It might not be the first place dermatologists look, but diseases of the vulva are skin conditions. An itchy, sore vulva can be caused by a number of different skin conditions, which were described by Gayle Fischer, University of Sydney, Australia, in a presentation given at the AAD Summer Meeting.
“Vulvar disease is skin disease. It is dermatology with a twist,” she said. The commonest non-erosive dermatoses of the vulva are dermatitis, psoriasis, chronic vulvovaginal candidiasis and lichen sclerosus, Fischer added. “All these conditions are itchy and if excoriated or fissured they can be sore. They are also all erythematous, except for lichen sclerosus which is white.”
A suspected diagnosis of lichen sclerosus can be confirmed with a skin biopsy; the histology of lichen sclerosus is distinctive so a biopsy will help to differentiate it from other skin diseases.
Lichen sclerosus can scar the vulva and around 5% of women with it will develop cancer, but long-term preventive treatment with topical corticosteroids can reduce the risk of these complications, she said.
Unfortunately there are no diagnostic tests for erythematous non-erosive skin conditions, so diagnosis is reliant on the skills of the clinician, she emphasised, but there are some pointers, for example, dermatitis and psoriasis do not involve the vagina whereas candidiasis does.
In terms of treatment, lichen sclerosus, dermatitis and psoriasis should be treated similarly to anywhere else on the skin, Fischer said. However, low dose acitretin can be very effective for psoriasis, in post-menopausal women, although it should of course be avoided in women of childbearing age because of the risk of birth defects.
Chronic vulvovaginal candidiasis has a very large impact on quality of life because it is associated with pain and dyspareunia. In contrast to recurrent vulvovaginal candidiasis, where patients are asymptomatic between discrete attacks, in chronic vulvovaginal candidiasis patients present with chronic, continuous symptoms, which improve during menstruation and remit with antifungal therapy, often recurring when this therapy has ceased, particularly after short courses.
A diagnosis of chronic vulvovaginal candidiasis depends on accurate history taking, as vaginal swabs are not always positive for Candida even in the presence of intense symptoms and obvious signs, Fischer pointed out. Long term antifungal treatment can control chronic vulvovaginal candidiasis, which is an estrogen dependent and probably genetic condition.
Other presenters discussed a number of rarer conditions that affect the vulva that fall under the umbrella of “erosive or ulcerative” diseases. They include dermatological conditions such as mucosal lichen planus, fixed drug eruption and cicatricial pemphigoid. Aphthous ulceration, infective conditions such as genital herpes and systemic diseases such as Crohn’s disease also involve the vulva.
“Unless dermatologists become involved in identifying and managing these conditions it leaves these patients with no place to go,” Dr. Fisher told Dermatology Times in an interview. “There are no other specialties with the expertise necessary and even though this may not be day to day ‘office dermatology’, trained dermatologists have all the expertise needed to extend their skills to helping these patients.”
REFERENCE
Fischer G. U017 - Vulvar Disease, Friday, July 27; 4:30 PM - 5:30 PM. AAD Summer Meeting, July 26-29, 2018, Hyatt Regency Chicago, Chicago, IL.
