Download Vulval Problems: Sallie Neill

Vulval problems in the post
menopausal years
Dr. Sallie Neill MB ChB FRCP
St John’s Dermatology Unit
St Thomas’ Hospital London
June 7th 2008
Mucous membrane or skin ?
Problems
„
Irritant eczema
\
non scarring
„
Psoriasis
/
„
Lichen sclerosus
\
Scarring
„
Lichen planus
„
Malignancy
„
Pain syndromes - vulvodynia
/
SCC, verrucous Ca, EMP and vulval intraepithelial
neoplasia
Rx
„
Soap substitute
„
Barriers
„
Topical steroid
„
Topical local anaesthetic
„
Topical immune modulating cream
„
“Control
versus
Cure”
Eczema
Irritant
Contact
/
\
Allergic
Rx
Contact eczema
Avoidance of irritants
Soap substitute
Mild steroid
Daily barrier ointments e.g.
zinc,metanium
Patch test if ? Allergic CD
Psoriasis
„
„
„
Flexural
Pruritus and burning. Intolerance
to irritants
Other sites
flexures,
scalp,
auditory canals,
nails,
knees and elbows
Eczema and psoriasis
„
Difficult to distinguish
„
Look for evidence at other sites
„
FH Eczema or psoriasis
„
Irritants. Bubble bath, shampoo, swimming
Continent? Vaginal discharge?
„
Rx soap substitute
Barriers
Mild to mod potent steroid
?pimecrolimus
Scarring dermatoses
„
Lichen sclerosus
„
Lichen planus
„
Mucous membrane pemphigoid
Clinical
Lichen sclerosus
o
Atrophy
Wrinkled skin
Ecchymosis
o
Scarring
o
Mucosal sparing
Loss of architecture
No vaginal
lesions
o
Predilection for anogenital skin
o
Extragenital lesions 1 in 10
o
Koebnerises
Lichen sclerosus in the older woman
Treatment Ultra potent topical steroid
Dermovate
Once a day
Month 1
Daily
Month 2
Alt days
Month 3
Twice a week
Then as required and see the patient than
Complications
Scarring
Malignancy
Sexual
Still symptomatic but disease quiescent
Another agenda?
Psychosexual
→ Psychosexual therapist
Lichen planus
Treatment
Vulval disease
„
„
Potent topical steroid
? Drug induced
Vaginal lichen planus
Divide adhesions/EUA
Prednisolone suppositories
Colifoam
Dilators
Vaseline petroleum jelly
5% lidocaine is touch sensitive
Complications
Scarring
Malignancy
Sexual
Safe steroid use
frequency once a day
amount
Finger tip
30gm in 3/12 initially
6/12 maintenance
wrong place
Topical steroid problems
„
Steroid ointment not used
„
Ultrapotent steroid reactivates viral infection or masks tinea
„
Contact allergy
„
Inappropriate use
frequency
amount
wrong place
wrong indication
Steroid ointment not used
„
Fear of steroid
„
Package insert
„
Physical inability
„
Unaware of anatomy
„
Symptoms worsen
Rx
EMP Imiquimod
Immune response modifier
cytokine activation INF α + IL12 →
INF γ
TNF α
↑ TH1 response
cytotoxic T cells
Type IV
Vulval intraepithelial neoplasia VIN
Full thickness atypia
VIN undifferentiated
Atypia confined to the lower
layer
VIN differentiated
VIN Undifferentiated
Verrucous carcinoma
„
Background of lichen sclerosus
„
Missed on small biopsies
„
Rx
„
? Role of acetretin
Wide local excision
Vulvodynia or vulval dysaesthesia
Definition
no visible or inducible explanation for sensation of
pain or itch.
Soap substitute
Ung emulsificans
Few preservatives
ÈIrritancy ‘stingers’
No detergents
Local anaesthetic
5% lignocaine oint
Cheap
Contact dermatitis rare
Amitriptyline
Not for depression
Side effects a problem start 10mg
Need 50mg or more
Unresponsive 90mg . Try alt RX
pregabalin, venlafaxine
Influences
Social
Physical
Pain
Personality
Psychological
Stress and depression
Important role in perpetuation
? in initiation
Lifestyle
Life events
Coping mechanisms
www
A genital problem
5 questions to ask yourself
„
Is it red or white?
„
Is this scarring or non scarring?
„
Is it affecting skin or mucous membrane?
„
Should I biopsy?
„
Do the symptoms fit the clinical picture?
Good dermatology website
DermNetNZ
„
Information for docs and patients
„
Information sheets