vulvar disorders

Question 1

Lichen Sclerosus etiology

Answer 1

1. Autoimmune
2. Genetics
3. Environmental

Question 2

Who does lichen sclerosis MCly occur in?

Answer 2

Postmenopausal women

Question 3

MC sx in lichen sclerosis

Answer 3

Pruritus

Question 4

Other sx’s in lichen sclerosis

Answer 4

1. Dysuria
2. Dyspareunia
3. Anal discomfort

Question 5

lichen sclerosis PEx findings

Answer 5

1. Sharply, well-demarcated white plaques: “Cellophane paper”
2. Fragility/thin skin: Hallmark

Question 6

What risk/condition is associated with lichen sclerosis? Who is more likely to develop this?

Answer 6

Squamous cell carcinoma

Elderly, hyperkeratotic lesion

Question 7

What autoimmune disorder is highly associated with lichen sclerosis?

Answer 7

Hypothyroidism

Question 8

lichen sclerosis diagnosis

Answer 8

Punch biopsy

Question 9

lichen sclerosis treatment

Answer 9

Topical high potency steroid OINTMENT: Clobetasol 0.05% ointment

Question 10

Clobetasol SE’s

Answer 10

1. Atrophy
2. Dermatitis
3. Rosacea

Question 11

Lichen Simplex si/sx

Answer 11

1. Vulvar pruritus and/or burning (wks-mos): “itch that rashes”.
2. Anxiety/depression association

Question 12

Lichen Simplex physical exam findings

Answer 12

Eczematous process:

Poorly marginated, red, scaling plaques

Question 13

What are the initial signs in lichen simplex

Answer 13

1. Weeping
2. Excoriations
3. Crusting

Question 14

What are the chronic signs in lichen simplex

Answer 14

1. Lichenification

2. Hypopigmentation with moisture

Question 15

What is the definitive dx in lichen simplex

Answer 15

Vulvar punch biopsy

Question 16

Lichen Simplex pharm treatment

Answer 16

1. Topical steroid cream: Lower dose potency
   - Hydrocortisone 1-2%
   - Triamcinolone acetonide
   - Betamethasone valerate
2. Antihistamines
3. SSRI: if h/o anxiety/depression

Question 17

Lichen planus clinical presentation

Answer 17

1. Introital irritation
2. Burning (less commonly pruritus)
3. Vaginal discharge

Question 18

Non-erosive disease in lichen planus

Answer 18

Lacy, white epithelium (fern-like appearance)

White striae

Question 19

erosive disease in lichen planus

Answer 19

Deep vaginal redness
vulvar erosions
purulent vaginal secretions

Question 20

1st line treatment in lichen planus

Answer 20

Topical steroid cream:

Hydrocortisone acetate 25mg suppository QHS

Question 21

2nd treatment in lichen planus

Answer 21

1. Topical Tacrolimus 0.1% ointment QOD - BID

2. Systemic corticosteroids

Question 22

What is Vulvar Intraepithelial Neoplasia (VIN) U associated with?

Answer 22

HPV: 16, 18, 31

Question 23

VINU risk factors

Answer 23

1. Smoking: 50-80%
2. Immunosuppression
3. Multiple sex partners

Question 24

VINU presentation

Answer 24

Burning and itching=50%

Question 25

What is VINU highly associated with?

Answer 25

High grade CIN

Question 26

VINU diagnostic procedure

Answer 26

Vulvar Colposcopy: 3-5% acetic acid Sit for 3-5 minutes Lesions gray-white-red/black

Question 27

What is the standard of care in VINU?

Answer 27

Surgical treatment: 1. CO2 laser vaporization-do not perform if invasion suspected 2. Local wide excision 3. Vulvectomy

Question 28

What is the post-treatment recurrence rate in VINU?

Answer 28

30-50%

Question 29

What population does VIND mainly effect?

Answer 29

Older population: >70

Question 30

What is VIND associated with?

Answer 30

Squamous cell hyperplasia | lichen sclerosis that likely went untx

Question 31

VIND prevention and treatment

Answer 31

Prevention: Proper tx of underling condition Tx: Surgical excision

Question 32

What is the ACOG/ASCCP position statement for VINU and VIND

Answer 32

Vaccination with Gardasil

Question 33

What is the post-tx f/u in VINU/D?

Answer 33

Colposcopic vulvar inspection: 6 and 12 months Annually thereafter

Question 34

Vulvar CA common comorbidities

Answer 34

1. Type 2 DM 2. Obese 3. HTN

Question 35

What is the MC age in Vulvar CA?

Answer 35

Bimodal: 1. 20-40yrs: HPV related (VINu) 2. 60-70yrs: d/t chronic irritation

Question 36

80% of women with vulvar CA have what untreated long-lasting conditions?

Answer 36

1. lichen sclerosus | 2. lichen simplex chronicus 3. squamous cell hyperplasia

Question 37

Vulvar CA clinical presentation

Answer 37

1. ASYMPTOMATIC 2. Pruritus: MC sx 3. Vulvar bleeding/pain

Question 38

Vulvar CA treatment

Answer 38

1. Complete surgical removal w/ inguinal node dissection | 2. Radiation: indicated w/ lymph node spread

Question 39

Behcets clinical presentation

Answer 39

1. Oral ulcerations 2. Urogenital lesions 3. Skin lesions 4. Ocular dz

Question 40

Behcets diagnostic criteria

Answer 40

Recurrent oral aphthae at least 3 times in 1 year plus 2 of the following: 1. Recurrent genital ulcers 2. Uveitis 3. Skin lesions 4. (+) Pathergy test: 2mm papule at injection site within 48h

Question 41

Behcets treatment

Answer 41

1. Temovate 0.05% ointment 2. Intralesional Triamcinolone: 5 – 10mg/mL 3. Systemic corticosteroids for refractory cases

Question 42

Bartholin cyst/abscess treatment

Answer 42

1. I&D w/ insertion of word catheter 2. Culture purulent material: Polymicrobial, E. coli, MRSA, STI 3. +/- empirical antibiotic therapy: Bactrim, Augmentin

Question 43

Severe or recurring Bartholin cyst treatment

Answer 43

Marsupialization

Question 44

Vulvodynia clinical presentation

Answer 44

1. Vulvar "burning"* 2. Absent clinical findings: Everything looks nl 3. Introital pain with intercourse

Question 45

Vulvodynia pharmacologic treatment

Answer 45

1. Topical lidocaine ointment 2. Topical vaginal estrogen w/ testosterone 3. Amitriptyline or nortriptyline 4. SNRIs 5. Gabapentin