Vulvar skin disorders

Question 1

Lichen simplex chronicus

Answer 1

Intense itching and scratching
Occurs in mid to late adult life
Family history of seasonal allergies, asthma, eczema

Question 2

Lichen sclerosus

How is it diagnosed

Answer 2

Affects anogenital skin in post menopausal women and pre-pubertal girls
Etiology unknown but thought to be auto immune

Porcelain white applies and plaques or ecchymosis, cigarette paper
Usually affects mucocutaneous junction
Figure of 8 pattern

SCC 2-5%

Question 3

When to biopsy

Answer 3

New pigmentation
Indurated 
Fixed to underlying tissue
Bleeding or ulcerated
Lesion does not respond to standard therapy

Question 4

Treatment for lichen sclerosus

Answer 4

Clobetasol ointment o.05% daily for 4 weeks, alternate nights for 4 weeks then 2xweekly for 4 weeks

Reassess in 3 months then 3-6 no after that

Adherence to individualized regimen decreases scarring and progression to vulvar carcinoma

Intralesion injection of triamcinolone 10-20 mg is an alternative

Question 5

Lichen planus

Diagnosis

Treatment

Answer 5

White reticulate lacy fernlike striae (wickham striae)
Erosive lichen planus- deep painful erosive lesions
Oral involvement is common
Biopsy nonspecific
Inflammatory cells and immature parabasal cells

High potency topical steroid
Topical calcineaurin inhibitors
Intravaginal steroids (hydrocortisone acetate 25 mg intravaginally b.i.d.)

Question 6

Management of VIN

Answer 6

LSIL can be followed for 2 years. If stable space screening to 2-3 yrs
No tx required

HSIL should be treated with laser, excision, medical therapy

• 5%imiquimod
• 5-FU

Follow q6 mo for 5 yr

Question 7

Potential causes of vulvar pain

Answer 7

Neoplastic
Inflammatory
Infection
Malignancy
Trauma
Hormonal
Neuropathy

Question 8

Treatment for genital warts

Answer 8

Cytodestructive

1. Podofilox- pt applies bid for 3 days then takes 4 days off. Repeat up to 4x
2. TCa.80-90% weekly for 6w

Immune mediated
Imiquimod- 3x/wk for 6w