Women's health

Question 1

What should we ask about in someone presenting with a vulval issue?

Answer 1

Symptoms:
- Pain
- Itch
- Vaginal discharge
- Duration of symptoms and treatments to date.
STI risk
Other skin conditions
Gynaecological and obstetric history
Sexual function
Potential irritants

Question 2

What general advice should be recommended for all vulval conditions?

Answer 2

• Avoid contact with soaps, shampoos and bubble baths
• Use emollients as soap substitutes and general moisturiser
• Avoid tight-fitting clothes
• Avoid spermicidal-lubricated condoms
• Apply a barrier emollient to sore areas to protect against local irritants.
• Encourage women to self examine to become familiar with the appearance and be more likely to notice any changes

Question 3

What form of topical treatment is preferred for vulval lesions

Answer 3

Ointment bases rather than creams as the contain fewer preservatives (which may cause secondary contact dermatitis) and less water (which can sting)

Question 4

Name some useful websites for vulval conditions

Answer 4

http://vulvovaginaldisorders.com/
www.bssvd.org
www.dermnetnz.org

Question 5

What if you are unsure of a cause for a patient’s vulval symptoms?

Answer 5

If they persist and suspicious lesions are present- refer!

Question 6

What are the causes of vulval eczema? (dermatitis)

Answer 6

Irritant contact dermatitis (most common)
Atopic eczema
Allergic contact dermatitis (delayed type 4 hypersensitivity reaction)
Seborrheic dermatitis (Occasionally affects the vulva)

Question 7

What are the symptoms of vulval dermatitis?

Answer 7

Symptoms: Pruritis, Soreness, Pain. Discharge can indicate secondary infection.
Signs:
- Usually symmetrical erythemawhich can extend perianally
- Excoriations
- Erosions

Question 8

How is vulval eczema (dermatitis) managed?

Answer 8

• Avoid irritants and allergens
• Manage urinary incontinence
• Emollient as soap substitute
• Daily application of topical steroid for 7-10 days.
• Treat co-existing infection with combination steroid/antifungal (or antibacterial)
• Sedating antihistamine can help with nocturnal itching

Question 9

Is vulval psoriasis a thing?

Answer 9

Psoriasis is an immune-mediated chronic inflammatory skin disease affecting 2% of the population. Genital skin is affected in 29-46% of patients with psoriasis.

Question 10

What are the signs and symptoms of psoriasis?

Answer 10

Vulval itch, pain or burning sensation
Signs: Symmetrical erythematous plaques, well defined lesions with round margins. Fine silvery scale is less common than other locations.
Lesions can extend into the inguinal, perineal and pubic area.

Question 11

What is the management of vulval psoriasis?

Answer 11

• Emollients for all
• Steroids
• Coal tar preparations
• If pubic hair present may be better treated with solutions, foams or gels.

Question 12

What is lichen simplex chronicus?

Answer 12

A common condition of chronic itch-scratch cycle leading to characteristic clinical features

Question 13

What are the features of lichen simplex chronicus?

Answer 13

Symptoms: Chronic or intermittent severe pruritus usually in evening or in sleep. Burning, soreness or dyspareunia.
Signs: Poorly demarcated lichenified plaques, leathery feeling skin, erosions, ulcers, secondary infection, broken hair, change to skin pigmentation.

Question 14

What can trigger lichen simplex chronicus?

Answer 14

• Psychological factors (Anxiety, OCD ect)
• Environmental factors
• Generalised itching disorder

Question 15

What is the management of lichen simplex chronicus?

Answer 15

-Emollient as soap
- Consider mildly sedative antihistamine for nocturnal itch.
- In severe disease- super-potent topical corticosteroids
- Silk underwear may reduce need for steroids
- consider referral if not responding

Question 16

What is lichen sclerosis?

Answer 16

• Inflammatory dermatosis of unknown aetiology
• Predominantly affects the anogenital skin
• Does not typically involve the vagina
• Is associated with a slight increased risk of squamous cell carcinoma

Question 17

What are the signs of lichen sclerosis?

Answer 17

• Pale, white, hypertrophic or atrophic plaques
• Pupura
• Erythema, erosions and fissuring
  -Hyperkeratosis
• Localised changes or figure of eight distribution.

Question 18

Why is early diagnosis important in lichen sclerosis?

Answer 18

• Early treatment prevents scarring and possibly malignant change
• Diagnosis can be made clinically in typical presentations

Question 19

When should we refer to a specialist for biopsy or opinion in suspected lichen sclerosis?

Answer 19

• Diagnosis is uncertain
• Suspicious lesions are present
• Failure of treatment
• Patient is a child or young/premenopausal woman

Question 20

What is the treatment of lichen sclerosis?

Answer 20

• Should be initiated by a specialist
• reducing regimen of ultrapotent steroids.
• Emollients for symptomatic relief, barrier preparation as soap substitute. Avoid irritants.

Question 21

What counselling and advice should be given to patient’s with lichen sclerosis?

Answer 21

-Advise about the small risk of cancer and the importance of being vigilant to any worsening of symptoms
- Self examination in identifying any changes in appearance or new lesions.
- Seek medical advice if symptoms recur or new lesions appear

Question 22

What is lichen planus?

Answer 22

-An inflammatory condition of unknown (probably immune) pathogenesis.
- Can affect the skin, hair, genital and oral mucous membranes.
- Can affect the vagina (unlike lichen sclerosis)
- Usually presents in women in their 50’s
- Is associated with increased risk of squamous cell carcinoma.

Question 23

What are the symptoms of lichen planus?

Answer 23

Itch, pain and soreness, dyspareunia, dysuria, vaginal discharge/post-coital bleeding.

Question 24

What are the 3 main clinical presentations of lichen planus?

Answer 24

Erosive, classical and hypertrophic

Question 25

What are the features of erosive lichen planus?

Answer 25

Most common subtype.
Mucosal erosions with red/purple epithelial edges.
Wickham’s striae sometimes seen.
Vaginal lesions: friable telangiectasia and patchy erythema.
Healed erosions can cause scarring/loss of architecture/vaginal stenosis.

Question 26

What are the features of classical lichen planus?

Answer 26

Papules on keratinised anogenital skin with or without Wickham’s striae on vulva mucosa.
Hyperpigmentation frequently follows their resolution.
May be asymptomatic.

Question 27

What are the features of hypertrophic lichen planus?

Answer 27

Rare and difficult to diagnose.
Thickened warty plaques which may be ulcerated/painful.

Question 28

What is the management and who should be referred with lichen planus?

Answer 28

• Erosive lichen planus
• recalcitrant cases or in those whom systemic treatment may be required
• This is not a condition we see frequently in primary care, so I would refer ALL patients with suspected lichen planus for confirmation of diagnosis and management!

Question 29

What are some features of postmenopausal vulva?

Answer 29

Vulval appearance can change with age, and particularly with the menopause.
Menopausal vulvovaginal atrophy can cause symptoms of soreness and dyspareunia.
Vulval tissue becomes pale, fragile and atrophic.
Architectural change can occur, such as shrinking of the labia minora and clitoral hood.

Question 30

Which vulval dermatoses are particularly common in older women?

Answer 30

Irritant dermatitis is widespread in women with urinary incontinence.
Lichen sclerosis incidence peaks in postmenopausal women, and an estimated 1/30 elderly women develop it.

Question 31

How to tell in older women if it is an inflammatory dermatosis or just atrophy?

Answer 31

Ask about specific symptoms: dryness is more a feature of atrophy, and itch is the predominant symptom in dermatoses such as lichen sclerosus.
If there is architectural change, look for other features of an inflammatory dermatosis (e.g. white plaques, ecchymoses, erosions, progressive scarring and anatomical distortion).
- Refer if any doubt about the diagnosis or symptoms persist as vulval neoplastic conditions also peak in elderly women

Question 32

What are the key takehome messages about vulval conditions?

Answer 32

-Vulval symptoms may be due to infections such as candida. But, if symptoms persist, examine and look for another explanation.
-Give patients with vulval symptoms verbal and written advice on general vulval healthcare.
-Irritant contact dermatitis is the commonest eczema to affect the vulva.
-Vulval psoriasis presents with erythematous plaques which are not usually scaly. Extra-genital disease provides a clue to diagnosis.
-Vulval lichen simplex is common, and results from a chronic itch–scratch cycle.
-Lichen sclerosus and lichen planus are both inflammatory skin conditions which cause erythema, erosions and architectural destruction of the vulva. Involvement of the vagina does not occur in lichen sclerosus.
-Vulvovaginal atrophy can cause vulval symptoms, but vulval dermatoses are also common in postmenopausal women.