Royal College of Obstetricians and Gynaecologists

Dr Jennifer Yell, Consultant Dermatologist, North West of England, presented an overview of vulval disease management in her presentation at Royal College of Obstetrics and Gynaecologists (RCOG) World Congress 2019. Here are some highlights from her presentation.

How do patients present?

Dr Yell presented figures showing the relative frequency of symptoms of women referred to a vulval clinic in Leeds. Pruritus was by far the most common symptom, followed by pain, dysuria, lumps, rash and discharge.

Most patients report having symptoms for 2-5 years.

"It can be surprising how long patients may suffer in silence. There is a lot of frustration attached to that. A number of patients will say that their GP didn't offer to examine them or refused to examine them on some occasions."

What are the common skin diseases of the vulva apart from lichen sclerosus and lichen planus?

The most common skin disease diagnoses of the vulva apart from lichen sclerosus (20% of cases), lichen simplex (14%) and lichen planus (9%) are:
vulvodynia, psoriasis, genital warts, cysto-/ urethrocele, seborrheic dermatitis, seborrheic warts and bacterial vaginosis

Assessment

Patient factors
If you are running a vulval clinic in conjunction with a vulval dermatologist, it is important to note that the patient may need a lot of time. It is likely that it may have taken them a long time to reach this stage of their clinical journey.

The patient may be confused, wary or distressed and will need a lot of understanding. Their personal relationship may be under pressure or they may be struggling to conceive. They may also not have spoken to anyone else about the situation.

History
When taking a history, it is useful to consider the following:

• interventions the patient may have had that previously did or did not help
• urinary incontinence (this may have an impact on skin diseases such as psoriasis)
• sexual activity
• all topical applications
• hygiene/ washing routine
• previous swabs, biopsies and investigations

Examination
Dr Jenner strongly emphasised the importance of observing the vulva closely, including all folds and fissures. Some fissures cannot be detected without close observation.

Factors for a successful examination of the vulva include:

• good lighting
• checking for loss of architecture, splitting, redness
• observing all the skin on a person’s body, including their mouth (eg check whether there are any ulcers in the mouth)
• checking all areas systematically: the mons pubis, folds, labia majora and minora, clitoris, introitus, fourchette and perianal area

Dermatological terminology that may be useful to describe what you see on the vulva includes:

• erythema (glazed or other), macula, papule, nodule, vesicle, bulla, erosion, excoriation, fissuring, lichenification, atrophy and fusion

Investigations
If after examination of the patient, it is still not clear what the diagnosis is, certain investigations may be appropriate, including:

• considering referral to a genito-urinary medicine (GUM) clinic
• viral and bacterial swabs (candida is very common without obvious clinical signs)
• patch testing (if allergic contact dermatitis is suspected)
• clinical photography (it is useful for the patient to bring photos, especially if the condition is intermittent and patient is asymptomatic at the time of examination)
• biopsy

It is helpful to encourage patients to keep an eye on their own anatomy

Management objectives for vulval dermatology

• Exclude invasive disease
• Symptom relief
• Preservation of function
• Sustained remission
• Reducing the risk of malignant progression

Complex patients need a multidisciplinary team, which may include dermatology, GUM, urogynaecology, pathology, physiotherapy, psychosexual counselling, general practice and patient support groups

Treatment

Emollients

• The importance of emollients for vulval skin conditions cannot be underestimated
• Emollients repair the skin’s barrier and prevent penetration by allergens, irritants and bacteria
• They reduce itch and make skin feel more comfortable
• They can be used as both a soap substitute and leave-on moisturiser

Types of emollient

Lotions: These are light, spread easily and are cooling but not very moisturising

Creams: These are heavier than lotions but not as moisturising as ointments

Ointments: These do not contain water; they are thick and may be difficult and greasy to apply but are very good at moisturising

Which emollient is best?

There is no "best" emollient. Compliance is essential, so the best emollient is the one the patient will use

Topical steroids

• These can be very effective and are safe to use on the vulva
• Underuse of steroids is a much greater problem than overuse

Top-line recommendations for steroid use:

• Do not use steroids more than twice daily
• Use with regular emollients
• Stop using steroids when the skin condition is completely clear
• Start again if necessary

Vulval eczema - an overview

• It is very common
• When diagnosing vulval eczema, it is important to look for signs of eczema elsewhere
• It is often atopic
• It is always itchy and often worse at night

Treatment

• Explain the diagnosis to the patient
• Emollients
• Avoid soap
• Recommend loose cotton underwear
• Prescribe topical corticosteroids if appropriate
• Consider irritants and allergens (eg wet wipes)

Vulval eczema predisposes a patient to candidiasis due to impaired barrier function. Patient will need to be swabbed to check for this.

Vulval psoriasis - an overview

• It is important to look for signs of psoriasis elsewhere on the body
• There may be a family history of psoriasis
• In terms of symptoms, it is often sore and can be psychologically debilitating

Treatment

• Explain the diagnosis to the patient
• Emollients are helpful
• The patient should be referred to a dermatologist
• Mild or moderate steroids, topical non-irritant vitamin D analogues or immunomodulators (eg pimecrolimus or tacrolimus) may be appropriate; mild coal tar and possible systemic therapy may be prescribed