Prof khalid sait vlvar dermatosis ifcpc 2014

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Prof khalid sait vlvar dermatosis ifcpc 2014

  1. 1. Vulvar Dermatosis Khalid Hussain Sait Director of Gynecological Oncology Unit Professor Faculty of Medicine King Abdulaziz University Jeddah, Saudi Arabia
  2. 2. Epithelial Vulvar Disease (ISSVD),2004 —  Non neoplastic epithelial disorders of the vulva —  Sqamous cell hyperplasia —  Lichen sclerosus —  Other dermatoses —  Mixed neoplastic and nonneoplastic disorders —  Intraepithelial neoplasia —  Squamous —  Non-squamous —  Invasive
  3. 3. Epithelial Vulvar Disease (ISSVD),2004 —  Non neoplastic epithelial disorders of the vulva —  Sqamous cell hyperplasia —  Lichen sclerosus —  Other dermatoses —  Mixed neoplastic and nonneoplastic disorders —  Intraepithelial neoplasia —  Squamous —  Non-squamous —  Invasive
  4. 4. Squamous cell hyperplasia —  Chronic, intense itching that results in repetitive scratching and rubbing —  The skin responds by thickening (lichenification). The thickening of the skin is caused by the scratching
  5. 5. Squamous Cell Hyperplasia —  Benign epithelial disorder —  vulvar pruritus —  localized nonspecific vulvar skin thickening
  6. 6. Squamous cell hyperplasia -Etiology —  Develops in several itchy skin conditions: Atopic dermatitis (eczema) Contact dermatitis Lichen sclerosus —  Contact dermatitis can start this condition or be the main long-term promoting factor
  7. 7. Treatment —  Stop the itch-scratch-itch cycle —  Sitz baths and soaks, no irritants —  Reduce inflammation with superpotent steroids, i.e., clobetasol or halobetasol ointment - bid for two weeks, - once a day for four weeks
  8. 8. 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
  9. 9. —  Lotion Oil mixed with water. Can be drying as it may have alcohol —  Ointment Oil base. Greater penetration. More abrasive. However, very moisturizing. —  Cream Water-soluble. Moderately moisturizing. Least abrasive
  10. 10. Treatment —  Triamcinolone  10  mg/ 1  ml  use  3  ml  mix  with   6  ml  ns  inject  0.1  ml/ 1cm  (subcutaneously)   —  Hydrocor@son  100  mg     4ml    mixed  with  8  ml   ns  mixed  with  1  %   lidocain  7  ml  
  11. 11. Epithelial Vulvar Disease (ISSVD),2004 —  Non neoplastic epithelial disorders of the vulva —  Sqamous cell hyperplasia —  Lichen sclerosus —  Other dermatoses —  Mixed neoplastic and nonneoplastic disorders —  Intraepithelial neoplasia —  Squamous —  Non-squamous —  Invasive
  12. 12. Lichen Sclerosus —  A common chronic vulvar disease —  An inflammatory skin condition —  Prevalence 1 in 300 to 1 in 1,000 —  Most commonly found in middle-age women, but it can be seen in very young children and the elderly —  Recognized familial association and certain HLA subtypes occur more often in affected families
  13. 13. Lichen sclerosus —  Benign epithelial disorder —  Epithelial thinning with edema and fibrosis of dermis —  Shrinkage and agglutination of labia —  Typically does not involve vagina and urethra
  14. 14. Lichen sclerosus
  15. 15. Lichen Sclerosus
  16. 16. Lichen sclerosus
  17. 17. Lichen sclerosis- treatment —  High potency steroids —  0.05% clobetasol propionate —  Applied bid X 2-3 weeks for 12 weeks. Resolution can take several months —  Treat secondary infection
  18. 18. Lichen sclerosis-treatment cont’d —  2% Testosterone ointment. Testosterone propionate in sesame oil 100mg/ml mixed in petrolatum base —  2% Progesterone ointment 100mg in oil per oz of aquaphor cream base —  Topical Tacrolimus 0.1% ointment
  19. 19. Lichen sclerosis- treatment —  Mineral oil , hydrogenated vegetable oil good for symptomatic relief —  Soaks in Sitz bath or Burows solution helpful if used infrequently —  Non-medicated moisturing soap —  Cotton underwear —  Avoid perfumes and scented pads
  20. 20. Lichen sclerosis- treatment —  Vaginal dilators may reduce stenosis —  3-9% of women with LS develop sqamous cell carcinoma
  21. 21. Nerve supply
  22. 22. —  Medical Denervation —  0.1 ml 95% alcohol
  23. 23. Vulvar edema
  24. 24. Surgical denervation of the vulva( Mering procedure) —  Under GA —  Use Drains
  25. 25. Epithelial Vulvar Disease (ISSVD),2004 —  Non neoplastic epithelial disorders of the vulva —  Sqamous cell hyperplasia —  Lichen sclerosus —  Other dermatoses —  Mixed neoplastic and nonneoplastic disorders —  Intraepithelial neoplasia —  Squamous —  Non-squamous —  Invasive
  26. 26. Lichen Planus An inflammatory, mucocutaneous eruption with a distinctive pattern on: - skin, scalp, nails - mucous membranes - oral, genital, esophageal
  27. 27. Etiology of LP —  Unknown —  Multifactorial - genetic —  - autoimmune —  - environmental factors —  NOTE: Often associated with autoimmune conditions, e.g. thyroid disease, vitiligo, etc. —  Familial cases have been reported
  28. 28. Symptoms LP —  Irritation with burning and soreness —  Can be very itchy, and scratching flares it —  Thickening of the vulva —  Dyspareunia —  Symptoms depend on extent of disease - e.g. when vagina is involved with erosions, there is discharge and burning
  29. 29. Diagnosis LP —  Look at rest of skin and mucous membranes —  Look in the mouth
  30. 30. Erosive Lichen Planus
  31. 31. 5 p= purpul polygonal papule plaque prurities
  32. 32. Lichen Planus - histology —  Basal cell liquification —  Subepidermal lymphocyte infiltration
  33. 33. Treatment LP —  Treat secondary infection —  Restore barrier function with Sitz bath or tub bath 1- 2 times a day —  Reduce inflammation with topical superpotent corticosteroids halobetasol or clobetasol 0.05% ointment 1- 2 times a day
  34. 34. Treatment LP —  For the vagina - hydrocortisone acetate foam (80 mg) at night or in a compounded suppository 100 mg —  For localized disease consider intralesional steroids —  Consider dilators for vaginal narrowing
  35. 35. Severe LP —  Oral Prednisone 1 - 1.5 mg / kg / day for 2 weeks and tapering over 2-4 months —  +/- Cyclosporine 4 mg per kg per day and continue until the patient is clear —  Plaquenil 200 mg bid and / or hydrocortisone acetate vaginally —  Doxycycline, metronidazole, —  Acitretin, —  Tacrolimus
  36. 36. Prognosis LP 1/3rd complete resolution 1/3rd significant resolution 1/3rd ongoing problems
  37. 37. Conclusion — Skin disorders not uncommon — Rule out cancer — Biopsy essential for diagnosis prior to treatment
  38. 38. Conclusion cont’d — General Vulva care is essential — Steroid Therapy is the main line of treatment —  Rarely, medical and/or surgical denervation may be necessary
  39. 39. Conclusion cont’d A dermatologic cliché is to dry wet lesions (soaks and compresses) and moisturize dry lesion (creams and ointments)
  40. 40. Thank you

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