Vulval Skin Problems, Dysplasias & Vulvodynia

Allergic vulvitis

Vulval dermatoses

Vulval dysplasias

Vulvodynia

---

Besides allergic vulvitis, there are a number of conditions that present as white or coloured raised lesions of the vulva, with a number of causes. Some are premalignant.

ALLERGIC VULVITIS

Diagnosis

• The rash appears as a typical allergic rash
• The patient may be using a new type of underwear, soap or skin care product in the region of the external genitals
• Shaving may produce an eczema-like response

Management

• Remove the allergen

VULVAL DERMATOSES

Dermatoses affecting the vulva include psoriasis, eczema and lichen planus

Diagnosis

• Ask for a history of rash anywhere on the body
• Look for evidence of dermatosis elsewhere:
  • Psoriasis on extensor surfaces
  • Eczema on flexor surfaces
  • Lichen planus in the mouth

Ask for an experienced colleague’s opinion

Management

1. Refer to dermatology
2. Steroids are frequently used for these conditions

VULVAL DYSPLASIAS 

These conditions include lichen sclerosus, vulval intraepithelial neoplasia, Paget’s disease of the vulva. These lesions have variable malignant potential or may be associated with carcinoma, which must therefore be excluded.

Diagnosis

• These lesions may present with itching or soreness
• Non-troublesome lesions may be noticed by the patient, or incidentally by a clinician
• Before making a diagnosis, arrange for vulvoscopy(looking closely with a colposcope) and biopsy. Call an experienced consultant for guidance with vulvoscopy
• Biopsy: raise a bleb of local with a dental/diabetic/orange needle. Biopsy with Keye’s/Stieffel punch biopsy. Remove tissue with pointed scalpel e.g. blade no 11. Stop bleeding with silver nitrate stick
• Do a Pap smear, to be interpreted in conjunction with the vulval biopsy

Appearance on vulvoscopy

• Lichen sclerosus – pale, onion-skin, hour glass pattern around the labia and anus. Uniform in colour
• Vulval intraepithelial neoplasia (VIN) – discrete lesions of any colour, may or may not be raised
• Vulval Paget’s disease – pearly appearance, any colour
• Carcinoma – ulceration, raised areas, rough areas, etc.

Management

1. Lichen sclerosus – high dose topical steroid clobetasol propionate 0.05% (Dermovate) cream twice daily for 2 weeks followed by low dose betamethasone valerate 0.05% (Betnovate Half-Strength) or Hydrocortisone 0.5% or 1% cream for one month, repeating if necessary 
2. VIN - excision or ablation of VIN 2 & 3, observation of VIN 1, with long term follow-up. Ensure cervical follow up also – both dysplasias may be HPV16 and 18 dependent; instruct smokers with VIN to terminate their habit – recurrence & progression is increased
3. Paget’s disease – excision and follow up. The association with underlying adenocarcinoma is more rare than with breast Paget’s
4. Malignant lesions – treat according to oncology protocols (Vulval Cancer)

Vulvodynia

This is a chronic condition of unknown aetiology that may occur at any age of adulthood that has no known cause. Sharp pain, burning, stinging, or irritation is experienced on the vulva. In a severe form vulval pain is experienced by touch with a cotton bud or swab at the introitus and is called ‘Vulvar vestibulitis’.

Diagnosis

This is a diagnosis of exclusion. The differential diagnosis includes infections (candidiasis, herpes, HPV); inflammation (lichen planus, other dermatoses); neoplasm or dysplasia (Paget’s disease, VIN, vulval cancer); neurological disorder (neuralgia secondary to herpes virus, spinal nerve injury).

Management

This is difficult. Supportive counseling may have some but sometimes limited benefit. SSRIs have been used. Ultimately vestibulectomy may be performed but should only be the choice of a clinician experienced in the condition.