Clinical Review

Vulvovaginal disorders: 4 challenging conditions

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TABLE 1

CDC guidelines for treatment of candidiasis
Any of these intravaginal or oral regimens may be used

DOSE (NUMBER OF DAYS)
INTRAVAGINAL AGENTS
Butoconazole
2% cream*5 g (3)
Butoconazole-1 sustained-release cream5 g (1)
Clotrimazole
1% cream*5 g (7–14)
100 mg1 tablet (7)
2 tablets (3)
500 mg1 tablet (1)
Miconazole
2% cream*5 g (7)
100 mg*1 suppository (7)
200 mg*1 suppository (3)
Nystatin
100,000 U1 tablet (14)
Tioconazole
6.5% ointment*5 g (1)
Terconazole
0.4% cream5 g (7)
0.8% cream5 g (3)
80 mg1 suppository (3)
ORAL AGENT
Fluconazole
150 mg1 tablet (1)
* Over-the-counter

2. Contact DermatitisNine essentials of treatment

Contact dermatitis, the most common form of vulvar dermatitis, is inflammation of the skin caused by an external agent that acts as an irritant or allergen. The skin reaction may escape notice because changes ranging from minor to extreme are often superimposed on complex preexisting conditions such as lichen simplex chronicus, lichen planus, and lichen sclerosus.6

Contact dermatitis occurs readily in the vulvar area because the skin of the vulva reacts more intensely to irritants than other skin, and its barrier function is easily weakened by moisture, friction, urine, and vaginal discharge. The 3 main types of irritant dermatitis are7:

  • A potent irritant, which may produce the equivalent of a chemical burn.
  • A weaker irritant, which may be applied repeatedly before inflammation manifests.
  • Stinging and burning, which can occur without detectable skin change, due to chemical exposure.

Many products can cause dermatitis. Even typically harmless products can cause dermatitis if combined with lack of estrogen or use of pads, panty hose, or girdles.

No typical pattern

Patients complain of varying degrees of itching, burning, and irritation. Depending on the agent involved, onset may be sudden or gradual, and the woman may be aware or oblivious of the cause. New reactions to “old” practices or products are also possible.

Ask about personal hygiene, care during menses and after intercourse, and about soap, cleansers, and any product applied to the genital skin, as well as clothing types and exercise habits. Review prescription and OTC products, including topicals, and note which products or actions improve or aggravate symptoms. A history of allergy and atopy should heighten suspicion.

The physical exam may reveal erythema and edema; scaling is possible. Severe cases manifest as erosion, ulceration, or pigment changes. Secondary infection, if any, may involve pustules, crusting, and fissuring. The dermatitis may be localized, but often extends over the area of product spread to the mons, labiocrural folds, and anus. C albicans often complicates genital dermatologic conditions.


9-step treatment

  1. Stop the offending product and/or practices.
  2. Restore the skin barrier with sitz baths in plain lukewarm water for 5 to 10 minutes twice daily. Compresses or a handheld shower are alternatives.
  3. Provide moisture. After hydration, have the patient pat dry and apply a thin film of plain petrolatum.
  4. Replace local estrogen if necessary.
  5. Control any concomitant Candida with oral fluconazole 150 mg weekly, avoiding the potential irritation caused by topical antifungals.
  6. Treat itching and scratching with cool gel packs from the refrigerator, not the freezer (frozen packs can burn). Stop involuntary nighttime scratching with sedation: doxepin or hydroxyzine (10–75 mg at 6 PM).
  7. Use topical steroids for dermatitis:
    • Moderate: Triamcinolone, 0.1% ointment twice daily.
    • Severe: A super-potent steroid such as clobetasol, 0.05% ointment, twice daily for 1 to 3 weeks.
    • Extreme: Burst and taper prednisone (0.5–1 mg/kg/day decreased over 14–21 days) or a single dose of intramuscular triamcinolone (1 mg/kg).
  8. Order patch testing to rule out or define allergens.
  9. Educate the patient about the many potential causes of dermatitis, to prevent recurrence.
COMMON VULVAR IRRITANTS

CAUSTIC AGENTS

Bichloracetic acid

Trichloroacetic acid

5-Fluorouracil

Lye (in soap)

Phenol

Podophyllin

Sodium hypochlorite

Solvents

WEAK CUMULATIVE IRRITANTS

Alcohol

Deodorants

Diapers

Feces

Feminine spray

Pads

Perfume

Povidone iodine

Powders

Propylene glycol

Semen

Soap

Sweat

Urine

Vaginal secretions

Water

Wipes

PHYSICALLY ABRASIVE CONTACTANTS

Face cloths

Sponges

THERMAL IRRITANTS

Hot water bottles

Hair dryers

Source: Lynette Margesson,MD26

FIGURE 1 A mutilating disease of mysterious origin


Though lichen sclerosus is a disfiguring disease, the intensity of symptoms does not necessarily correlate with clinical appearance. Generally, the first change is (A) whitening of an irregular area on the labia, near the clitoris, on the perineum, and/or other vulvar areas. In some cases (A and B), inflammation can alter the anatomy of the vulva by flattening the labia minora, fusing the hood over the clitoris, effectively burying it beneath the skin, and shrinking the skin around the vaginal opening. Images courtesy Lynette Margesson, MD

3. Lichen SclerosusLifelong follow-up is a must

Although it has long been described in medical journals and textbooks, information on lichen sclerosus was often unreliable until recently, and adequate treatment guidelines were lacking. The cause still has not been fully elucidated, but a wealth of information now allows for considerable expertise in the management of this disease.

Lichen sclerosus is a chronic inflammatory and scarring disease that preferentially affects the anogenital area and is 6 to 10 times more prevalent in women than men.8 Any cutaneous site may also be affected, but the vagina is never involved.

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