Max Brinsmead MB BS PhDMay 2015

Incidence, Types and PresentationAffects 1:5 women in a lifetimeLichen sclerosis & atrophicus – 25%Lichen planusAssociated with other skin disease

Lichen simplex with dermatitisPsoriasis

PremalignantVulval wartsVulval intraepithelial neoplasia (VIN)

CandidiasisPresents with pruritis and or pain

Taking a HistoryRoutine gynaecological questionsAsk about urinary and bowel incontinenceAny other skin problems?Any other disorders

Especially auto immune diseaseImmune deficiency

Drugs and OTC preparationsSystemicLocal applicationsSmoking & other

Family HistoryAtopy i.e. eczema and allergies, asthma etc.Autoimmune disorders

Common Vulval Irritants

Excessive drying – use of talc etc.Topically applied deodorants, antiseptics , douches

etc.Soaps and detergentsSanitary pads, incontinence pads etc.Lubricants and rubber (condoms)DyesClose fitting clothes especially syntheticsItch and scratching, towel drying, nail polish etc.

Examination

Adequate exposureGood lightMagnification (colposcopy) not mandatoryLower genital tract, Pap and colposcopy

only for suspected VINExamine mouth, scalp, nails and all skin

Especially elbows and knees

InvestigationsExclude diabetes, hypothyroidism & iron

deficiencyGram stain and culture for CandidaTests for STDs when clinically indicatedAutoimmune tests after a diagnosis of

lichen sclerosis or planusBiopsy

Only for suspected VINOr failure to respond to treatmentCan be done with LA as an outpatient

Lichen sclerosis & atrophicusMore common in the postmenopausal

But it does not respond to hormones

Thickened, white skin = hyperkeratosisCauses intense pruritis

Worse at nightScratching leads to secondary skin damage

Other skin becomes atrophic causing stenosis, adhesions and scarring

Lichen sclerosis & atrophicus

Lichen planusCan affect any skin but most commonly

oral mucosaTypically polygonal violaceous plaques &

papulesOften ulcerated and painful on the vulva

Lichen simplex = NeurodermatitisErythema and swellingScratch injuryLichenification but no atrophy

Vulval Intraepithelial Neoplasia

Comes in two forms:Warty excrescences

Commonly women <55 yearsAssociated with HPV – typically Type 16

Differentiated VINCommonly women >55About 5% of lichen sclerosis will have this as

wellProgresses more quickly to squamous carcinoma

Differential Diagnosis

Not all that important because the treatment for lichen sclerosis, planus and simplex with dermatitis is the same…

Potent topical corticosteroidsBiopsy anything that is clinically suspicious…

Has a raised edgeAbnormal vessels visibleHard to gentle palpation

Or does not respond to treatment

TreatmentGeneral measures to protect vulval skinPotent fluorinated corticosteroid applications

Advantan = MethylprednisoneDiprosone = Betamethasone propionateElocon = MometasoneClobetasol = the most potent available

Use ointment rather than creamProlonged use results in skin atrophy

Daily for a month2nd daily for a monthTwice weekly for a monthWeekly for a monthThen as required

A 30g tube should last 3 months

General Measures to Protect Vulval SkinShower rather than bathUse neutral soap substitutesHands only – no flannels or spongesPat or blow dry – no towellingUse water with inert emollient cream other timesWear loose fitting silk or cottonRemove underwaer whenever possibleWash clothes in neutral soap or gel - avoid all

biological (enzymes) detergents and bleaches Avoid dyes – in dark clothes & toilet paperMinimal use of vulval pads of any typeAvoid all OTC applicationsKeep aqueous cream in the fridge for soothing

Treatment (2)About 10% fail to respond to topical

corticosteroidsTopical Tacrolimus, an immunodifier , is a second

line treatment for lichen sclerosisUsually occurs with supervision from a Dermatlogy

ClinicBecause there is a small risk of malignant

transformationWarts can be treated with Imiquimod cream =

Aldara15 – 80% response rateCompliance is an issue

Some 15% of VIN will have unrecognised invasive disease disclosed by excision biopsy

Follow Up

40 – 60% 0f VIN progresses to Ca over 8+ yearsCan be reduced to <5% by adequate biopsy

excisionAnd reconstructive surgery when requiredFollow up with colposcopy and cytologyAnd encourage self examinationRelapse of lichen sclerosis is common

Up to 80% within 4 yearsBut it has a much smaller potential for malignant

change so follow up can be with a GP

Some Rare Vulval LesionsBeçhet’s Disease

Recurrent oral and genital ulcers

Extramammary Paget’s DiseaseFlorid eczema and lichenificationBiopsy to exclude underlying adenoCa & look for

primary in breasts, GI or urinary tracts

Zoon’s VulvitisInfiltrated with plasma cells and haemosiderin

Vulval Crohn’s DiseaseGranulomas, abscess, ulcers and sinusesUsually associated with small gut pathology

Recurrent CandidiasisFirst confirm the diagnosis

Requires swab and culture >48 hrs after fungicidal application

Exclude imidazole-resistant organismsThis requires the use of borates for treatment

Exclude diabetesAvoid broad spectrum antibiotics

Recolonization of vaginal Acidophilus with natural yoghurt?

Use systemic antifungal = Oral DiflucanMost respond to recurrent and intermittent

Imidazole Use Canesten PRN

There are many “natural therapies” Try Tea Tree oil (Melaleuca alterniflora) 2 -3 drops in

sweet almond oil on a tampon 8-hourlyThere may be a role for immune boosting by

transfusions with Transfer Factor

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