Guidelines 2016 – Vulvar Conditions
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Primary vulvar conditions are those that arise from abnormal epithelial growth, which can be inflammatory, dermatologic, or congenital in origin, or from neoplastic alterations. Because the vulva includes the labia majora and minora, the mons veneris, fourchette, and vestibule and encompasses the urethral and vaginal orifices and the ducts of the Skene’s and Bartholin’s glands, vulvar conditions are varied both in origin and in clinical manifestations. Please refer to separate guidelines for STIs that can cause clinical signs and symptoms on the vulva and guidelines for Bartholin’s cyst, molluscum contagiosum, herpes, and condyloma.
II. ETIOLOGY
A. Nonneoplastic epithelial disorders
1. Squamous cell hyperplasia
2. Lichen simplex chronicus
3. Lichen sclerosis
4. Lichen planus
5. Pigmented lesions
6. Systemic diseases (inflammatory bowel disease, Behçet’s syndrome)
7. Psoriasis
B. Neoplastic disorder
1. Vulvar intraepithelial neoplasia (VIN)
a. Low-grade squamous intraepithelial lesion (SIL): mild dysplasia
b. High-grade SIL: moderate-to-severe dysplasia
c. Squamous cell carcinoma in situ—Bowen’s disease, bowenoid papulosis
d. Basal cell carcinoma
e. VIN 2 to 3
f. Invasive VIN
2. Other neoplastic disorders
a. Extramammary Paget’s disease versus vulvar vaginal Candidiasis
b. Melanoma (5% is vulvar)
III. HISTORY
A. What the patient may present with
1. Pruritus, rash
2. Hypopigmentation or hyperpigmentation
3. Bullae
4. Weeping, scaling, crusting
5. Excoriation
6. Maceration
7. Thickening
8. Hyperkeratosis
9. Fissures
10. Abscesses
11. Lesions: macules, papules, vesicles, warty, pedunculated, domed, flat, plaques
12. Lichenification
13. Change in color of vulva
14. Dyspareunia
15. Burning
16. Genital erosions
17. Vaginal/vulvar discharge
B. Additional information to be considered
1. Type of clothing commonly worn
2. Type of underwear: cotton or synthetic
3. Use of feminine deodorant products
4. Use of scented deodorant tampons, pads, panty liners
5. Douching; shaving of perineum
6. Detergents, bathing soap, fabric softeners
7. Bubble bath or oils, body washes, lotions, creams
8. Family or personal history of diabetes
9. Sexual partners, activity; contraception; STI history
10. Fungal infection of hands and feet, self or partner; oral Candidiasis
11. LMP
12. Perimenopausal symptoms
13. History of dermatologic conditions: human papillomavirus (HPV), psoriasis, eczema, seborrheic dermatitis
14. Fever, malaise, flulike symptoms, recent streptococcal infection
15. Character and changes in lesions
16. Partner with symptoms
17. History of Crohn’s disease; other systemic disease
18. Genital HPV history, history of Pap smear with HPV, any abnor- mal Pap history
19. Any other possible allergens: plant, makeup, nail polish, depilatories, piercings, and jewelry
IV. PHYSICAL EXAMINATION
A. Vulva
1. Skin appearance: inflammation, edema, dry or moist, thickening hyperkeratosis, erythema with a demarcation between normal and abnormal tissue (strawberries-and-cream appearance)
2. Lesions present
3. Weeping, scaling, crusting
4. Fissuring
5. Lichenification
6. Excoriation
7. Hypopigmentation
8. Hyperpigmentation
9. Ulcers
B. Adenopathy
C. Groin, inner thighs, buttocks
1. Lesions
D. Other systems as indicated by history and drugs
V. LABORATORY EXAMINATION
As indicated by history and appearance of lesions
A. Bacterial cultures and sensitivities
B. Wood’s lamp examination
C. Gram-stained scraping from lesions
D. Scrapings for KOH
E. Punch biopsy of lesions
F. Colposcopic examination
G. Staining with 1% toluidine blue
H. Fasting blood sugar
I. HPV testing
VI. DIFFERENTIAL DIAGNOSIS
A. Allergic vulvitis, cellulitis
B. Inflammatory conditions and reactions
C. Bacterial, viral, fungal infections
D. Lichen sclerosis
E. Necrotizing fasciitis
F. Lichen planus
G. Pigmentation disorders
1. Hyperpigmentation
2. Congenital hypopigmentation
H. Benign epithelial changes
I. Neoplasms: VIN, Paget’s disease, melanoma
J. Lesions from Crohn’s disease
K. Trauma
L. Infestation
M. Zinc deficiency
N. Fixed drug reaction
O. HSV infection
VII. TREATMENT
A. Medication
1. Contact dermatitis: cool, tepid, warm compresses or sitz baths; midpotent corticosteroid ointment, triamcinolone oil 1% twice a day; identify and remove irritant. Apply petrolatum to open areas.
2. Bacterial infections: Erythromycin 250 mg four times a day for 14 days; tetracycline 250 mg four times a day for 10 to 14 days or until resolved/culture and sensitivity for medication coverage
3. Tinea: topical antifungals such as Gyne-Lotrimin, Mycelex, Monistat Derm, Loprox
4. Analgesics for pain: no topical Lanacane creams (high degree of sensitivity); Xylocaine 5% ointment 1/8 teaspoon three times daily and cotton ball in the vestibule at bedtime. If burning continues, have ointment buffered by compounding pharmacy.
5. Topical antibiotics: Bactroban 2% ointment may be considered.
6. Fixed drug reaction—check on any new medication; must go off medication for 2 months to see resolution; contact primary care provider to change medication
B. Lifestyle changes and self-care measures
1. Wear loose, cotton underwear; do not wear underwear in bed
2. Keep area dry and clean
3. Discontinue use of irritant or allergen
4. Sitz baths
C. Teaching and reassurance
VIII. COMPLICATIONS
A. Secondary infection
B. Progressive disease
C. Masking more serious disease
IX. CONSULTATION/REFERRAL
A. Unable to identify lesion or condition
B. No response to treatment
C. Progression of disease or persistence of condition
D. For biopsy, diagnostic workup
E. For surgical excision or other surgical intervention
F. To specialist for systemic disease or dermatoses beyond the vulva
G. To specialist for vulvar vestibulitis and vulvodynia
X. FOLLOW-UP
A. See patient again in 1 to 2 weeks to assess therapy/treatment
B. As indicated by therapy or for further diagnostic work
See Bibliographies.
Website: www.cancer.about.com/od/vulvarcancer/a/vulvarexam.htm