Download Handout version Genital Dermatology

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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
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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
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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
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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
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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
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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
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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
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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
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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