Pathology Of

Common Benign
Vulval Disorders

Dr. Shauntelle Winchester


Vulval Anatomy
 ASSESSMENT

History:
 Pain

 Pruritus

 Pattern of intensity and flare

 Aggravating and Relieving factors

 Drug history

 Allergies
 ASSESSMENT

Examination:

Use an adequate light source and a systematic

approach.

Ask patient to identify symptomatic area.

Examine other sites patient may identify as

affected.
 INVESTIGATIONS

 Thyroid function tests

 Fasting blood glucose test

 A Vulval skin swab

 STI screen

 Biopsy
SUMMARY OF 2011 ISSVD
VULVAR DISORDERS
1. Skin- Coloured lesion
a. Skin coloured papules and nodules
e.g Bartholin gland Cyst, warts, Skin tags

b. Skin coloured Plaques

e.g Lichen Simplex
VIN

2.Red lesions: patches and plaques

a. Eczematous and lichenified diseases
e.g Dermatitis, lichen simplex
b. Red patches and plaques:-
c. Candidiasis, psoriasis
SUMMARY OF 2011 ISSVD
VULVAR DISORDERS

3. White Lesions

a. White Papules and nodules e.g warts, scars

b. White patches and plaques e.g lichen

sclerosis, lichen planus, vitiligo.

4. Blisters: herpes simplex

5. Erosions and Ulcers: beçhets, chancre

Common Benign Disease

 Lichen Sclerosis

 Lichen Planus

 Lichen Simplex

 Vulval Candidiasis

 Contact Dermatis

 Psoriasis

 Blistering and Ulcerative conditions

 Vulva lumps and bumps

 Lichen Sclerosis

 Chronic inflammatory skin condition

 Affects women of all ages- common in

postmenopausal

 Often but not always association with other

autoimmune disease
 Lichen Sclerosis

 SYMPTOMS:
 Pruritus, often severe. 80-90% of pts
 Dyspareunia: 60-70%
 Pain with defecation: 20% (esp children)

 SIGNS:
 Predilection for genital skin. Does not involve the
vagina.

 Flat, pearly white papules and plaques

(hypopigmentation) extending from vestibule outward.

 Perianal involvement is common - forming a “figure of

8” configuration
 Lichen Sclerosis
Histology

 Epidermal atrophy

 Hydropic degeneration of the basal layer

 Dermal inflammation

 Sclerotic Stroma
 Lichen Sclerosis
Risk of neoplasia

3-5% risk (above baseline) of developing SCC

(squamous cell carcinoma)

Cannot be sure by visual appearance – biopsy to r/o or

confirm neoplasia.
 DIAGNOSIS
of
Lichen Sclerosis
 Can be made clinically in “classic cases” by
experienced provider.

 Histologic confirmation is preferred.

 Even “fully developed” LS can be inapparent on bx

and diagnosis vague. Several bx may be required.

 Bx to confirm your diagnosis and r/o neoplasia

Classic LS manifested by
white, sharply
demarcated
plaque.

Skin is shiny and crinkled

with
loss of labia minora and
partial agglutination of
clitoral hood.
Classic LS manifested by
white, sharply
demarcated
plaque.

Skin is shiny and crinkled

with
loss of labia minora and
partial agglutination of
clitoral hood.
Cellophane paper crinkling of
perianal skin is nearly
pathognomonic for LS
Periclitoral area is often the first
affected.

Edema and smooth, shiny skin are

early skin changes of LS.
Smooth, hypopigmented, nearly
waxy skin occurs in some women
with LS

Noted here on the medial labia

majora
More long-standing disease is
likely to manifest as hyperkeratotic
or macerated skin.

The perineal body is especially

prone to thickened LS
Superimposed thickening and
purpura from rubbing
 TREATMENT
of
Lichen Sclerosis
 Improve the environment! Control of local
irritants and treat infections.
 Ultrapotent topical steroids: Clobetasol
0.05% ointment once to twice daily x 1- 3 months.
 Second line: Topical tacrolimus
 Surgical: Surgery of CO2 laser vaporisation do not
relive the symptoms but they have a role in
restoring function impaired by agglutination and
adhesion of the vulva.
 Freq visits at 2, 6 & 12 wks.
After treatment the skin
exhibits normal color and
texture
 PROGNOSIS

 Cannot reverse architectural damage that has already

occurred.
 Steroid treatment can prevent further/on-going
destruction.
 For example: clitoral hood agglutination will likely not
regress, but may be surgically released. Will re-
agglutinate if fail to treat postop with potent topical
steroids.
 May develop post-inflammatory hyperpigmentation
 Lichen Planus

 Affects skin anywhere in the body

 Mainly mucosal surfaces, oral mucosa

 Presents with polygonal purple plaques and

plaques with a fine reticular pattern.

 Common in postmenopausal women

 Lichen Planus

 Small lifetime risk of SCC of the vulva

 2.3 % lifetime risk

 Management

 First line: High potency topical corticosteriods

 Chlobetasol and tacrolimus appears to be effective

 Oral corticosteriods in some cases

 Lichen Simplex

 “The Scratch that Itches” – a vicious cycle

 Often misdiagnosed as “yeast infection”

 Antifungals may decrease, but not

eliminate sx
 Genital pruritus is the single most
frequent presenting symptom in
anogenital region
 Often severe, intractable, awakes from sleep.
Will scratch “till it hurts or bleeds”
 Erythema and odematous swelling with discrete areas
of thickening and lichenification often secondary to
scratching.

 Exacarbated by chemical irritants, contact dermatitis,

stress or low body iron stores.

 Full skin exam

 Bx generally not necessary except to r/o other

conditions
 LSC - Treatment

 Vulvar care measures: Stop the Itch-Scratch-Itch cycle

 R/O infection as precipitating or driving factor

 Steroids

 Sedation

 Pt education re: chronicity. Recurrence is expected and does not

represent a treatment failure.
LSC – Treatment - Steroids

 Systemic vs Topical

 Clobetasol oint 0.05% BID x2 wks, then daily for 2 wks, then 3x/wk for 2
wks. Then prn.

 Oral corticosteroids may be necessary (short term). Prednisone (40 mg

Q am x 5, then 20 mg po Q am x10)

 IM steroids – Triamcinolone (Kenalog) 80 mg deep into buttock

LSC – Treatment - Sedation

 Nighttime Itching:

 Benadryl 2 hrs prior to bedtime

 DTCA (amitriptyline) 10 mg with gradual

increase to 50 mg QHS 2 hrs prior to
bedtime.
 LSC – Treatment –
Sedation

 Daytime Itching

 If nighttime therapy is insufficient to control daytime

itch/scratch

 SSRI – Prozac (20 mg Q am), Paxil, Zoloft

 Celexa 10-20 mg Q am, increase weekly to max of 60 mg.

 Quite effective – mechanism of action poorly understood.

Note the thick,
rough skin

Hyperpigmentatio
In dark skin

Activation of
melanocytes from
inflammation and
rubbing
Red, lichenified,
poorly
demarcated
plaques classic
for
LSC
Thickened from
rubbing.
Irregular erosions
from scratching

Redness less well

appreciated in dark
skinned pts
Erythema
Exaggeration of
skin lines
Scale
Fissuring
Licenification
Erosions
 Contact Dermatitis

 Caused by Irritants, Allergens or Both

 Sx: Vulvar Burning, Irritation, Pain,

 Signs:

 Acute – Erythema, Edema, Erosions

 Chronic – “dusky” or “violaceous” hues, cracks,

fissures, dry or chapped skin
Contact Dermatitis (cont)

 Deeply ingrained hygiene practices

 “No problems in the past” “Used this same product for

years”. The same product can cause sx after long use
without problems.
 Correct dx based on hx. Pts forgetful, reticent or ashamed to
admit to practices.
 Sometimes iatrogenic (TCA, Aldara, Podophyllin etc)

 Never underestimate what products women might

apply to the vulva when desperate!
Contact Dermatitis (cont)

 Causes

 Wet: Urine, feces, sweat, panty liners/pads

 Dry: Over energetic hygiene – perceived odor,

“dirty”. Hot water, harsh detergents, harsh
towels. “Normal” soap and water too frequently.
 Common Vulvar
Allergens/Irritants
ALLERGENS (initial sensitization to antigen 7-10 d)
 Benzocaine (Vagisil) – The most common offender!

 Preservatives

 Neomycin / Bacitracin / Sulfa products

 Latex condoms

 Chlorhexadine (K-Y)

 Lanolin

 Perfume

 Nail polish

 Nickel (piercing)

 Semen

 Yeast as an allergen?
 IRRITANTS

Soaps/Cleaners

Sweat/Urine/feaces

Rx Creams (alcohol)

Douches

Spermicides

Yeast creams

Panty liners/pads
Harsh disinfectants
produce
an exudative, vesicular,
edematous acute
irritant
dermatitis
 Contact Dermatitis
Treatment

 STOP offending agent or behavior!

 Easier said than done.

 Educate re hygiene practices. Warm H20 only. No

soap. No daily panty liners. Shaving/waxing?
Products a/w these practices?
 Skin protection (plain zinc oxide ointment or paste
keeps moisture away from skin) Lubrication/moisturizer
- vegetable oil, Crisco, petrolatum
 Contact Dermatitis
Treatment (cont)

 Sitz baths

 Topical steroid Ointments (not creams – which

have ETOH, preservatives, stabilizers)

 Mid-High potency – Triamcinolone 0.1% or

Fluocinonide 0.05% BID for 1-2 wks.
 Vulval Candidiasis

 Irritation and soreness

 Risk factors: DM, obesity, antibiotic therapy

 O/E: leading edge of inflammation with satelitte

lesions may be seen extending to inner thighs or
mons pubis.
Candidiasis

Edema, scale and fissuring

 Management

 Prolonged topical antifungal therapy. Oral and

topical

 Small study suggested increased clearance with

combine approach and to reduce reoccurence.
 PSORIASIS

 Can involve the entire vulva but not vaginal mucosa

 Appearance differs from typical scale of non genital sites

 Appears as smooth, non scaly red or pink discrete lesions

 Scratching may cause infection, dryness and skin

thickening.

 Full exam: including nails, scalp

 Management: Emollients, soap susbstitutes, topical

steroid
 HERPES

 Acute vulva pain

 Genital blisters or ulcers

 Take Swab for conformation any typing

 Beçets Disease

 Chronic multisystem disease characterised by

recurrent oral and genital ulcers.

 Recurrent, painful and leave scarring.

 Treatment is to control flares and reduce symptoms

basrd on topical or systemic immunosuppressants.
 Bartholin’s Cyst

 Common in women of child bearing age

 Can grow form the size of a pea to gulf ball

 Marsupalization is treatment of choice, allows

gland to drain and reduces the risk reoccurence.
 Sebaceous Cyst

 Mobile mass which consist of fibrous tissue filled

with inspissated sebaceous material.

 Common in hair bearing areas, smooth and to the

touch and vary greatly n size.

 Involves primarily labia majora

 Excision of central punctum to prevent

reoccurence.
 Key Points

 Vulval itch common complaint

 Skin biopsy is not always necessary unless you

suspect malignancy or disease condition does not
improve with treatment

 Advice on general vulval care

 Lumps and Bumps are common in vulval area

 Many dermatoses can be recognised fromhx and

classical features on examination
 Reference

 Crucickshank ME, Hay I. The management of vulva

skin disorders. RCOG greentop guideline NO 58,
2011

 Lynch PJ, Moyal- Barracoo M Scrurry J, Stockdale C.

2011 ISSVD terminology and classification of
vulvar dermatological disorders an approach to
clinical disorders: an approach to clinical diagnosis
JLGTD 2012;16 339-44

 http://lichensclerosus.org/checkyourvulva