Clinical Review

Chronic vulvar symptoms and dermatologic disruptions: How to make the correct diagnosis

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When a patient reports chronic symptoms, it’s important to look beyond yeast infection and other common causes to accurately identify her condition and select the optimal treatment



Nearly one in every six women will experience chronic vulvar symptoms at some point, from ongoing itching to sensations of rawness, burning, or dyspareunia. Regrettably, clinicians generally are taught only a few possible causes for these symptoms, primarily infections such as yeast, bacterial vaginosis, herpes simplex virus, or anogenital warts. However, infections rarely produce chronic symptoms that do not respond, at least temporarily, to therapy.

In this two-part series, we focus on a total of 10 cases of vulvar symptoms, zeroing in on diagnosis and treatment. In this first part, we describe five patient scenarios illustrating the diagnosis and treatment of:

  • lichen sclerosus
  • vulvodynia
  • lichen simplex chronicus
  • lichen planus
  • hidradenitis suppurativa.

In many chronic cases, more than one entity is the cause
Specific skin diseases, sensations of rawness from various external and internal irritants, neuropathy, and psychological issues are all much more common causes of chronic vulvar symptoms than infection. Moreover, most women with chronic vulvar symptoms have more than one entity producing their discomfort.

Very often, the cause of a patient’s symptoms is not clear at the first visit, with nonspecific redness or even normal skin seen on examination. Pathognomonic skin findings can be obscured by irritant contact dermatitis caused by unnecessary medications or overwashing, atrophic vaginitis, and/or rubbing and scratching. In such cases, obvious abnormalities must be eliminated and the patient reevaluated to definitively discover and treat the cause of the symptoms.

A 62-year-old woman schedules a visit to address her anogenital itching. She reports pain with scratching and has developed introital dyspareunia. On physical examination, you find a well-demarcated white plaque of thickened, crinkled skin ( FIGURE 1 ). A wet mount shows parabasal cells and no lactobacilli.

Diagnosis: Lichen sclerosus and atrophic vagina.

Treatment: Halobetasol ointment, an ultra-potent topical corticosteroid, once or twice daily; along with estradiol cream (0.5 g intravaginally) 3 times a week.

Lichen sclerosus is a skin disease found most often on the vulva of postmenopausal women, although it also can affect prepubertal children and reproductive-age women. Lichen sclerosus is multifactorial in pathogenesis, including prominent autoimmune factors, local environmental factors, and genetic predisposition. 1

Although there is no cure for lichen sclerosus, the symptoms and clinical abnormalities usually can be well managed with ultra-potent topical corticosteroids. However, scarring and architectural changes are not reversible. Moreover, poorly controlled lichen sclerosus exhibits malignant transformation on anogenital skin in about 3% of affected patients.

The standard of care is application of an ultra-potent topical corticosteroid ointment once or twice daily until the skin texture normalizes again. The most common of such corticosteroids are clobetasol, halobetasol, and betamethasone dipropionate in an augmented vehicle (betamethasone dipropionate in the usual vehicle is only a medium-high medication in terms of potency.) One of us (L.E.) finds that some women experience irritation with generic clobetasol.

The ointment form of the selected corticosteroid is preferred, as creams are irritating to the vulva in most women because they contain more alcohols and preservatives than ointments do. The amount to be used is very small—far smaller than the pea-sized amount often suggested. By using this smaller amount, we avoid spread to the surrounding hair-bearing skin, which is at greater risk for steroid dermatitis and atrophy than the modified mucous membranes.


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