Vulval Dermatology

Lichen sclerosus

Lichen planus

Eczema / lichen simplex

Psoriasis

Sebopsoriasis

Painful vulval conditions

Vulvovaginitis in children

Incidental lesions

Lichen sclerosus

Onset 45 to 60 years but can occur in childhood

(Up to 15% onset before 13 years)

In children onset 3 to 6 years

Pruritus common but may be asymptomatic

May be sore +/- dyspareunia

Occasionally spontaneous resolution occurs,

particularly in girls around the menarche (25%)

Extra-genital lichen sclerosus

Affects 10% of woman with vulval LS

94% of patients with extra-genital LS will have

genital involvement

Most common on the trunk, particularly flexures

Pruritus uncommon, usually asymptomatic

Atrophic (cigarette paper) skin and bruising

common

Treatment of lichen sclerosus of

vulva

Dermovate ointment nightly 1 month then

alternate nights one month

Soap substitute

Children

Betnovate or Elocon nightly for 2 to 4 weeks

Eumovate ointment for maintenance

Lichen planus

Lichen planopilaris

Post menopausal frontal

fibrosing alopecia Pterygium

Treatment

Dermovate ointment nightly 2 – 4 weeks

Vulvovaginal-gingival lichen

planus

Erosive LP of vulva and vagina with a

desquamating gingivitis

Chronic and painful

Discharge, dysuria, dyspareunia, post coital

bleeding

Vaginal stenosis

Treatment of VVG-LP

Dermovate nightly 2-4 weeks

Steroid foams or suppositories

Oral steroids, acitretin, methotrexate, ciclosporin and azathioprine

Eczema

Atopic eczema

Lichen simplex

Contact dermatitis

Seborrhoeic eczema/sebopsoriasis

Eczema treatment

Soap substitute

Eumovate ointment nightly

(to increase to Betnovate if more severe)

Lichen simplex treatment

Soap substitute

Betnovate ointment nightly for 2 weeks then 1

week as necessary; maximum of 1 week in 3

+/- Hydroxyzine at night initially

Contact irritant or allergic

dermatitis

Irritants – urinary incontinence, vigorous

cleaning

Allergies – fragrances, preservatives, rubber.

BUT contact allergy of the vulva is rare without

involvement of perianal skin

Fragrance ++

Seborrhoeic eczema

Psoriasis

Sebopsoriasis

An overlap between seborrhoeic dermatitis and

psoriasis and has features of both conditions

Yellowish, greasy scale in typical seborrhoeic

dermatitis areas (scalp, nasolabial folds,

eyebrows, behind the ears and over the sternum)

Thicker scale than normally seen in seborrhoeic

dermatitis but less silvery scale than seen in

classic psoriasis

Sebopsoriasis

Yellowish, greasy scale in typical

seborrhoeic dermatitis areas (scalp,

nasolabial folds, eyebrows, behind the

ears and over the sternum)

Thicker scale than normally seen in

seborrhoeic dermatitis but less silvery

scale than seen in classic psoriasis

Treatment of genital or

sebopsoriasis psoriasis

Trimovate cream nightly for 1 to 2 weeks and

then for 3 nights as necessary

Warn patients it may stain clothing

Vulval pain syndromes

Dysaesthetic vulvodynia

Pain is diffuse, constant and spontaneous

Vestibulodynia

Localised pain triggered by touch

Vulval pain syndromes

Dysaesthetic vulvodynia

Post menopausal women

Depression

Vestibulodynia

Younger patients

Dyspareunia

Onset during stressful time

Anxiety common

o/e Tenderness in vestibule +/- erythema

Vulval pain syndromes - Treatment

Unrushed and sympathetic consultation

Soap substitutes and avoid irritants

5% lidocaine ointment PRN

Amitriptyline 10mg nocte increasing by 10mg

per week

Pregabalin, gabapentin, carbamazepine

Psychological help if necessary

Vulvovaginitis in children

Commonest gynaecological problem in prepubertal girls

Itching and soreness

Discharge

Dysuria

Redness of the introitus

Excoriation

Discharge

Swab introitus

Gp A Beta haemolytic streptococcus

Candida

Sexually transmitted infections

Threadworms

Vulvovaginitis

Up to 75% no cause

Avoid soaps, shower gels etc – use aqueous or

Diprobase cream

Avoid other irritants

Barrier creams eg Epaderm

Mild/moderate topical steroid

And finally…

Angiokeratomas (of Fordyce)

Over 40s scrotum > vulva

Composed of dilated capillaries

Usually symptomless and may only be

noticed when they bleed

Fordyce spots

1-5mm white or yellow papules

Prominent sebaceous glands in over 80% adults

Present at birth but increase in size at puberty