1. Benign lesions of the vulva
Dr Prafull Ghatage
Tom Baker Cancer Centre,
Calgary, Canada
March 2012

2. Learning objectives
n Anatomy of the vulva
n Physiology of vulvar itching
n Definitions
n Classification – ISSVD
n Management

4. 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

5. Pruritis
n Fine unmyelinated C fibers
n Also control pain, touch ,temperature
n Subepidermal to lateral spinothalamic tract
thalamus sensory cortex

6. 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

7. 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

8. Benign and Malignant Lesions of the Vulva
n Non-neoplastic
n Infectious
n Neoplastic

9. 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

10. Vitiligo

11. Vitiligo
n Psoralen photochemotherapy ( PUVA)
n Treatment with narrow band ultraviolet B
phototherapy

12. Seborrheic dermatitis
n Common in
neonates
n Cause unknown
n Often occurs in
areas of sebaceous
glands

13. Seborrheic dermatitis

14. Contact
Dermatitis

15. Psoriasis
n 2% of population
n Silver white plaques
n Check elbows ,knees ,
forearms

16. Psoriasis
n Rarely well demarcated
n Can be annular
n Steroids

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

18. Lichen Planus - Etiology
Unknown
? Autoimmune triggered by exogenous
antigens, possibly
- viral
- bacterial (superantigen)
- chemical
- drug
- trauma

19. 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

22. Diagnosis LP
n Look at rest of skin and mucous
membranes
n Look in the mouth
n Biopsy
- regular histopathology (H&E)
- immunofluorescence

24. Erosive Lichen Planus

25. Lichen Planus - histology
n Basal cell
liquification
n Subepidermal
lymphocyte
infiltration

26. 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

27. 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

28. 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

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

30. 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

31. 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

32. 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

34. Lichen sclerosus

35. Lichen sclerosus

36. Lichen Sclerosus

37. 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

38. 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

39. 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

40. 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

41. Lichen sclerosis- treatment
n Vaginal dilators may reduce stenosis
n 3-9% of women with LS develop sqamous cell
carcinoma

42. 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

43. 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

44. Squamous Cell Hyperplasia
n Benign epithelial disorder
n vulvar pruritus
n localized nonspecific vulvar skin thickening

48. Squamous cell hyperplasia - histology
n thick epithelium
n broad rete ridges
n no significant
inflammation

49. 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

50. 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

51. Nerve supply and sites
of steroid injection

52. Medical Denervation

53. n 0.1 ml 95% alcohol

54. Vulvar edema

55. Surgical denervation of the vulva
n Under GA
n Use Drains

56. Conclusion
n Skin disorders not
uncommon
n Rule out cancer
n Biopsy essential for
diagnosis prior to
treatment

57. 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

58. Thank you