SAN FRANCISCO Spend plenty of time addressing parents' concerns about a child's vulvovaginal disease or their worries may contribute to the problem, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.
When a skin lesion, pain, or itching develops in a girl's genital area, parents often become hypervigilant, inspecting the anogenital skin five or six times a day. "Parents will often ask, 'Honey, are you itching?' when the kid is sitting there watching television or not even thinking about it," causing the child to focus more on her symptoms, said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.
Some girls learn to get secondary gain from the problem, complaining of symptoms and asking a parent to look at the problem area, sometimes for attention and sometimes to avoid unwanted tasks.
The parents frequently worry about the implications of the problem. Does the child have cancer? Will she grow up to have normal sexual function? Will the child be able to have children later on? Will she be psychologically wounded from the genital problem? Parents "often need lots and lots of reassurance," she said.
By the time Dr. Edwards sees a referral for pediatric vulvovaginal disease, the child usually has been worked up for sexually transmitted disease, especially if there's an ulcer-like lesion present, "and the parents are unbelievably distraught," she added.
Irritant contact dermatitis is a common cause of vulvar inflammation, itching, or raw, burning sensations. Prepubertal genital skin is easily irritated, even more so than postmenopausal genital skin. Soaps, creams, bubble bath, urine, and diarrhea can cause itching or burning. Mothers often overwash the child's genital area in response, aggravating the problem.
Physicians compound the problem by prescribing antifungal medication for presumed yeast infection, a disease that is rare in girls after the diaper years and before puberty. "Topical antifungals do little more than irritate the skin" in most cases, she cautioned. If you suspect yeast infection in girls at higher risk for itsuch as girls with obesity or diabetesget a culture to confirm the diagnosis, she advised.
To treat irritant contact dermatitis in the vulvovaginal area, stop the irritant. Change diapers more often, if that's a factor. Stop any unnecessary medications. Apply a topical corticosteroid ointment, avoiding creams because they will burn and sting upon contact.
"Even on an intact vulva, cream is going to be more likely to burn a child than an adult," Dr. Edwards said.
For dosing, "I start high, and back off," usually with clobetasol ointment, she said. "I just wish they would come out with a 2-g tube," because the available tubes are too big for this indication, she added.
Have a strong discussion with parents about potential side effects if they overuse corticosteroids, give them a handout with warnings, do not prescribe refills, and have them bring the child back in 34 weeks, she suggested.
Never insert dry, cotton-tipped applicators into a child's introitus because this causes pain and may cause erosions. Moisten cotton-tipped applicators if you plan to use them on the vulva, and touch the skin but don't rub it.
Bland emollients to cover skin cracks and fissures can help reduce irritation and pain. Night-time sedation may be helpful if the child scratches while sleeping.
Lichen sclerosus is an uncommon cause of anogenital itching and irritation in prepubertal girls. It looks the same as in adults, except that children with the disease often have more irritation because their skin is so easily torn from scratching.
Treat by stopping any irritants and prescribing an ultrapotent topical corticosteroid ointment, which should resolve symptoms but not cure the disease. Like adults, children with lichen sclerosus will need ongoing therapy. Emphasize to parents that they should not stop therapy when symptoms resolve in 45 days, because recurrences can cause progressive, irreversible scarring, she said.
During the first 45 days of therapy, the immunosuppressive effects of corticosteroids increase the risk of secondary infection in the fragile, eroded skin, so oral antibiotics may be warranted, Dr. Edwards said.
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