Benign vulvar disorders march 2012 ghatage

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Benign vulvar disorders march 2012 ghatage

  1. 1. Benign lesions of the vulva Dr Prafull Ghatage Tom Baker Cancer Centre, Calgary, Canada March 2012
  2. 2. Learning objectives n  Anatomy of the vulva n  Physiology of vulvar itching n  Definitions n  Classification – ISSVD n  Management
  3. 3. Itch is an unpleasant sensation which evokes the desire to scratch-Samuel Hafenreffer,Nosodochium,in Quo Cutis,1660 n  Itching – exteroceptive sensation elicited only by stimulation of the skin or skin-to-mucosa transitional surfaces. n  Stratification of receptors limits itching to the epidermis and epidermis/dermis transition. Maximal sensitivity at the basal layer n  Itching induces a scratch reflex
  4. 4. Pruritis n  Fine unmyelinated C fibers n  Also control pain, touch ,temperature n  Subepidermal to lateral spinothalamic tract thalamus sensory cortex
  5. 5. Definitions n  Lotion Oil mixed with water. Can be drying as it may have alcohol n  Ointment Oil base. Greater penetration. More abrasive. However, very moisturizing. n  Cream Water-soluble. Moderately moisturizing. Least abrasive
  6. 6. Potency ranking of topical steroids Class Generic Name I Very high Clobetasol proprionate 0.05% ointment / cream II High Betamethasone diproprionate 0.05% ointment III Betamethasone diproprionate 0.05% cream IV Mild Triamcinalone 0.1% cream V Betamethasone Valerate 0.1% cream VI Low Clobetasol butyrate 0.05% cream VII Hydrocortisone 1% cream / ointment
  7. 7. Benign and Malignant Lesions of the Vulva n  Non-neoplastic n  Infectious n  Neoplastic
  8. 8. Epithelial Vulvar Disease (ISSVD),2004 n  Nonepithelial disorders of the vulva n  Lichen sclerosus n  Sqamous cell hyperplasia n  Other dermatoses n  Mixed neoplastic and nonneoplastic disorders n  Intraepithelial neoplasia n  Squamous n  Non-squamous n  Invasive
  9. 9. Vitiligo
  10. 10. Vitiligo n  Psoralen photochemotherapy ( PUVA) n  Treatment with narrow band ultraviolet B phototherapy
  11. 11. Seborrheic dermatitis n  Common in neonates n  Cause unknown n  Often occurs in areas of sebaceous glands
  12. 12. Seborrheic dermatitis
  13. 13. Contact Dermatitis
  14. 14. Psoriasis n  2% of population n  Silver white plaques n  Check elbows ,knees , forearms
  15. 15. Psoriasis n  Rarely well demarcated n  Can be annular n  Steroids
  16. 16. Lichen Planus An inflammatory, mucocutaneous eruption with a distinctive pattern on: - skin, scalp, nails - mucous membranes - oral, genital, esophageal
  17. 17. Lichen Planus - Etiology Unknown ? Autoimmune triggered by exogenous antigens, possibly - viral - bacterial (superantigen) - chemical - drug - trauma
  18. 18. Symptoms LP n  irritation with burning and soreness n  Can be very itchy, and scratching flares it n  thickening of the vulva n  dyspareunia n  Symptoms depend on extent of disease - e.g. when vagina is involved with erosions, there is discharge and burning
  19. 19. Diagnosis LP n  Look at rest of skin and mucous membranes n  Look in the mouth n  Biopsy - regular histopathology (H&E) - immunofluorescence
  20. 20. Erosive Lichen Planus
  21. 21. Lichen Planus - histology n  Basal cell liquification n  Subepidermal lymphocyte infiltration
  22. 22. Treatment LP n  Treat secondary infection n  Restore barrier function with Sitz bath or tub bath 1- 2 times a day n  Reduce inflammation with topical superpotent corticosteroids halobetasol or clobetasol 0.05% ointment 1- 2 times a day
  23. 23. Treatment LP n  For the vagina - hydrocortisone acetate foam (80 mg) at night or in a compounded suppository 100 mg n  For localized disease consider intralesional steroids n  Consider dilators for vaginal narrowing
  24. 24. Severe LP n  Oral Prednisone 1 - 1.5 mg / kg / day for 2 weeks and tapering over 2-4 months n  +/- Cyclosporine 4 mg per kg per day and continue until the patient is clear n  Plaquenil 200 mg bid and / or hydrocortisone acetate vaginally n  Doxycycline, metronidazole, n  Acitretin, n  Tacrolimus
  25. 25. Prognosis LP 1/3rd complete resolution 1/3rd significant resolution 1/3rd ongoing problems
  26. 26. Etiology of LS n  Unknown n  Multifactorial - genetic n  - autoimmune n  - environmental factors n  NOTE: Often associated with autoimmune conditions, e.g. thyroid disease, vitiligo, etc. n  Familial cases have been reported
  27. 27. Lichen Sclerosus n  A common chronic vulvar disease n  An inflammatory skin condition n  Prevalence 1 in 300 to 1 in 1,000 n  Most commonly found in middle-age women, but it can be seen in very young children and the elderly n  Recognized familial association and certain HLA subtypes occur more often in affected families
  28. 28. Lichen sclerosus n  Benign epithelial disorder n  Epithelial thinning with edema and fibrosis of dermis n  Shrinkage and agglutination of labia n  Typically does not involve vagina and urethra
  29. 29. Lichen sclerosus
  30. 30. Lichen sclerosus
  31. 31. Lichen Sclerosus
  32. 32. Lichen sclerosis histology n  Thin epithelium with loss of rete edges n  Hyperkeratosis, fibrin deposition and loss of vascularity n  Chronic inflammatory cell infiltrate of lymphocytes in deeper layer
  33. 33. Lichen sclerosis- treatment n  High potency steroids n  0.05% clobetasol propionate n  Applied bid X 2-3 weeks for 12 weeks. Resolution can take several months n  Treat secondary infection
  34. 34. Lichen sclerosis-treatment cont’d n  2% Testosterone ointment. Testosterone propionate in sesame oil 100mg/ml mixed in petrolatum base n  2% Progesterone ointment 100mg in oil per oz of aquaphor cream base n  Topical Tacrolimus 0.1% ointment
  35. 35. Lichen sclerosis- treatment n  Mineral oil , hydrogenated vegetable oil good for symptomatic relief n  Soaks in Sitz bath or Burows solution helpful if used infrequently n  Non-medicated moisturing soap n  Cotton underwear n  Avoid perfumes and scented pads
  36. 36. Lichen sclerosis- treatment n  Vaginal dilators may reduce stenosis n  3-9% of women with LS develop sqamous cell carcinoma
  37. 37. Squamous cell hyperplasia n  Chronic, intense itching that results in repetitive scratching and rubbing n  The skin responds by thickening (lichenification). The thickening of the skin is caused by the scratching n  An itch-scratch-itch cycle starts and perpetuates the problem
  38. 38. Squamous cell hyperplasia -Etiology n  Develops in several itchy skin conditions: Atopic dermatitis (eczema) Contact dermatitis Lichen sclerosus n  Contact dermatitis can start this condition or be the main long-term promoting factor
  39. 39. Squamous Cell Hyperplasia n  Benign epithelial disorder n  vulvar pruritus n  localized nonspecific vulvar skin thickening
  40. 40. Squamous cell hyperplasia - histology n  thick epithelium n  broad rete ridges n  no significant inflammation
  41. 41. Treatment n  Stop the itch-scratch-itch cycle n  Sitz baths and soaks, no irritants n  Reduce inflammation with superpotent steroids, i.e., clobetasol or halobetasol ointment - bid for two weeks, - once a day for four weeks n  Intralesional steroids if severe. 5 mg of triamcinolone suspension in 2 ml of saline subcutaneously
  42. 42. Lichen Sclerosus Lichen Planus SCH Itch or burn Itch or burn Severe itch Scars Scars No scarring On the vulva On vulva and On the vulva in vagina Oral lesions frequently seen
  43. 43. Nerve supply and sites of steroid injection
  44. 44. Medical Denervation
  45. 45. n  0.1 ml 95% alcohol
  46. 46. Vulvar edema
  47. 47. Surgical denervation of the vulva n  Under GA n  Use Drains
  48. 48. Conclusion n  Skin disorders not uncommon n  Rule out cancer n  Biopsy essential for diagnosis prior to treatment
  49. 49. Conclusion cont’d n  Soap n  Underwear n  Avoid public pools / baths A dermatologic cliché is to dry wet lesions (soaks and compresses) and moisturize dry lesion (creams and ointments) n  Rarely, medical and/or surgical denervation may be necessary
  50. 50. Thank you

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