Evaluation and Medical Management
of Vulvar Dermatoses
Katherine “Casey” Monahan, FNP-C, Dermatology
Providence Little Co. of Mary Dermatology & Laser Center
Types
• Dermatitis – acute inflammation
• Contact dermatitis
• Dermatoses – chronic inflammation
• Lichen simplex chronicus
• Lichen sclerosus
• Lichen planus
History
• Specific areas to address include:
• Major complaints
• Hygienic practices
• Types of clothing
• Medications
• Personal and family history
• Sexual history
Physical Examination & Diagnostics
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Inspect the entire vulvar and perianal area with good lighting
Inspect the mouth
Swabs for microbiology
Skin biopsy
Patch testing
Exogenous (Contact) Dermatitis
• Vulvar dermatitis (eczema) – the most common vulvar dermatosis
• Two types of contact dermatitis
• Allergic (20% of cases)
• Irritant (80% of cases)
Contact Dermatitis
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Vulvar tissue more permeable than exposed skin
Typically, allergens are new exposures
Allergic reactions require prior exposure to a product
Irritants cause an immediate response, whereas allergic reactions occur 12 to
72 hours after exposure
Contact Dermatitis
• Signs and Symptoms
• Redness, swelling, and scaling of the labia minora
• Superficial fissures
• Pain and burning at rest
• Introital dyspareunia
• Generalized pruritus less common
Contact Dermatitis
Contact Dermatitis
• Allergens
• Fragrances, preservatives, topical medications, and rubber
• Propylene glycol
• Irritants
• Anti-fungal, anti-bacterial, and steroidal creams/ointments
• Preservatives, stabilizers, and delivery vehicles in drugs, as well as the
drugs themselves
Contact Dermatitis
Irritants
Allergens
• Bubble baths
• Chlorhexidine
• Baby wipes
• Perfume
• Talcum powder
• Neomycin
• Urine
• Nickel
• Feces
• Nail polish
• Deodorants
• Latex
• Sanitary protection
• Spermicides
• Soaps
• Benzocaine
Contact Dermatitis
• Management
• Identify and eliminate causative agent(s)
• Replace all known irritant agents with hypoallergenic moisturizing preparations
• Local measures
• Oatmeal colloidal soaks
• Ice packs
• Mild steroidal ointment in petroleum
• Aqueous 4% Xylocaine solution
Contact Dermatitis
Lichen Simplex Chronicus (“LSC”)
• Occurs in chronic cases of dermatitis, resulting from rubbing and scratching
• Characterized by skin lichenification and excoriation, together with
pigmentary abnormalities
• Accentuation of skin lines/markings
• Leathery texture
LSC
LSC
• Management
• Goal: cessation of pruritus
• Avoid scratching
• High-potency steroid cream/ointment initially, then medium- to lower-strength
topical steroids
• Occlusion of medium-potency steroids
• Intralesional kenalog injections (5 – 10mg/ml)
• Unna boot
Lichen Sclerosus
Lichen Sclerosus et Atrophicus (“LS&A”)
• Most common vulvar dermatosis/disease
• Chronic, inflammatory, autoimmune disease of the skin and mucosae, preferentially
affecting the vulva
• Most common among post-menopausal women (up to age 90 yrs.); females
predominately
• May affect children (from age 5 mos.) and young adults
• If untreated, can result in fusion around the clitoris (phimosis), atrophy and splitting
of the vestibule, severe narrowing of the vaginal orifice, and, rarely, vulvar cancer
(squamous cell carcinoma (“SCC”))
LS&A
• Signs
• Atrophy
• White patches surrounded by erythematous or violaceous halos
• Lesions may coalesce into large atrophic erosions, making the skin smooth,
wrinkled, soft, and white
• Excoriations or superficial fissures
• *characteristic signs that help distinguish LS&A *
LS&A
• Signs
• Thickened areas
• Vulvar and perineal involvement leads to “figure-eight” or “hourglass”
shape around the anus
• Obliteration of architecture with loss of labia minora, clitoral hood, and
urethral meatus
• Labial stenosis or fusion
LS&A
LS&A
LS&A
• Symptoms – mean duration 99 months
• Intense pruritus
• Soreness
• Burning
• Dyspareunia
LS&A
• Management
• Biopsy
• Clobetasol ointment = drug of choice
• Effective in 90% of patients with reversal of epidermal atrophy
LS&A
• Refractory/Severe Cases
• Cortisone injections
• Oral retinoid therapy and topical tretinoin
• Maintenance with testosterone ointment and progesterone cream
• Surgery rarely indicated
Lichen Planus
• Chronic, inflammatory, autoimmune disease involving:
• Glabrous skin (flexor surfaces of arms and legs)
• Hair-bearing skin and scalp
• Nails
• Mucous membranes of the oral cavity and vulva
• >70% of patients between the ages of 30 and 60 years
Lichen Planus
• Vulvo-vaginal-gingival syndrome: involves vulva and vagina with gingivitis
• Oral lesions may precede or follow vulvovaginal lesions by months or
years or may be simultaneous
• Vaginal mucosa involved in two-thirds of cases
• In one-third of cases, reticulate buccal involvement
• 10% have concurrent cutaneous lesions
Lichen Planus
• Vulvovaginal signs
• Rarely presents as the classic widespread shiny, violaceous, pruritic, flat-topped
papules
• Erosive/ulcerative form most common presentation in mucous membranes
• Mucosal: white reticulate or lace-like changes (Wickham’s striae) or erosions
• Vulvar: erythematous erosions with narrow rim of white reticulation
• Vaginal: glazed erythema, easy friability
Lichen Planus
• Vulvovaginal symptoms
• Pruritus on hair-bearing vulvar skin
• Severe burning pain in the vestibule or vagina
Lichen Planus
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May be subtle and mistaken for vulvodynia
Typically, morphology similar to vulvar lichen sclerosus
Late scarring with loss of labia minora and clitoral hood
Adhesion formation in upper part of vagina
Total vaginal obliteration
Erosive mucosal cases considered pre-malignant
Lichen Planus
Lichen Planus
Lichen Planus
Lichen Planus
Lichen Planus
Lichen Planus
• Management
• Biopsy: histological evaluation superior to direct immunofluorescence
• Topical and/or intravaginal steroid = first-line therapy
Lichen Planus
• Vulvar management
• Clobetasol or another high-potency topical steroid ointment BID
• Long-term maintenance with low or mid-potency topical steroid
ointment
• Calcineurin inhibitors: tacrolimus (Protopic) and pimecrolimus (Elidel)
cream BID or suppository QHS
• Oral hydroxychloroquine (Plaquenil), cyclosporine, azathioprine
(Imuran), etanercept (Enbrel), methotrexate
Lichen Planus
• Vaginal management
• Anusol hydrocortisone suppositories
• Vaginal dilation
• Surgery