIV and diabetes, again assuming she has had yeast infections The patient calls back some weeks later and tells the office staff that the medication did not work. The patient is then prescribed another antifungal treatment with plenty of refills to treat persistent yeast The Story Continues Eventually the patient is referred to Gyn for chronic vaginal itching. The patient is desperate at this point since nothing has worked to treat her itching. These types of patients are encountered daily in gyn offices The first thing I tell the patient is that I do not think you have a yeast infection so let s figure out what is really going on. 1

2 The Pitfalls of Self Diagnosis Self diagnosis has been shown to be correct less than one third of the time, leading to millions of dollars wasted on treating the wrong entity. Diagnosis by phone has been shown only to be marginally better than chance. The symptoms of vaginitis are often confused and/or complicated by irritation, allergy or other systemic disease. Miller, Merida MD Recurrent Vulvovaginitis: Tips for treating a common condition Contemporary OB/GYN August 1, 2014 Look Before You Treat Dermatitis Lichen simplex chronicus Eczema Atrophic vaginitis Lichen Sclerosis Psoriasis VIN/ vulvar cancer Vulvar vaginal itching Hidradenitis supurativa Staph candida BV Trich Herpes HPV 2

3 Vaginitis Curriculum Vaginal Environment The vagina is a dynamic ecosystem that contains approximately 10 9 bacterial colony forming units. Normal vaginal discharge is clear to white, odorless, and of high viscosity. Normal bacterial flora is dominated by lactobacilli other potential pathogens present. Acidic environment (ph ) inhibits the overgrowth of bacteria Some lactobacilli also produce H 2 O 2, a potential microbicide 7 Vaginitis Curriculum Wet Preps: Common Characteristics Saline: 40X objective RBCs PMN Sperm Squamous epithelial RBCs cell Artifact Source: Seattle STD/HIV Prevention Training Center at the University of Washington 8 Vaginitis Curriculum Wet Prep: Lactobacilli and Epithelial Cells Lactobacilli Saline: 40X objective Lactobacilli Artifact NOT a clue cell Source: Seattle STD/HIV Prevention Training Center at the University of Washington 9 3

4 Trichomoniasis Vulvovaginal Candidiasis (VVC) Bacterial Vaginosis (BV) 10 Vaginitis Curriculum Vaginitis Differentiation Symptom presentation Vaginal discharge Clinical findings Normal Trichomoniasis Candidiasis Clear to white Itch, discharge, 50% asymptomatic Frothy, gray or yellowgreen; malodorous Cervical petechiae strawberry cervix Itch, discomfort, dysuria, thick discharge Thick, clumpy, white cottage cheese Inflammation and erythema Bacterial Vaginosis Odor, discharge, itch Homogenous, adherent, thin, milky white; malodorous foul fishy Vaginal ph > 4.5 Usually < 4.5 > 4.5 KOH whiff test Negative Often positive Negative Positive NaCl wet mount Lacto-bacilli Motile flagellated protozoa, many WBCs Few WBCs Clue cells (> 20%), no/few WBCs KOH wet mount Pseudohyphae or spores if nonalbicans species 11 Vaginitis Curriculum Vaginitis Usually characterized by: Vaginal discharge Vulvar itching Irritation Odor Common types Trichomoniasis (15% 20%) Bacterial vaginosis (40% 45%) Vulvovaginal candidiasis (20% 25%) 12 4

5 Candida in the Older women Candida thrives in a well estrogenized, glycogenated environment. Candida is unlikely with vaginal atrophy. Candida in a post menopausal woman is likely to be non albicans. Risk factors for candida: HRT and immune suppression Candidiasis Curriculum Clinical Manifestations Vulvovaginal Candidiasis Source: Health Canada, Sexual Health and STI Section, Clinical Slide Gallery 14 Candidiasis Curriculum Clinical Manifestations Clinical Presentation and Symptoms Vulvar pruritis is most common symptom Thick, white, curdy vaginal discharge ("cottage cheese like") Erythema, irritation, occasional erythematous "satellite" lesion External dysuria and dyspareunia 15 5

6 Candidiasis Curriculum PMNs and Yeast Buds Diagnosis Saline: 40X objective Folded squamous epithelial cells PMNs Yeast buds Source: Seattle STD/HIV Prevention Training Center at the University of Washington 16 Candidiasis Curriculum Yeast Pseudohyphae 10% KOH: 10X objective Masses of yeast pseudohyphae Diagnosis Lysed squamous epithelial cell Source: Seattle STD/HIV Prevention Training Center at the University of Washington 17 Candidiasis Curriculum Management CDC Recommended Treatment Regimens Intravaginal agents: Butoconazole 2% cream, 5 g intravaginally for 3 days Butoconazole 2% sustained release cream, 5 g single intravaginally application Clotrimazole 1% cream 5 g intravaginally for 7 14 days Clotrimazole 100 mg vaginal tablet for 7 days Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days Clotrimazole 500 mg vaginal tablet, 1 tablet in a single application Miconazole 2% cream 5 g intravaginally for 7 days Miconazole 100 mg vaginal suppository, 1 suppository for 7 days Miconazole 200 mg vaginal suppository, 1 suppository for 3 days Nystatin 100,000 unit vaginal tablet, 1 tablet for 14 days Tioconazole 6.5% ointment 5 g intravaginally in a single application Terconazole 0.4% cream 5 g intravaginally for 7 days Terconazole 0.8% cream 5 g intravaginally for 3 days Terconazole 80 mg vaginal suppository, 1 suppository for 3 days Oral agent: Fluconazole 150 mg oral tablet, 1 tablet in a single dose Note: The creams and suppositories in this regimen are oil-based and may weaken latex condoms and diaphragms. Refer to condom product labeling for further information. Over-the-counter (OTC) preparations. 18 6

7 Trichomoniasis Curriculum Clinical Manifestations Strawberry cervix due to T. vaginalis Source: Claire E. Stevens/Seattle STD/HIV Prevention Training Center at the University of Washington 19 Trichomoniasis Curriculum Wet Prep: Trichomoniasis Diagnosis Saline: 40X objective PMN Yeast buds Trichomonas* PMN Trichomonas* Squamous epithelial cells *Trichomonas shown for size reference only: must be motile for identification Source: Seattle STD/HIV Prevention Training Center at the University of Washington 20 Trichomoniasis Curriculum Pathogenesis Trichomonas vaginalis Source: CDC, National Center for Infectious Diseases, Division of Parasitic Diseases 21 7

8 Trichomoniasis Curriculum Management Treatment CDC recommended regimen Metronidazole 2 g orally in a single dose CDC recommended alternative regimen Metronidazole 500 mg twice a day for 7 days No follow up necessary 22 Bacterial Vaginosis Curriculum Pathogenesis Microbiology Overgrowth of bacteria species normally present in vagina with anaerobic bacteria BV correlates with a decrease or loss of protective lactobacilli: Vaginal acid ph normally maintained by lactobacilli through metabolism of glucose/glycogen Hydrogen peroxide (H 2 O 2 ) is produced by some Lactobacilli,sp. H 2 O 2 helps maintain a low ph, which inhibits bacteria overgrowth Loss of protective lactobacilli may lead to BV 23 BV in the Older Woman BV is estrogen dependent. Postmenopausal women unless they are on HRT rarely get BV 8

9 Bacterial Vaginosis Curriculum Diagnosis BV Diagnosis: Amsel Criteria Vaginal ph >4.5 Amsel Criteria: Must have at least three of the following findings: Presence of >20% per HPF of "clue cells" on wet mount examination Positive amine or "whiff" test Homogeneous, non-viscous, milky-white discharge adherent to the vaginal walls 25 Bacterial Vaginosis Curriculum Diagnosis Wet Prep: Bacterial Vaginosis Saline: 40X objective NOT a clue cell Clue cells NOT a clue cell Source: Seattle STD/HIV Prevention Training Center at the University of Washington 26 Bacterial Vaginosis Curriculum Treatment CDC recommended regimens: Metronidazole 500 mg orally twice a day for 7 days, OR Metronidazole gel 0.75%, one full applicator (5 grams) intravaginally, once a day for 5 days, OR Clindamycin cream 2%, one full applicator (5 grams) intravaginally at bedtime for 7 days Management Alternative regimens: Metronidazole 2 g orally in a single dose, OR Clindamycin 300 mg orally twice a day for 7 days, OR Clindamycin ovules 100 g intravaginally once at bedtime for 3 days 27 9

10 Herpes May be recurrent or primary outbreak. Lesions are often missed on exam. Primary outbreak often has systemic symptoms and enlarged inguinal nodes. May be type 1 or 2 Herpes Symptoms Swelling, pain, itching, redness, dysuria Herpes diagnosis Culture: gold standard but poor sensitivity Exam Serum tests may be negative early in primary outbreak. IgG signifies past exposure 10

11 Herpes Treatment Primary Outbreak: Acyclovir 400mg tid x 7 10 days, Famvir 250mg tid x 7 10days or Valtrex 1 gram bid x 7 10 days Recurrent Outbreak: Acyclovir 400 mg tid x 5 days, Famvir 125mg bid x 5 days, or Valtrex 500mg bid x3 5 days Suppressive Treatment: Acyclovir 400mg bid, Famvir 250mg bid, Valtrex 500mg qd Of the skin and on the skin Vulvar Eczema: Allergic or Irritant Dermatitis Thickened or red excoriated skin. Skin changes may be minimal. Postmenopausal skin more easily irritated. 11

12 Contact and Allergic Dermatitis Unestrogenized skin of older patients is more susceptible to irritants Symptoms are vulvar and not vaginal: need treatment to the vulva May have had previous contact with agent without untoward reaction Propylene Glycol C3H8O2 Cosmetic grade mineral oil that acts as a humectant Found in shaving creams, baby wipes, feminine wipes, soap, body wash, ointments, deodorant, shampoo May take chronic exposure to lead to skin irritation Industrial grade found in brake and hydraulic fluid Vulvar Care Measures No soap on the vulva. Mild soap on the rest of the body. Avoid frequent baths even though this may feel soothing. Symptoms cannot be washed away Avoid pads/panty liners if possible Wear white cotton underwear, no underwear at night Avoid tight fitting clothes Avoid all irritants 12

13 Lichen Simplex Chronicus: (Squamous hyperplasia) End stage of the itch scratch itch cycle of vulvar irritation Nothing helps Years of chronic itch Lichen Simplex Chronicus Skin is thick and often red Intense and repetitive rubbing and scratching Lichen Simplex Chronicus Treatment: eliminate irritants Triamcinolone 0.1% bid or clobatasol 0.05% Recheck every 4 weeks May need a sleeping agent such as benedryl or amitriptyline 13

14 OTC remedy to quiet irritated skin Directions: add 1 packet to 1 pint of warm water. Soak area tid for minutes Lichen Sclerosis Chronic dermatological condition. Etiology unknown Primarily a disease of postmenopausal women and prepubertal children 3 5%lifetime risk of vulvar cancer Clinical Findings Lichen Sclerosis Texture change Thin, white finely wrinkled Loss of vulvar architecture including labia minora Fissures Excoriations Fusing of skin around clitoral hood 14

15 Lichen Sclerosis No vaginal involvement Symptoms: vulvar itching, burning, dyspareunia, pain with defecation Biopsy in early disease may only report inflammation Lichen Sclerosis Treatment: clobetasol 0.05% Bid for 6 weeks. Recheck in 6 weeks. Gradually decrease dose but continue med until skin texture has normalized. May need maintenance therapy. 96% have complete or partial relief Continue monitoring annually VIN and vulvar cancer Squamous Cell Carcinoma in Situ (VIN III) has a significant risk for progression to invasive cancer if left untreated. 15

16 Squamous Cell Carcinoma in Situ Median age of premalignant lesions is 40, malignant age 65 Chronic itching is the most common symptom (60%) May present as an elevated white, red, pink, gray or brown lesion. Multifocal disease % of lesions are positive for high risk HPV Biopsy to confirm Referral to oncology for surgical treatment 90% of vulvar cancers are squamous cell Risk Factors: DM, HTN, obesity, smoking Vulvar Intraepithelial Neoplasia VIN I: immature cells in the lower 3 rd of the epithelium VIN III: complete loss of cellular maturation VIN II: intermediate Paget s Disease of the vulva Generally affects postmenopausal women Long standing itching and tenderness are common Present with well demarcated eczematoid lesion (velvety red) May progress peri rectally, inguinal areas, buttocks May be associated with adenocarcinoma Needs biopsy and surgical treatment with oncology 16

17 Vulvar Cancer Take Home Message The vast majority of these patients are under the care of a physician and have not undergone a biopsy. Any vulvar lesion should be biopsied for proper diagnosis and treatment. Thank You Keep on Looking 17