The Vulvar Lichen Disorders: Simplex, Sclerosus, Planus Paul Summers, M.D. Department of Obstetrics and Gynecology University of Utah School of Medicine
Areas of Concern 1. Dermatopathology 2. Spongiotic Dermatitis 3. Patch testing: nickel, etc 4. Risk for squamous cancer
Skin Flakes (lichen) Normal healthy skin exfoliates individual epithelial cells Flaking skin is common at fragile body sites Skin flakes are called reactive change when seen in the pap smear Skin flakes are found frequently in the saline wet prep Unfortunately, flakes are not yet listed as an element to evaluate in the saline wet prep
Skin Flakes in the Pap Smear Reactive, Reparative changes are reported in many pap smears Characteristic of smears with reactive/reparative changes: 1. cells tend to form sheets (Alexander Meisels, Carol Morin Cytopathology of the UterusASCP Press 1997:128) 2. spongiosis is a prominent feature if the cervix is biopsied (Yao S. Fu, Pathology of the Uterine Cervix, Vagina and Vulva Saunders 2002:281)
Skin Flakes in the Saline Wet Prep Skin flake typically due to a lichen skin disorder Vulvovaginal irritant and allergic response causes the skin to flake, as is seen frequently in the saline wet prep
Skin Flakes in the Wet Prep Thin skin flake Hyperkeratotic skin flake Folded edge of skin flake Skin flake melting in KOH
Flakes in the Wet Prep at the University of Utah 17/20 biopsy proven cases of lichen sclerosus showed skin flakes 36/36 biopsy proven cases of vulvar contact dermatitis showed flakes 14/14 presumed by history but not confirmed cases of vulvar contact dermatitis showed flakes
Vulvovaginal Irritant and Allergic Contact Dermatitis Lichen Simplex
What is Lichen Simplex? Vulvar irritant or allergic contact dermatitis Dermatopathology shows Spongiotic Change with or without eosinophils Typically secondarily infected: Staph, Strep, or Yeast
Contact Dermatitis Affects 40% of adults continuously All adults will have contact dermatitis at some time Vulva is at special risk (fragile, increased trans epidermal water loss) Results in flaking skin, even in the vulvovaginal area
Irritant Contact Dermatitis Irritants cause immediate or delayed burning Typically, there is no visible skin change Erythema is present in severe cases Most commercial creams and lotions contain irritants
Allergic Contact Dermatitis Itch-scratch cycle perpetuates the disorder The majority also have recurrent sinusitis, asthma, hay fever, or eczema Diagnosis is confirmed by hyperkeratosis, spongiosis and eosinophils on biopsy
Vulvar Susceptibility to Irritants and Allergens (Farage Arch Gynecol Obstet 2005;272;167-72) Relatively increased skin hydration Significantly increased transepidermal water loss (TEWL) Increased penetration of irritants, especially in the vestibule Increased susceptibility to mechanical damage (higher friction coefficient) Vulvar irritant dermatitis is often occult
Spongiotic Change with Contact Dermatitis 1. Intraepidermal edema 2. Liquifaction of dermal-epidermal interface 3. Langerhans cells blue arrows
Severe Spongiotic Dermatitis
Vulvar contact dermatitis was the principal diagnosis in 54% of 141 patients referred to a dermatologist for chronic vulvovaginitis Fischer GO, The Commonest Causes of Symptomatic Vulvar Disease: a Dermatologist s Perspective. Australias J Dermatol. 1996;37:12-18
38% of women with chronic vulvitis demonstrate an allergic or irritant response to vaginal creams and medications Nardelli A, Degreff H, Goossens A. Contact Allergic Reactions of the Vulva: a 14-year Review. Dermatitis. 2004;15:131-6
Vaginal Immunology HIV has taught us that the lactobacillus and ph are not the protectors for the vagina A normal CD4 immune cell response is essential for vulvovaginal health The vaginal mucus contains numerous essential antimicrobial chemicals
Vulvovaginal Microbicides (Braff. J Invest Dermatol 2005;125:9-13) Over 50 anti-microbial substances are produced by the skin (over 800 chemicals in all) Some are innate Some are activated by a Th1 response A Th2 response can inhibit the release of microbicides hbd-3 has a Minimal Inhibitory Concentration of 13.2 ug/ml against Saccharomyces cerevisiae (Garcia. Cell and Tissue Research. Published online 11 September 2001)
The Consequences of Allergic Dermatitis Deficient cathelicidin (LL-37) and beta defensin (hbd-2, 3) allows microbe colonization of the skin (staph, strep, yeast) Flaking of the stratum corneum facilitates microbe entry into the skin Deficient cell-mediated Th-1 response allows microbe proliferation in the skin
35 Cases of Vulvovaginal Contact Dermatitis at the University of Utah 25/35 have at least one yeast infection confirmed in the University clinic 28/31 have history of asthma, allergic rhinitis, eczema 23/31 have irritant reaction to creams 26/35 pre menopausal 9/35 post menopausal
Allergic Vulvar Dermatitis with Recurrent Yeast Infection Deficient hbd2, 3
Lichen Simplex Chronicus Scratching here History of asthma, hay fever, eczema, sinusitis
Vulvar MRSA
Vulvar Carcinoma 50% related to HPV, but many of the remainder are related to lichen dermatitis
Contact Dermatitis may Trigger Recurrent Herpes other Disorders Vulvar Crohns Behcets Aphthous major or minor
Primary herpes, in atopic skin with a poor Th1 response Increased risk for recurrent HSV
Therapy for Vulvar Contact Dermatitis Obtain a history of products that burn to help identify Irritants to avoid Consider patch testing by a dermatologist Treat once or twice daily with a non-irritating (compounded?) steroid ointment Moisturize at other times with Vaseline, Crisco, or coconut oil
Therapy for Vulvar Contact Dermatitis Consider the long-term risk of squamous cancer Oral fluconazole or topical clotrimazole for yeast infection Treat Staph folliculitis or Strep cellulitis
What is CMC? Processed Wood Pulp
Uses Of CMC Industrial Grade: Oil drilling, Paper, Paint German patent in 1918 with increasing use after the 1940 s Food Grade: Bread and Bakery, Ice Cream, Pudding, Beverages, Toothpaste, Cosmetics Dog and other pet foods
Annual Production: $1.2 Billion 33% Food and Beverages
CMC is Declared safe for Human use in Europe and America But a known skin irritant
The Rely Tampon Carboxymethyl cellulose was used to increase absorption of menstrual blood Presumed by the designer to be totally safe since CMC is a common safe food additive Around 500 million Rely Tampons produced Between 800 and 2000 cases of toxic shock and at least 84 deaths in 2 years of use
Rely Tampon Toxic Shock Vaginal Irritant reaction to CMC (Rare) severe vaginal spongiotic change Proliferation of staph (strep or yeast) 5-25% of Staph aureus can produce TSST-1 toxic shock protein TSST-1 is released in large amounts after an exponential growth phase
Toxic Shock Syndrome Eventually all adults are likely to have antibodies against TSST-1 from low level exposure Mortality from Staph toxic shock is around 10% Mortality from Strep toxic shock is over 50%
Lessons from the Rely Tampon Vulvovaginal contact dermatitis is a reality Irritant susceptibilities are unique to the individual Expect consequences from secondary infection with Staph, Strep, or Yeast
Nickel Sensitivity 11% of women and 3% of men Irritation from cheap jewelry (ear rings) Chocolate, Nuts, and bitter green vegetables have a high nickel content Low Nickel Diet may help decrease urinary nickel
Contact Dermatitis in Musicians Brass instrument mouthpiece Exotic wood Varnish Rosin for the bow
Patch Testing by a Dermatologist Identifies environmental irritants to avoid Unfortunately, the vulva reacts to a wider range of irritants than the back Useful if topical steroid and moisturizers fail
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An Excellent Review! *
Lichen Sclerosus Mild lichen sclerosus is relatively common (minimal visible skin change) Often hour glass-shaped rash Any age group Associated with recurrent yeast infection Treat any concurrent post menopausal atrophy Increased irritant susceptibility
Lichen Sclerosus Complications: 1. Irritant reaction 2. Allergy, yeast infection 3. Cancer
Lichen Sclerosus Issues Secondary development of contact dermatitis (mixed dystrophy) Irritant reaction to most commercial creams Yeast infection Vulvar cancer
Lichen Sclerosus treatment Twice daily topical steroid ointment and moisturize with vaseline Crisco, coconut oil Irritant avoidance Treat yeast Biopsy lesions to exclude cancer
Autoimmune Vulvovaginitis Lichen Planus Zoon s disorder Aphthous ulcer disease
Vulvovaginal Lichen Planus Immune trigger, similar to graft vs host reaction Significant vaginal pain and discharge Saline wet prep shows numerous WBCs, parabasal squamous cells, shift in flora
Other likely Names Desquamative Inflammatory Vaginitis (USA Ob-Gyn) Aerobic Vaginitis ( AV in Europe and Asia)
Oral Genital Syndrome Simultaneous oral and vaginal lichen planus in possibly 20% of cases Oral Lichen Planus is treated by the dermatologist
Lichen Planus and Cancer Oral Lichen Planus can cause aggressive oral squamous cancer Associated cervical or vaginal cancer is rare but aggressive Plan an annual pap smear with no age limit even after hysterectomy
Parabasal cells Lichen Planus, saline wet prep White blood cells
Vulva, Severe Erosive Lichen Planus Stenosis is more often in upper vagina
Chronic oral ulcer in the same patient
Same patient after 3 months of Imuran to block the excessive Th1 (autoimmune) response
Vaginal erosion Atrophic cervix Localized Vaginal Lichen Planus
Painful erosions in the vestibule Zoon s disorder (vestibulitis) (Plasma cell vulvitis)
Known Lichen Planus Triggers Hepatitis C Influenza vaccine Contact with nickel, chemicals, pigments NSAIDs Blood pressure medications
Therapeutic possibilities for mild Topical steroids Topical estrogen Lichen Planus Clindamycin vaginal cream Celebrex Oral Metronidazole 500 mg BID for 30 to 60 days (Asher V. Wahba-Yahav Ideopathic lichen planus: treatment with metronidazole. J Am Acad Dermatol 1995;33(2:1):301-2 Arzu Bueyuek Oral metronidazole treatment of lichen planus J Am Acad Dermatol 2000;43:260-2)
Areas of Concern 1. Dermatopathology 2. Spongiotic Dermatitis 3. Patch testing: nickel, etc 4. Risk for squamous cancer
The Skin Physiology vs. the Microbe The End