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Handout version Genital Dermatology Dr Elizabeth Ogden EQUIP meeting 12.3.15 Genital skin problems • Very common • Very uncomfortable, distressing and embarrassing • Can interfere with sexual functioning • Impact on self-image and interpersonal relationships • Some genital disorders are infectious, including sexually transmitted diseases Learning Points • You need a good light • Look around the perianal area as well as the genitals if possible • Look for lichenification (thickening), excoriation (signs of scratching), architectural change and colour change • If you see a problem ask about it • Look at knees, hands, mouth and nails How Male Genital Problems Present • • • • • • • • Pruritus Red patches and plaques Phimosis Erosions, ulcers and blisters Palpable lumps and bumps Colour changes Pain Swelling The Vulva Hood of clitoris Vulva Clitoris Labia Majora Labia Minora Urethra Vagina Anus How Vulval Problems Present • • • • • • • Itching Recurrent Thrush Avoiding Smears Bleeding Painful Intercourse Splitting of skin Burning Pain Vulval Problems • Are often not presented directly by patient • Often not aware of colour change • Can be a covert presentation • “I get recurrent thrush” = ITCH How to Reach a Diagnosis • Good history – – – – History of this problem Personal and Family history of skin problems Topical treatments and used Drug treatments • Examination – Skin as whole and then the genital area and perineum – Look especially at knees, elbows, face, scalp and in mouth • Response to treatment – If slow to improve reassess – take history again, re examine, think about biopsy and patch testing History • • • • • Ask about use of bath products/shower gels Use of Dettol, Savlon, OTC products Use of Wet Wipes Continence problems Condoms – For Women • Use of Douching etc • Feminine products • Sanitary protection Genital Skin Infections Bacterial infections • Boils (deep infection of hair follicle) • Folliculitis (surface infection of hair follicle) • Impetigo (school sores) • Erythrasma (dry brown patches) Conditions confused with bacterial infections in the groin: • Balanitis • Hidradenitis suppurativa • Hailey Hailey • Fungal skin Infections (Jock itch) • Vulvovaginal candidiasis (thrush) and bacterial vaginosis Genital Skin Infections • Viral Infections • Viral warts • Herpes Simplex • Herpes Zoster • Molluscum – pox virus Pruritus • Commonly due to an dermatitis (eczema). The types of dermatitis most often affecting the genitals are: – Lichen Simplex (localised itch-scratch-itch response) – Atopic Dermatitis (familial tendency) – Seborrhoeic dermatitis (usually affects scalp as well) – Irritant contact dermatitis (from wetness, urine, vigorous cleansing) – Allergic contact dermatitis (most often due to topicals, perfumes, latex and nickel) • Other skin conditions causing genital itch include: • Psoriasis (persistent red scaly or moist patches) • Lichen sclerosus (white scarred patches) • Lichen planus (can be purple and white lacy surface) Anogenital Irritants • • • • • • • • Sweat Sebum Soap and detergents Clothing Toiletries Toilet paper Friction Bodily secretions Treatment of the Common Genital Dermatoses • Lichen Simplex – potent topical steroids and sedating antihistamines at night • Eczema/Dermatitis – moisturisers and moderately potent topical steroids • Psoriasis – Trimovate® or moderately potent or potent topical steroid • Arrange/refer for patch testing if appropriate • Advice sheet Pruritus Ani • • • • • • Is common Can be due to Dermatitis and Psoriasis or Bacterial infection including streptococci or Corynebacteria (erythrasma) Or yeast infection especially Candida albicans The anal skin is exposed to irritating digestive products which may result in a rash (irritant dermatitis). The rash is made worse by: – Frequent stools (diarrhoea) – Straining at stool (constipation) – Scratching – Vigorous use of toilet tissue – Scrubbing with soap and water – Acidic or spicy foods Patient Information Painful Conditions • • • • • • Aphthous ulceration Herpes simplex Behcets disease Lichen Planus (usually also affects the mouth) Plasma cell balanitis/vulvitis Vulvodynia -provoked localised vulvodynia (vestibulodynia) or generalised unprovoked vulvodynia (dysaesthetic vulvodynia) Behcet’s Disease • Is difficult to diagnose • Recurrent mouth and genital ulcers, uveitis and skin sores this is suggestive of Behcet’s The International criteria for classification of Behcet disease defines the conditions as: • At least 3 episodes of recurrent oral ulcers in a 12-month period plus at least two more of the following: • Genital ulcers • Eye involvement (uveitis or retinal damage) • Skin lesions • Positive pathergy test Treatment of Lichen Planus • Usual measures of advice for vulval problem • Protecting the vulval skin from urine • Potent topical steroids - Dermovate® – clobetasol propionate topically • If affecting vagina – Prednisolone rectal foam aerosol daily for 2 weeks • Occasionally oral steroids • Topical anaesthetics – Lidocaine 5% cream can be bought OTC Vestibulitis now called Localised Provoked Vulvodynia • • • • • • • • Form of chronic vulval pain Younger age group Cotton bud test ? Early contraceptive pill use a cause Topical lidocaine – can get OTC Ketoconazole cream for 3 months Amitriptyline Psychological / Psychosexual counselling Vulvadynia- Burning Vulva • Older age group than Vestibulitis • No physical signs • Constant diffuse pain usually of burning quality • 60% respond to tricyclics but side effects • ?Pudendal nerve damage • Emollients and supportive measures • Use of Gabapentin and Lyrica Incidence of Lichen Sclerosus • It was thought to be a rare disease -1 in 300 to 1 in 1000 • Now felt to be much commoner than that and estimates are 1 in 100 in ♀ ? in ♂ • Very difficult to collect statistics • Children's incidence is less - 1 in 800 • Two peak ages of presentation – pre puberty and post menopausal women • Up to 20% have coexisting thyroid problem Anal Lichen Sclerosus • Classically forms a figure of eight with the vulval lichen sclerosus • Can be easier to see around the anus especially the hypopigmentation Vulval Intraepithelial Neoplasia • Otherwise known as VIN • The term Bowens disease no longer used • Used to be graded as for cervical cytology VIN1,VIN2, VIN 3 with the grades mild, moderate and severe dysplasia • VIN I felt to be just due to irritation so will no longer be used • VIN only used now for high grade dysplasia which was 2 or 3 previously VIN • Causes felt to be similar to those associated with cervical cytology changes • Smoking, HPV viruses esp. types 16 and 18 • Can be found in conjunction with CIN and AIN • Commoner in the immunosuppressed • Presents as warty or patches of discoloured skin • Needs biopsy • The average age at presentation is 45-50 years but increasing numbers of younger women are being found – even teenagers • 50% of those with VIN have associated cervical intraepithelial neoplasia • Should have yearly smears • Has been successfully treated with PDT and Imiquimod Penile Carcinoma in Situ Terminology is complex Almost exclusively in uncircumcised men • Erythroplasia of Queyrat (EQ) • Bowen’s Disease of the Penis (BPD) • Bowenoid papulosis (BP) General Advice • Avoid all soaps, gels and scented products including shampooing hair in bath • Emollients to wash with • Avoid moistened wipes • Rinse urine off skin with jug of water • Cotton underwear Time to get a referral to a Specialised Vulval Clinic • Average 3.8 years • Shortest 3 months • Longest 20 years