NEW ORLEANS — A thorough skin exam should always include an examination of the vulva, because many skin conditions can affect the genitals and cause everything from transient discomfort to loss of anatomical structures, Lynette J. Margesson, M.D., said at the annual meeting of the American Academy of Dermatology.
Women have very little education about their vulvar health and thus, tend to ascribe every bout of itching to candidiasis. They usually will not offer information about genital discomfort. “As a result, women suffer with undiagnosed symptoms, waste millions on antifungals, and endure vulvar pain and dyspareunia. Instead of seeking help, they hide and scratch,” said Dr. Margesson, a dermatologist from Manchester, N.H.
“Imagine the rash somewhere else on the skin,” she advised. This can help ease any discomfort either the patient or physician might feel about a vulvar exam.
She described 10 “vulvar traps” to avoid:
Missing the missing bits—check for what's not there. Lichen sclerosis and lichen planus can both eventually cause scarring of the labia and clitoris, and marked introital stenosis. Dyspareunia is usual. “These poor women can completely lose their labia and clitoris,” Dr. Margesson said. “Don't let that happen to your patient.”
Mistaking the normal for abnormal. Dermatologists aren't gynecologists and might not be familiar with benign variances in vulvar anatomy. Sebaceous hyperplasia can be confused with an unusual rash or neoplasm. Characterized by variably sized yellow papules on the labia minora, sebaceous hyperplasia is a benign condition that doesn't require treatment.
In vulvar papillomatosis, papillae can cover the entire mucosal surface of the labia minora. Labial hypertrophy is a normal size variant and doesn't require treatment, unless the affected labia interfere with sexual function or other activities, or are irritated by clothing.
Not looking closely enough. It's easy to miss signs of herpes simplex infection (HSV), because women are often asymptomatic carriers. The typical simplex pustules may be hidden or missed in a confusing background of ulcers, erosions, and/or fissures. However, HSV is the most common cause of vulvar ulcers, so patients with unexplained symptoms or lesions should be tested.
Mistreating simple problems, such as candidiasis. Don't diagnose candidiasis over the phone, Dr. Margesson stressed. Candida infections complicate all vulvar skin problems, especially lichen planus, lichen sclerosis, and lichen simplex chronicus. Scratching further irritates the skin and some over-the-counter (OTC) antipruritics can cause contact dermatitis. “Persistent candida” may occur because the yeast is a resistant strain or because the symptoms are actually from a contact dermatitis to the topicals being used. Culture on Sabouraud's medium to identify resistant strains, and be prepared for an extended course of treatment—perhaps as long as 6 months.
Missing contact dermatitis. Faced with vulvar pruritus of any etiology, women tend to slather on OTC medications that can cause severe contact dermatitis. This frequent problem is another complication for vulvar dermatoses, Dr. Margesson said. “Women often consider their vulva 'dirty' and scrub it unnecessarily with soap or cleansers.” Urinary incontinence can complicate the problem, so hygiene counseling is important. Topical benzocaine can cause a severe, ulcerated contact dermatitis.
Misusing or misunderstanding topical steroids. Adequate courses of superpotent topical steroids are usually necessary to control vulvar inflammation from lichen sclerosis and lichen planus. Less potent steroids will not be effective. “Patient education is critical,” she said. The vulva is relatively steroid-resistant, whereas the perineal areas are steroid-sensitive. Women should be told exactly where to put the topicals, how much to apply, and for how long. All women on topical steroids should be seen at regular intervals.
“Everything white is lichen sclerosis.” Several vulvar conditions mimic the white plaques of lichen sclerosis, including lichen planus, lichen simplex chronicus, mucus membrane pemphigoid, vulvar intraepithelial neoplasia, and vitiligo. “Biopsy is essential to confirm diagnosis,” Dr. Margesson said.
Inadequate follow-up. Because women may be reluctant to share vulvar symptoms, and dermatologists may be reluctant to examine the area, problems may go untreated. Some serious vulvar disorders, such as lichen sclerosis, lichen planus, and even malignancy, may be asymptomatic.
Missing concomitant disease. “Look for more than one problem,” she said. One condition can predispose to another, and women may present with several at once. The most commonly missed concomitant vulvar disorders are candidiasis, contact dermatitis, HSV, atrophy, and cancer.
Not checking on compliance. This is another important reason to examine the vulva. Noncompliance generally arises from ignorance or miscommunication. Women may be afraid of using potent steroids and ignorant of exactly where to apply them. There may also be psychosocial issues. “Some women … may be getting a secondary gain by using their condition as a way of avoiding sex,” Dr. Margesson said.