HOUSTON — Elizabeth “Libby” Edwards, M.D., gave an overview of erosive, noninfectious skin diseases at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.
According to Dr. Edwards, chief of dermatology at the Southeast Vulvar Clinic in Charlotte, N.C., and a faculty member at the University of North Carolina, Chapel Hill, gynecologists should consider the following skin conditions:.
▸ Lichen planus. This skin condition is well known to gynecologists, she said. An autoimmune disease, it also presents in the mouth and can cause scarring in the vagina and vulva. Its clinical appearance ranges from white reticulate papules to nonspecific erosions that often require biopsy to diagnose. Numerous therapeutic options include corticosteroids, an anti-inflammatory antibiotic given with fluconazole to prevent yeast development, and supportive care.
▸ Desquamative inflammatory vaginitis spectrum. Also known as sterile inflammatory vaginitis, this condition is often misdiagnosed, according to Dr. Edwards. It presents with a red or eroded vaginal epithelium and yellow/green secretions that contain a high number of white blood cells. Though the etiology is not known, she suspects it is “an autoimmune problem in the same family as lichen planus.” If the patient initially was diagnosed with an infection but did not respond to penicillin, then Dr. Edwards considers desquamative inflammatory vaginitis spectrum as a possible diagnosis and gets a culture to tell for sure. If this diagnosis is confirmed, Dr. Edwards prescribes clindamycin cream intravaginally or hydrocortisone suppositories or both.
▸ Posterior fourchette fissures. This common erosive condition can occur every time a woman has intercourse, and it heals quickly. “If she does not come in within a day of intercourse, you won't see it,” Dr. Edwards said. Some physicians treat this condition with topical estrogen, but she said the only therapy that has worked for her patients is perineoplasty.
▸ Skin fold fissures. These fissues are often compared with paper cuts, according to Dr. Edwards. They sometimes present as fine red lines. They can be caused by irritation from another condition, especially Candida albicans, but sometimes occur in patients who have nothing else wrong. Dr. Edwards recommends doing lots of cultures. If the cultures don't turn up anything, she uses a “shotgun” approach to eliminating the unknown cause by treating with an antifungal, clobetasol ointment, and cephalexin.
▸ Fixed drug eruption. This condition is a blistering/erosive reaction to a medication. Dr. Edwards said to make a diagnosis of the disease by history and clinical appearance. “Treatment is local care and avoidance of the medication,” she said.
▸ Blistering erythema multiforme. Also known as Stevens-Johnson syndrome and toxic epidermal necrolysis, this condition can be a hypersensitive allergic reaction to an infection or recurring herpes simplex virus, according to Dr. Edwards. An acute condition, it presents with red nonscaling papules and plaques, blistering, and erosion that can cover 40% of skin. Dr. Edwards warned that it is a dangerous disease with a 40% mortality rate “that comes on like gangbusters. … Call a dermatologist; call an intensivist, and often send these patients to a burn center,” she advised, urging gynecologists to do all they can to protect the vulva. “The guys in the ICU are not thinking about that,” she said. “The guys in the ICU are trying to save this person's life.”
▸ Cicatricial pemphigoid. This condition presents with erosion and scarring of mucous membranes. It can lead to blindness, tooth loss, obliteration of the vaginal space, labia minora agglutination, and narrowing of the introitus, according to Dr. Edwards. She said to diagnose by biopsy and immunofluorescence of adjacent skin, and treat in most cases with oral prednisone. Sometimes a topical medication or antimetabolite can be tried.
▸ Pemphigus vulgaris. Another autoimmune blistering disease of the skin and mucous membranes described by Dr. Edwards is pemphigus vulgaris. She said it does not scar except in vulvovaginal areas, where it can lead to disfigurements similar to cicatricial pemphigoid. Diagnosis and treatment are also similar.
▸ Contact dermatitis. This skin condition can be caused by poison ivy, scrubbing the skin with too much [pumice-containing] soap, or something else a woman is using, according to Dr. Edwards. “You have to ask specifically, 'What are you putting in the area?'” she said.