Guidelines 2016 – Vulvar Dermatology
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
vulvar dermatology is defined as a branch of science that deals with skin conditions of the vulva, which is the external genitalia that track from the mons pubis to the posterior perineum and the lateral inguinal creases to the hymnal ring. vulvar conditions are complex, misunderstood, and often difficult to diagnose, leading to misdiagnoses and poor treatment. the true prevalence of vulvar conditions is unknown because many women often do not seek treatment. a careful history and examination are imperative for a correct diagnosis.
II. HISTORY
a. medical history
1. medications
2. allergies—medications, foods, seasonal, environmental
3. review of autoimmune, endocrine, rheumatologic, gastrointesti- nal (gi), neurologic, psychiatric conditions, including history of asthma
4. Dermatologic conditions—skin and mucus membranes
B. obstetrical and gynecological history
1. menstrual history
2. contraceptive methods
3. sexual partners/lifetime
4. vaginal infections, including stis, Hiv, human papillomavirus (HPv)
5. menopause
6. gravida, para, living, terminations
7. method of deliveries—traumatic births/episiotomies/lacerations
c. sexual history
1. orientation
2. sexual partner/lifetime partners
3. current sexual activity
4. libido, dyspareunia
D. social history
1. smoking history: age of first cigarette use, number of cigarettes/ packs per day, medications used for smoking cessation
2. alcohol use: age of first drink, current use; number of drinks/day, type of alcohol
3. recreational drug use: past/current use, types of drugs used
4. intimate partner violence screening: past/current
e. Hygiene
1. Frequency
2. Products used: soaps, detergents, shower gels, brands used
3. cleaning method: washcloth, loofah, puff
4. Hygiene products: douches, sprays, deodorants, wipes
5. menstrual products: tampons, pad, panty liners (use daily or with menses), scented/unscented, brands used
6. urine/stool incontinence: products used and hygiene practices
7. other: shaving methods/products, lotions, perfumes, creams, powders
8. table 14.1 shows common skin irritants.
F. Family history
g. History of current problem
1. onset of symptoms: acute onset or subtle; have symptoms improved or worsened since onset
2. Duration of symptoms, pattern of symptoms, relationship to menses
3. Quality of symptoms: itching/irritation, burning/ stinging, raw, tearing, pain
4. vaginal discharge: color, odor, amount, quality
5. medications/activities undertaken to relieve symptoms
6. medications/activities that aggravate symptoms
7. other symptoms: fissures, bleeding, pain with bowel movements
8. impact on daily life
9. other health care providers/specialists visited and interventions prescribed
Table 14.1 Potential Vulvar Irritants and allergens
Hygiene products • soaps, bubble baths, salts, detergents,
shampoo, conditioner, shower gels
• Douches, vaginal cleaning products
• Perfume, talcum/baby powder, lubricants, deodorants
• Baby, adult hygiene wipes
• Wash cloths, loofahs, bath/shower puffs
• shaving creams/gels, waxing agents
• scented or colored toilet paper/wipes
menstrual products • tampons, pads, panty liners
• incontinence pads
clothing • tight clothing or undergarments
• Pantyhose, girdles or undergarments with spandex (i.e., spanx), thongs
• nylon clothing, chemically treated clothing
• Wet or sweaty exercise clothing
Body fluids • urine, feces, menstrual blood, vaginal discharge
sexual products/aids • lubricants, spermicides, condoms
• Personal lubricants that heat on contact or contain chlorhexidine
• sex toys
over-the-counter medications
• Products containing benzocaine (i.e., vagisil, vagicane, lanacane), tea tree oil suppositories, monistat
Prescription medications • including aldara, podophyllin,
trichloroacetic acid (tca), 5-fluorouracil, terazol
latex products • condoms, diaphragms, gloves
III. PHYSICAL EXAMINATION
a. vital signs, height, weight, and Bmi
B. general physical exam
1. assess mental status
2. skin
3. Head, eyes, ears, nose, throat
4. thyroid/lymph nodes
5. Heart/lungs
6. Breasts—review Bse
7. extremities
c. gynecological exam
1. careful examination of the vulva from mons pubis to anus— identify normal anatomy; note any abnormalities in color, skin texture, lesions, fissures, excoriation, erosions, ulcerations
2. clitoral hood
3. labia minora/majora, labial sulcus—color, atrophy, diminution, lack of elasticity
4. Perineum and perianal folds
5. speculum exam, including bimanual exam
a. examine vaginal walls and cervix—color, texture, erosions, ulcerations, discharge
IV. LABORATORY TESTING
1. obtain wet prep, pH and whiff test
2. Pap smear if indicated by guidelines
3. sti testing, vaginal cultures
4. Biopsy: History and physical exam are only suggestive. a biopsy is needed for a definitive diagnosis. Punch biopsies are the most common form.
a. indicated for lesions, nodules, erosions, or ulcerations
b. indicated if exam is suggestive/suspicious for vulvar intraepi- thelial neoplasia (vin)
c. topical steroids should be discontinued 2 to 3 weeks prior to biopsy.
d. Biopsies should never be performed on normal skin.
e. advanced nurse practitioners (anPs) may perform biopsies with training. referral to physician or health care provider with this skill is warranted if untrained.
V. DIAGNOSES AND TREATMENT
a. contact dermatitis: inflammation of the vulvar skin postexposure to allergen or irritant
1. onset can be immediate or within 72 hours.
2. causes include common household items, soaps, detergents, per- fumes, topical medication, pads/panty liners, body fluids.
3. symptoms: irritation, itchiness, rash, burning, soreness, and pain; may have poorly demarcated, slightly erythematous patches with dryness, fissures, excoriation from scratching, and/or superim- posed infection
4. treatment
a. identification of allergen/irritant is imperative.
b. cool compresses to affected area
c. refrain from itching, scratching, rubbing area—may consider antihistamine with sedation properties for nighttime relief
d. may apply plain petroleum or zinc oxide for soothing and skin barrier
e. low-potency steroid cream such as hydrocortisone 2.5% cream, triamcinolone 0.1% ointment, or clobetasol propionate 0.05%
f. Patient education: vulvar health hygiene
B. lichen planus: chronic, painful, inflammatory erosive disease of the mucous membranes that can affect skin, scalp, and vulva. it affects approximately 1% to 2% of the population. the cause is unknown, but it is thought to be autoimmune related.
1. common in perimenopausal or postmenopausal women
2. appearance varies but may be classic—well-defined flat plaques or erosive—deep erythematous lesions around vestibule extend- ing into vagina
3. symptoms are vulvovaginal soreness, burning and itching, dys- uria, dyspareunia, and/or vaginal discharge.
4. Diagnosis is by history and clinical presentation with punch biopsy for confirmation.
5. treatment
a. First-line treatment—superpotent steroids: clobetasol 0.05%, halobetasol 0.05% at nighttime or twice daily for 2 to 4 weeks, then taper to three times a week. the course should be tailored to patient symptoms.
b. if steroids ineffective, consider the immunomodulation medica- tion tacrolimus. use with caution; can cause burning of skin; consider mixing with plain petrolatum to dilute.
c. vaginal involvement: vaginal corticosteroid acetate supposito- ries 25 (mild) to 100 mg/g (high dose)
d. consider referral to vulvar dermatology specialist for severe cases
c. lichen sclerosus—complex chronic inflammatory condition of vulva. more prevalent in women, affecting 1:300 to 1:1,000; in perimeno- pausal and postmenopausal women, White and Hispanic women; rare in african american women
1. cause is unknown but thought to be autoimmune related
2. symptoms: mild-to-moderate intractable itching of vulva; also burning, pain, dyspareunia, bleeding, skin fissures
3. on exam: macular whitened or blanched areas with tissue paper skin appearance, thickened white plaques, purpura, and excoria- tion from scratching. White areas may be hourglass shape, and architectural changes may be noted.
4. Diagnosis is by history, clinical exam, and biopsy.
a. Have 2% to 5% lifetime risk of vulvar cancer
5. treatment
a. may need long-term therapy
b. topical steroids
i. High-potency clobetasol 0.05%, halobetasol 0.05% at night- time or twice daily for 2 to 3 weeks, then taper to three times a week
ii. maintenance is clobetasol 0.05% weekly; may switch to milder steroid
iii. if infection is superimposed, treat with appropriate antibiotic
D. lichen simplex chronicus: vulvar itching that develops on normal skin, which often results in itch-scratch-itch cycle. this cycle leads to lichenification or thickening of the skin. this condition affects approximately 10% to 35% of women.
1. cause is unknown but underlying atopic dermatitis may be a factor.
2. symptoms: intractable itching with burning and pain. symptoms may be intermittent or chronic and worsen with heat, humidity, and contact with menses, urine, stool, medications, vulvar hygiene, and products.
3. on exam: initially redness with plaquing, then over time dusky or brown with skin roughing, scaliness, or whitening. excoriation with scratching may lead to fissures, ulcerations, or erosion.
4. Diagnosis is by clinical exam with biopsy for confirmation.
5. treatment: the goal is to stop the itch-scratch-itch cycle.
a. eliminate all vulvar irritants
b. For daytime itching, may use selective serotonin reuptake inhibitor (ssri) antidepressants such as celexa or Prozac; oral antihistamine may be prescribed for nighttime itching.
c. treat underlying disease and/or coexisting infections. culture sites. oral antibiotics include Keflex, Duricef, or azithromycin if there is a penicillin allergy plus Diflucan at end of antibiotic course.
d. Decrease inflammation—clobetasol 0.05% or halobetasol 0.05% every day or twice daily for 2 weeks, then daily for 2 to 4 weeks. then, taper to two to three times/week until follow-up.
e. correct skin’s barrier function—sitz baths twice daily, pat dry, apply moisture sealant such as petroleum jelly
f. Follow up at 6 to 8 weeks. if no improvement, a referral to a vul- var specialist is warranted.
Websites: International Society for the Study of Vulvovaginal Disease (ISSVD), www.issvd.org; Association for Lichen Sclerosus and Vulvar Health, www.lichensclerosus.org; American Society for Colposcopy and Cervical Pathology (ASCCP), www.asccp.org