Overview
| Disorder | Features | Management |
|---|---|---|
| Lichen simplex chronicus | Thickened, discolored epithelium caused by chronic scratching. Leathery appearance. | Medium-potency corticosteroid (Betamethasone) |
| Lichen sclerosis | Symmetric thinning of labial skin (cigarette paper or parchment-like), distortion of normal anatomy and/or adhesions | Biopsy, High-potency corticosteroid (Clobetasol) |
| Lichen planus | Shiny, violaceous papules w/white striae; usually in middle-aged women. Lesions may be seen elsewhere. | Hydrocortisone suppositories |
| Vulvar eczema | White/red patches. Hyperkeratotic changes. Often seen in young girls. | Medium-potency corticosteroid (Betamethasone) |
| Vulvar psoriasis | Discrete red plaques with silver scaling. Also found in other intertriginous regions | Medium-potency corticosteroid (Betamethasone) |
Vulvar Pruritus
The most common cause is contact or allergic dermatitis*.* Other common causes of pruritus may be infection, trauma, neoplasia, or immune response. Itching may be acute or chronic. Remember to rule out infectious processes whenever a patient presents with pruritus.
- Causes
- Hygiene products (soaps, salts, shampoos, laundry detergents, sanitary napkins, sanitary wipes)
- Medications (contraceptive creams/jellies/foams, antiseptics, topical anesthetics, topical corticosteroids)
- Allergens (latex condoms, bodily fluids, foods)
- Others (dyes, emollients, etc.)
- Patient History
- Duration of itching
- Location
- Sensation
- Hygiene measures
- Medications
- PMHx
- OBHx
- SHx
- Associated Symptoms
- Pain
- Dyspareunia
- Bleeding
- Discharge
- Recommendations for vulvar hygiene
- Avoid scented products and those with multiple ingredients
- Wash with plain, clean water and pat dry
- Wear loose-fitting clothing
- For dryness or pain affecting intercourse, choose water-base or silicone lubricants rather than petroleum-based
- Keep nails trimmed short
Lichen Simplex Chronicus
Lichen simplex chronicus is epidermal thickening (lichenification) due to excessive itching usually secondary to some form of irritation.
- Patient History
- Irritative/allergenic products
- Other dermatoses that cause pruritus
- Symptoms
- Vulvar itching
- Physical examination
- Bilateral symmetric lichenification (discolored gray, leathery, and thick)
- Excoriation from frequent itching (may become infected)
- Treatment
- Mild-medium potency topical corticosteroid ointment (eg. Betamethasone)
- Non-irritative lubricants (plain petrolatum, vegetable oil, silicone-based products)
- Sitz baths
- PO antihistamines (reduces night-time pruritus)
- Clip nails (nails cause excoriation, excoriation leads to infection)
Lichen Sclerosis
Lichen sclerosis is a chronic inflammatory disease affecting the labia and perianal skin (figure 8 lesion). It is the vulvar lesion that is most associated with vulvar carcinoma, hence a biopsy is useful to exclude carcinoma (4-6% go on to develop vulvar SCC). Diagnosis is clinical. There are no curative options
- Patient History
- Post-menopausal
- Autoimmune disease
- Diabetes mellitus
- Symptoms
- Vulvar or Anogenital pruritus
- Worse at night
- Burning sensation
- Dyspareunia
- Vulvar or Anogenital pruritus
- Physical exam
- Affected areas appear thin, and crinkled and are described as “cigarette paper” or “parchment-like”
- Distortion of the external anatomy (including the introitus)
- Treatment
- Short-term high-potency steroid ointment (Clobetasol)
- Estrogen creams (for concurrent atrophic vaginitis)
- Tacrolimus (for concurrent vulvar eczema)
- Surgery (reserved for severe cases unresponsive to steroids and causing sexual dysfunction)
- Hygiene recommendations
Lichen planus
Lichen planus is an atrophic inflammatory condition characterized by shiny white-purple papules, especially of the labia minora, which may become eroded and inflamed. It is a systemic condition that has manifestations elsewhere (eg. on the wrist, forearms, and ankles.) ****Can be spontaneous. Usually seen in middle-aged women (30-60 yoa). Diagnosis is clinical, but a biopsy may be useful to r/o malignancy.
- Associations
- Drugs (anti-hypertensives)
- Stress
- Symptoms
- Vulvar pruritus
- Physical exam
- Shiny, purple papules on the affected areas which may be painful and are variably itchy
- Whitish discoloration of the skin
- Adhesion may be present (causing stenosis)
- Mild exudate
- Treatment
- Vaginal hydrocortisone suppositories
- Discontinue all potent irritants
- Vaginal dilators or surgery (for adhesions)
- Regular examinations to monitor progress
Vulvar Eczema
Vulvar eczema classically affects young girls in the first 5 years of life. Diagnosis is clinical. Treatment is similar to that of lichen simplex chronicus.
- Patient history
- Eczema elsewhere
- Other atopic diseases (Asthma, Allergic rhinitis)
- Symptoms
- Relapsing and remitting vulvar itching
- Physical examination
- Scaling
- White/red pruritic patches
- Localized thickening of the vulvar skin
- Treatment
- Mild-medium potency corticosteroids (Betamethasone)
- PO antihistamine at night
Vulvar Psoriasis
Vulvar psoriasis is an autoimmune dermatologic condition of varying severity. Psoriasis is due to increased cell turnover. There may be psoriasis elsewhere. Psoriasis lesions tend to persist while eczema lesions wax and wane. Diagnosis is clinical
- Symptoms
- Vulvar pruritus
- Associated with lesions
- Exacerbated by stress and menses
- Improves during pregnancy
- Psoriasis elsewhere (intertriginous regions)
- Vulvar pruritus
- Physical exam
- Thick, red plaques with silvery scales
- Treatment
- Short-term, high-potency corticosteroids (Clobetasol)
- Second-line
- Topical vitamin D
- UV therapy
- Immunomodulators