Clinical Care of Vulvar Pruritus, with Emphasis on One Common Cause, Lichen Simplex Chronicus

Geriatric Genital Dermatology

As women age, hormonal changes set the stage for a variety of vulvovaginal pathologies. Health care providers in long-term care facilities should be able to recognize and treat these conditions, especially because residents may be unable to communicate their discomfort. The objective of this article is to highlight the major vulvovaginal conditions affecting older women and provide up-to-date information on treatment for providers in long-term care facilities.

A large sample-based case-control study of related risk factors of two types of lichenoid vulvar disease (LVD)

PURPOSE

The purpose of this study is to identify the associated factors of two types of lichenoid vulvar disease (LVD) and to compare the differences in related factors between the different pathological types of lichenoid vulvar disease (LVD).

METHODS

The study conducted at the West China second Hospital of Sichuan University included a total of 1770 patients with biopsy-confirmed vulvar lichen simplex chronicus (VLSC)and vulvar lichen sclerosus(VLS), along with 1209 patients with normal vulvovagina as control. Further pathological subtype analysis was carried out on 163 cases of vulvar lichen simplex chronicus and 51 cases of vulvar lichen sclerosus. In addition, Univariate chi-square test and multivariate logistic regression were used to analyze the lichenoid vulvar disease group and vulvovaginal normal control group.

RESULTS

Univariate analysis revealed that there were statistically significant differences (P < 0.05) in factors between the LVD group and the control group, except for living type, sleep habit, history of drinking, and allergic diseases. There was no significant difference in late sleep, spicy diet, and coffee intake in the factors of life and eating habits and the concomitant disease factors. Furthermore, univariate analysis showed that except for eating seafood, humid living environment, residence, caffeinated drinks, hypertension, and vaginitis, there were statistical differences in the related factors of LVSC.

CONCLUSION

The incidence about lichenoid vulvar disease is influenced by various factors such as dietary habits, living environment, mental stress, concomitant diseases, hormone levels and so on, and there were no significant differences in these factors between VLS and VLSC except for income, work stress, systemic immune diseases, and menopause.

Vulvar dermatoses-Can a pattern-based approach improve diagnostic yield?

BACKGROUND

Vulvar dermatoses (VD) pose a formidable challenge to clinicians and pathologists owing to various factors. The factors included are the histopathological heterogeneity of the vulva, moist and frictional environment, and the limited experience of gynecologists and general histopathologists in this field. To address this issue, the International Society for the Study of Vulvovaginal Disease (ISSVD) proposed a histopathological tissue reaction-based classification system for VD. Therefore, we attempted to study the utility of the 2006 ISSVD classification in reporting VD. We further evaluated if a dermatopathologist review could improve the diagnostic yield.

MATERIALS AND METHODS

The vulvar biopsy reports (N = 106) were retrieved from histopathology case files, out of which benign non-infectious conditions (n = 55) were included in the study. The diagnosis retrieved from the case files was considered the initial diagnosis. Three dermatopathologists reviewed each biopsy, and a tissue reaction pattern/diagnosis was assigned as per ISSVD 2006, and this was considered a review diagnosis. The initial and review diagnoses were compared and analyzed. We further studied and analyzed the effect of the dermatopathologist's review on the diagnostic yield.

RESULTS

The sclerotic pattern (34.6%) was the commonest tissue reaction pattern, followed by spongiotic (18%) and acanthotic patterns (14.5%) independently or in combination. The non-specific/descriptive report rate was significantly decreased following 2006 ISSVD and the dermatopathologist's review (83.6% vs.1.8%).

CONCLUSION

Rendering tissue reaction patterns to vulvar biopsies will enable a comprehensive understanding of lesions and aid in clinically relevant reporting. In addition, dermatopathologists' review of difficult vulvar biopsies increases the diagnostic yield.

Vulvar Pruritus: A Review of Clinical Associations, Pathophysiology and Therapeutic Management

Vulvar pruritus is an unpleasant sensation and frequent symptom associated with many dermatologic conditions, including infectious, inflammatory and neoplastic dermatoses affecting the female genitalia. It can lead to serious impairment of quality of life, impacting sexual function, relationships, sleep and self-esteem. In this review, common conditions associated with vulvar itch are discussed including atopic and contact dermatitis, lichen sclerosus, psoriasis and infectious vulvovaginitis. We review the potential physiologic, environmental and infectious factors that contribute to the development of vulvar itch and emphasize the importance of addressing their complex interplay when managing this disruptive and challenging symptom.

Therapeutic Effects of Focused Ultrasound on Expression of Notch1, C-Fos and Transforming Growth Factor-β3 in Vulvar Skin of SD Rats with Vulvar Lichen Simplex Chronicus

The purpose of this study was to investigate the therapeutic effects of focused ultrasound on the expression of notch1, c-fos and transforming growth factor-β3 (TGF-β3) in genital skin of SD rats with vulvar lichen simplex chronicus (LSC). Fifty-six female SD rats with LSC were randomly divided into therapy and sham groups. The therapy group was exposed to focused ultrasound. The sham group received the same therapy with an instrument that had no power output. Four wk after a singly focused ultrasound therapy, histologic analyses revealed that recovered SD rats accounted for 75% of SD rats in the therapy group and 10.7% in the sham group. Total collagen fiber density in the superficial layer of dermis in the therapy group was significantly lower than that in the sham group. Notch1 and c-fos protein expression in the therapy group was significantly lower than that in the sham group, with the opposite effect present for TGF-β3. Focused ultrasound therapy may inhibit superficial collagen fibrosis in the dermis by affecting expression of notch1, c-fos and TGF-β3 in vulvar skin tissue and consequently reduce the recurrence rate of LSC.

Genital scabies: Haven of an unwelcome guest

The itch mite Sarcoptes scabiei var. hominis has been a menace to humanity for ages. Diagnosing scabies can be a challenge in view of the varied presentations of the disease. The male genitalia are an important area of predilection of the mite. Examination of this often overlooked area is essential as it may reveal both characteristic and atypical manifestations of scabies. Genital involvement also attains special relevance in view of the possible sexual transmission of the mite. In addition to the morbidity caused by itching, patients may have to deal with myths, stigma, and embarrassment.

[Focused ultrasound therapy for reducing recurrence of vulvar lichen simplex chronicus in rats: efficacy and mechanism]

OBJECTIVE

To explore the changes of collagen fibrosis in the vulva skin of SD rats with lichen simplex chronicus (LSC) after focused ultrasound therapy and explore the mechanism by which focused ultrasound reduces the recurrence of vulvar LSC.

METHODS

Fifty female SD rat models of vulvar LSC were established and randomly divided into the treatment group and the control group (n=25) for treatment with focused ultrasound and sham treatment, respectively. Before and after the treatment, vulvar skin tissues were sampled to observe the pathological changes with HE staining and assess the density of collagen fibers using Masson staining. The ultrastructure of the collagen fibers in the superficial dermis was observed using transmission electron microscopy. The expressions of notch1 and c-fos in the vulvar tissue were detected by immunohistochemistry and Western blotting.

RESULTS

After 4 weeks of focused ultrasound therapy, 16% (4/25) of the rats in the treatment group showed lesion progression to LSIL, 4% (1/25) still had LSC, and 80% (20/25) showed normal vulvar skin. In the control group, progression to LSIL occurred in 19 (76%) rats, 3 (12%) rats still showed LSC, and only 3 (12%) had normal vulvar skin. The difference in the cure rate differed significantly between the two groups (P < 0.05). The density of collagen fibers in the superficial dermis and the expressions of notch1 and c-fos in the vulvar skin were significantly lower in the treatment group than in the control group (P < 0.05).

CONCLUSIONS

Focused ultrasound therapy can inhibit superficial collagen fibrosis of the dermis by lowering the expressions of notch1 and c-fos in the vulvar skin to reduce the recurrence of vulvar LSC in rats.

Lichenoid vulvar disease: A review

Vulvar dermatoses are common, potentially debilitating conditions that can be seen by a variety of medical specialists. Lichenoid vulvar diseases, namely lichen sclerosus (LS), lichen planus (LP), and lichen simplex chronicus (LSC), can all negatively impact patients' quality of life and LS and LP also have an association with squamous cell carcinoma. It is essential that dermatologists are familiar with the unique features of each of these conditions to ensure the appropriate management and follow up. Herein, we provide an update on the epidemiology, clinical presentation, histopathology, and treatment of patients with vulvar LS, LP, and LSC.

2016 European guideline for the management of vulval conditions

Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).

Anogenital Pruritus - An Overview

Anogenital pruritus is defined as intense itching, acute or chronic, affecting the anal, perianal, perineal and genital skin, which is a dominant problem in the course of various cutaneous and systemic conditions. It is one of the common, extremely annoying symptom for which patients attend the Dermatology Outpatient Department (OPD). Anogenital skin is highly sensitive to soaps, perfumes, clothing and superficial trauma and it is more prone for itchy dermatoses as a result of warmth, friction, lack of aeration, sweating and occlusive inner garments. Anogenital pruritus is associated with a wide spectrum of diseases which includes localized infections, infestations, inflammatory dermatoses, allergic and irritant conditions, anorectal diseases, systemic causes, nutritional disorders, psychological and when the cause cannot be found out it is often termed idiopathic. Patients are highly reluctant in consulting the physician for anogenital itch in the early stage, they usually present at a later stage with either atypical manifestations or depigmentation and lichenification, secondary to constant scratching. They often resort to over the counter topical agents, particularly combination products which contain topical steroids. The irrational use of such products results in complications like skin atrophy, striae, incognito etc. A proper clinical history, clinical examination, investigations like scrapping for fungus and itch mite, skin biopsy, patch test and relevant blood investigations to rule out systemic conditions should be carried out, when needed, to arrive at an accurate diagnosis, before treating the patient.

Vulvar Dermatoses: A Primer for the Sexual Medicine Clinician

INTRODUCTION

Vulvar dermatoses are common dermatological conditions that affect the vulva, and can cause considerable pain, irritation, pruritus, and burning, and have an adverse impact on a woman's sexual function.

AIM

To provide an overview of the clinical features, etiology, and management options for the common vulvar dermatoses, including lichen sclerosus, lichen planus, lichen simplex, contact dermatitis, and vulvar psoriasis, and briefly describe the impact of vulvar dermatoses on sexual function.

METHODS

The key words "vulvar dermatoses," "lichen sclerosus," "lichen planus," "lichen simplex chronicus," "vulvar dermatitis," and "vulvar psoriasis," were utilized to search Medline and PubMed for articles, with special attention given to those published within the past 5 years.

MAIN OUTCOME MEASURE

Five hundred thirty-six results were generated from the literature search. Publications that were judged current and relevant to the pathophysiology, evaluation, and treatment of vulvar dermatoses were included in the review.

RESULTS

Fifty-seven articles were selected for inclusion in this review.

CONCLUSIONS

Vulvar dermatoses can cause chronic pain, itching, and dyspareunia, and can have a profound effect on a woman's sexual expression and comfort. Delay in diagnosis is often due to hesitancy to seek treatment on the part of the patient or delay in biopsy on the part of the provider. This can result in failed prescriptive and self-treatment measures, worsening symptoms, and frustration and sexual dysfunction for the patient, and potentially the development of squamous cell carcinoma. It is imperative for sexual medicine providers, who commonly treat women with vulvar concerns, to be familiar with the presentation, diagnosis, and treatment of common vulvar dermatoses and their effect on sexual function. Kellogg Spadt S and Kusturiss E. Vulvar dermatoses: A primer for the sexual medicine clinician. Sex Med Rev 2015;3:126-136.

Vulvar dermatosis

Vulvar dermatoses are inflammatory conditions responsible for chronic or recurrent itching and soreness. The lesions are either circumscribed to the vulva or associated with extragenital localizations which may help to assess the diagnosis. They should be differentiated from infectious or neoplastic diseases which may have clinical similarities. As opposed to the majority of all dermatoses that have a benign and regular course, lichen sclerosus or lichen planus could exceptionally foster the occurrence of an epithelial cancer precursor which may evolve to squamous cell carcinoma. Topical corticosteroids are the mainstay treatment of vulvar dermatosis. We do not know if the treatment of vulvar lichen sclerosus and vulvar lichen planus prevents squamous cell carcinoma.

Vulval pruritus: the experience of gynaecologists revealed by biopsy

Pruritus of the vulva is a common symptom among patients attending to outpatient clinics. In the present study, we aimed to assess pathologies causing vulval pruritus in the reliability of biopsy in a tertiary referral centre. A total of 137 patients undergoing vulval colposcopy because of vulval pruritus were reviewed from the hospital records retrospectively. The mean age of the patients was 47.61 ± 11.88 years and 36.5% of the patients were postmenopausal. In 101 (73.7%) of the patients, macroscopic lesions were present. In 88 (64.2%) of the patients, tolidine-positive stained areas were determined under colposcopy. In total, 68 (49.6%) of the lesions were plain, whereas 51 (37.2%) of them were depigmented. Lichen simplex chronicus, lichen sclerosis and chronic inflammation were the major pathologies associated with vulval pruritus (25.5%, n = 35; 20.4%, n = 28; 14.6%, n = 20). In conclusion, several pathologies out of vulvovaginal candidiasis may lead to vulval pruritus and clinicians should be aware of the importance of biopsy in determining the underlying pathology.

Therapies and nursing care of women with vulvar dermatologic disorders

Vulvar dermatologic disorders are common among women, and prevalence increases with age. Treatment can provide women with symptomatic relief and can halt further progression of disease. Numerous therapies are available, and nurses who work with women across the life span should have an understanding of vulvar dermatologic disorders and therapeutic modalities. We provide an overview of general vulvar care, four vulvar dermatologic disorders, and common treatment modalities including topical and systemic pharmacologic management.

Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus

Lichen sclerosus, lichen planus, and lichen simplex chronicus are dermatologic conditions that can affect the vulva. Symptoms include vulvar itching, irritation, burning, and pain, which may be chronic or recurrent and can lead to significant physical discomfort and emotional distress that can affect mood and sexual relationships. With symptoms similar to common vaginal infections, women often seek care from gynecological providers and may be treated for vaginal infections without relief. Recognition and treatment of these vulvar conditions is important for symptom relief, sexual function, prevention of progressive vulvar scarring, and to provide surveillance for associated vulvar cancer. This article reviews these conditions including signs and symptoms, the process of evaluation, treatment, and follow-up, with attention to education and guidelines for vulvar care and hygiene.

[Vulvar inflammatory dermatoses]

Vulvar skin disease is a common reason for consultation. The vulva, like the rest of the skin, can be affected by numerous diseases of various etiologies, but its particular anatomic and physiologic characteristics create additional diagnostic and therapeutic difficulties. The study of vulvar disease is emerging as a new branch of dermatology. In this article, we examine the characteristics of the normal vulva, and perform a brief, structured review of vulvar inflammatory dermatoses, which comprise a heterogeneous group of diseases in which a broad, multidisciplinary approach is essential.