News

Presentation of DIV Varies, Etiology Remains Unknown


 

BETHESDA, MD. — Most experts now believe that desquamative inflammatory vaginitis is not a diagnosis of one condition, but may represent a range of blistering disorders, such as lichen planus, mucous membrane pemphigoid, and pemphigus vulgaris, Hope K. Haefner, M.D., said at a conference on vulvovaginal diseases.

With descriptions in the medical literature dating to the 1950s, the signs and symptoms of desquamative inflammatory vaginitis (DIV) include dyspareunia and exudative, chronic vaginitis, with yellow-watery, purulent discharge that is occasionally blood-tinged, said Dr. Haefner, director of the University of Michigan Center for Vulvar Diseases, Ann Arbor.

Patients with DIV also may have a spotted rash on the vagina and cervix, massive vaginal cell exfoliation, and an increased vaginal pH, she said.

Previous terms used to describe this condition include exudative or membranous vaginitis, and hydrorrhea vaginalis.

DIV can occur at any age, and although it has been considered rare, it is being seen more frequently than in the past.

“Although we don't know what it is … we don't think it is an infectious process,” Dr. Haefner said, noting that in studies describing DIV in the 1950s and 1960s infectious organisms were detected in association with DIV but have since been ruled out as a cause.

Other forms of vulvovaginitis caused by trichomonas and other infections can be confused with DIV, as can noninfectious causes of erosive vulvovaginitis, such as lichen planus and graft-versus-host disease, she said. Other noninfectious causes of erosive vulvovaginitis include collagen vascular diseases and a local toxic effect of a drug. The cause also may be idiopathic.

Distinguishing DIV from atrophy can be difficult, since lab findings are similar to those found with atrophic vaginitis, with a nonspecific histology and parabasal cells and many polymorphonuclear leukocytes (PMNs) on cytology. Atrophic vaginitis has serosanguineous or watery discharge similar to that seen with DIV, as well as an elevated vaginal pH, with a thin vagina and red petechiae, Dr. Haefner said at the conference, sponsored by the American Society for Colposcopy and Cervical Pathology.

Atrophic vaginitis and erosive lichen planus are among the noninfectious conditions that are high on Dr. Haefner's list of differential diagnoses in a patient she suspects may have DIV. Lower on the list are other noninfectious causes of these symptoms, including lichen sclerosus, lupus erythematosus, cicatricial pemphigoid, Stevens-Johnson syndrome, graft-versus-host disease, pemphigus of the mouth and skin, and a local drug reaction such as contact dermatitis.

Like other experts in this area, Dr. Haefner believes that DIV can be an expression of erosive lichen planus, which can have the same wet smear, pH, cytology, and biopsy results. However, not all DIV is lichen planus, she pointed out.

Vulvovaginal symptoms of erosive lichen planus include burning; pruritus; dyspareunia that can be mild to severe, preventing coitus at times; bleeding spontaneously after coitus; and vaginal discharge, she said, noting that erosions are very painful. The difference with lichen planus is that it often is associated with erosive changes in the mouth, with a white reticulated border, adhesions, and atrophy, probably related to T-cell autoimmunity.

“When you see patients with DIV, think about looking in the mouth,” she advised.

In lichen planus, erosions may be found in the conjunctivae, external ear canal, esophagus, and anus.

In some cases, histology can help in diagnosing lichen planus, but in Dr. Haef-ner's experience, this has not been very helpful because lab and cytologic changes are nonspecific and may be similar to those found with atrophic vaginitis.

In diagnosing patients with DIV, she recommended considering what is happening with the whole patient, and whether the condition is acute or chronic and focal or diffuse. Also consider whether it involves the vestibule and/or the vagina and whether the patient has a local estradiol deficiency, oral mucosal or ocular disease, or any iatrogenic topical etiology.

For patients with chronic lichen planus, prophylactic dilation is important, because those patients often present with “shut” vaginas. However, prophylactic dilation is not necessary and would be considered overtreatment if used for all patients. To distinguish DIV from lichen planus, consider a biopsy and immunofluorescent studies to rule in or out some of the conditions in the differential diagnosis.

Because DIV is not a single disease, no one treatment will be effective in all cases. Treatment with 2% clindamycin cream for 2 weeks is a first-line therapy for most patients. Although DIV is not considered an infection, clindamycin is still useful because it has an antiinflammatory effect.

Those who need a second course of treatment may respond to hydrocortisone at a dose of 100 mg/g in a clindamycin 2% emollient cream base. A 5-g applicator should be inserted every other day for a total of 14 doses. This regimen is expensive and is not recommended for a first episode, said Dr. Haefner, who stated that she has no relevant financial relationships with any commercial interest relative to the subject of this presentation.

Next Article: