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[LIVE BLOG – Seattle] Vulvovaginal Dermatology w/ Libby Edwards, MD

In this morning session, Dr. Libby Edwards addressed the audience on the importance of understanding and treating vulvo-vaginal skin disease.  Lichen simplex chronicus and lichen sclerosus were highlighted. 

Fact: About 20% of women will develop difficult-to-diagnose vulvo-vaginal symptoms at sometime in their lifetime.  
Gynecologists used to lump all skin diseases as dystrophy, not understanding the complexity and variety of the case.  Dr. Edwards explained the climate of the vulvo-vaginal area and how this affects the display of skin disease in the area.  Psoriasis looks different here than it would on the elbow and so focusing specifically on the area is crucial. 
Things to Note in the Exam Room
1. Be aware the patient may be experiencing anxiety and depression
2. Know that normal variants can be confusing
3. Look carefully for subtle abnormalities 
4. Know that multifactorial processes are common
5. Latrogenic disease is common
6. Vaginal disease is also important: look inside the vagina; Get a swab
Inflammatory vaginitis with leukocytes and immature epithelial cells shed from a proliferative epithelium was diagnosed after tests, triggered by viewing redness, yellow discharge
7. Presentations of skin diseases are often atypical or non-specific compared to dry skin
(Genital psorasis looks different than dry skin)
8. Any inflammatory dermatosis can produce scaring
9. Look at other mucous membranes and skin surfaces
10. Biopsy specific lesions only, not nonspecific erythema or area of symptoms
+ Do shaves rather than punches for lychen sclerosis
+ Punches tend to scar or leave skin tags
+ Send biopsies to a dermatopathologist or gyn pathologist with interest in inflammatory 
+ Give differential diagnosis
+ Provide an explanation of the disease process, treatments, expectations
+ Use Handouts (can customize from Dr. Libby’s handouts from
+ Use Photographs – circle the area you’d like them to treat
+ Treat all factors, not just the ones the patient has come to have treated
+ Anticipate and minimize iatrogenic disease (yeast, irritant contact dermatitis)
+ Avoid cream vehicles on painful, or inflamed, or estrogen-deficient vulvar skin
will burn women with vulvademium
+ Avoid topical therapy in general and use oral medications, except for corticosteroids
(Remember: The vulva is relative steroid resistant– use ultrapotents.)
Recalcitrant Problems
1. Consider poor complance
2. Re-evaluate for infection (Staphlococcal, streptococcal, candidiasis, HSV)
3. Re-evaluate for irritant/allergic contact dermatitis
4. Re-evaluate for wrong/additional diagnosis
5. Re-evaluate for SCC/evolving SCC
Most people with genital eczema are “rubbers and scratchers” which will cause the extra irritation.
Note: If rubbing helps and feels good, it is mostly a sign of eczema.  For people of color, the redness will look white.
Therapy for LSC
1. Patient education
2. Ultrapotent corticosteroids ointment bid for a month
3. Eliminate irritants (including nighttime scratching)
4. Search and treat for infection
5.  Xylocaine/lidocine 2% jelly (Moisturize!) 
If it doesn’t improve:
6. May be a Neuropathic itch; Consider psychological exam
Quick Facts:
+ Pruritic skin disease diagnosed most often on the vulva
+ Post-menstral women
+ Quite common
+ Probably multifactorial etiology
+ Autoimmune
+ familial tendency
+ Environmental
+ Even after a vulvectomy, it can still recur due to environmental factors
+ Often begins periclitorally; notes includes: fragility, crinkled, waxy, smooth, shiny.
+ May be keratotic (this is where we are concerned about it turning into cancer)
+ Late disease scars regularly 
+ Patchy hyperpigmentation is common
+ May need to biopsy for safety
+ Melanoma is the 2nd most common cancer on the vulva (perhaps more common in women with lichen sclerosus)
Clobetasol ointment – until texture is normal, then once, three times a week, potentially ongoing.  Some treat according to symptoms but Dr. Libby disagrees.
It’s also important to explain to patient:
1. It will likely reoccur
2. About infection control
3. Most young girls will get an infection after treatment.
Other notes: 2-3% of untreated vulvar LS will turn into squamous cell carinoma;
chronic erosions can be worrisome as well.
[image by Graham]

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