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1. Vulvar Dermatosis
Khalid Hussain Sait
Director of Gynecological Oncology Unit
Professor
Faculty of Medicine
King Abdulaziz University
Jeddah, Saudi Arabia

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