1. Vulvar Dermatosis
Khalid Hussain Sait
Director of Gynecological Oncology Unit
Chairman of the scientific chair of prof. Abdullah Hussain Basalamah
for Gynecological Cancer
Professor
Faculty of Medicine
King Abdulaziz University

4. 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

5. 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

6. 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

7. Squamous Cell Hyperplasia
— Benign epithelial disorder
— vulvar pruritus
— localized nonspecific vulvar skin thickening

8. 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

12. 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

13. 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

14. — 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

15. 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

16. 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

17. 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

18. 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

22. Lichen sclerosus

23. Lichen Sclerosus

24. Lichen sclerosus

27. 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

28. 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

29. 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

30. Lichen sclerosis- treatment
— Vaginal dilators may reduce stenosis
— 3-9% of women with LS develop sqamous
cell carcinoma

31. Nerve supply

32. — Medical Denervation
— 0.1 ml 95% alcohol

33. Vulvar edema

34. Surgical denervation of the vulva( Mering
procedure)
— Under GA
— Use Drains

35. 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

36. Lichen Planus
An inflammatory, mucocutaneous eruption
with a distinctive pattern on:
- skin, scalp, nails
- mucous membranes - oral, genital, esophageal

37. 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

38. 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

42. Diagnosis LP
— Look at rest of skin and mucous
membranes
— Look in the mouth

45. Erosive Lichen Planus

46. 5 p= purpul polygonal papule
plaque prurities

47. Lichen Planus - histology
— Basal cell liquification
— Subepidermal lymphocyte
infiltration

48. 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

49. 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

50. 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

51. Prognosis LP
1/3rd complete resolution
1/3rd significant resolution
1/3rd ongoing problems

52. Conclusion
— Skin disorders
not uncommon
— Rule out cancer
— Biopsy essential
for diagnosis
prior to
treatment

53. 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

54. Conclusion cont’d
A dermatologic cliché is to dry wet
lesions (soaks and compresses) and
moisturize dry lesion (creams and
ointments)

55. Thank you