Vulvar disease in children: a clinical audit of 130 cases

Long-term evolution of prepubertal-onset anogenital lichen sclerosus: A 35-year retrospective and cross-sectional study from a single tertiary care maternal and pediatric center

BACKGROUND

Anogenital lichen sclerosus (ALS) in children may persist after puberty with potential clinical repercussions.

OBJECTIVE

The purpose of this study was to evaluate postpubertal evolution of girls with ALS diagnosed in the prepubertal period based on physical examination, the persistence of functional symptoms, and the effect on quality of life.

METHODS

We retrospectively reviewed 65 cases of girls with prepubertal-onset ALS. Onset, signs/symptoms, photos, evolution, and treatment were collected from the medical records. Subsequently, 30 of these 65 patients were assessed for persistence of signs/symptoms by physical examination and/or standardized questionnaire.

RESULTS

Signs of active disease after puberty based on physical examination were present in 92% (N = 23) of examined patients. A high proportion of cases with persistent ALS after puberty were asymptomatic (47%, N = 14).

LIMITATIONS

This is a single-center retrospective study with a limited number of patients. Half of our original cohort could not be reached or declined a follow-up visit.

CONCLUSION

Prepubertal lichen sclerosus is a chronic condition that can be asymptomatic after puberty despite continued disease activity. We recommend long-term follow-up of patients with prepubertal ALS to prevent associated morbidity.

Insights from a joint pediatric dermatology-gynecology vulvar clinic: A retrospective study

BACKGROUND/OBJECTIVES

Pediatric vulvar disease has not been widely explored in the medical literature. Few studies focus on vulvar disease in skin of color. The vulvar disease can be distressing for young patients given the sensitive location, and providers may lack experience in diagnosing and managing vulvar dermatoses. We sought to characterize the conditions seen, diagnostic challenges encountered, and the racial and ethnic factors associated with vulvar diseases in our multidisciplinary pediatric dermatology-gynecology vulvar clinic at Children's National.

METHODS

Medical records of 220 patients who presented to our multidisciplinary pediatric dermatology-gynecology clinic were reviewed retrospectively.

RESULTS

Lichen sclerosus (LS) (36%, n = 80), inflammatory vulvitis (11%, n = 23), and vitiligo (9%, n = 19) were the three most frequent conditions observed. These conditions were often misdiagnosed as one another. There was a mean delay in diagnosis after symptom onset in LS patients of 16.43 months.

CONCLUSIONS

LS, inflammatory vulvitis, and vitiligo are common vulvar diseases among pediatric patients. Accurate diagnosis is important because LS must be treated aggressively to prevent sequelae. Further studies are warranted to help differentiate LS and vitiligo with consideration of skin tone.

The Importance of Immunological Disorders in the Pathogenesis of Lichen Sclerosus in Pediatric Patients: A Systematic Review

Lichen sclerosus (LS) is defined as a chronic mucocutaneous inflammatory disease with a localization predominantly to the anus and genitals (vulvar sclerosus (VLS)). Pediatric lichen sclerosus (LS) is a chronic inflammatory skin condition with predilection for the anogenital area that if untreated can lead to scarring. Vulvar LS is characterized by two peaks in incidence: it occurs in prepubertal girls and in postmenopausal women. To date, several mechanisms and risk factors have been proposed in the pathogenesis of pediatric vulvar LS; however, the etiology of this condition is still not fully understood and constitutes a challenge for scientists and clinicians. The presented research aimed to systematically review the existing literature on the pathogenesis of pediatric LS and to identify possible underlying autoimmune mechanisms and molecular networks. The clinical presentation of pediatric lichen sclerosus and available treatment modalities are also presented to acquaint a broader audience with this underdiagnosed and undertreated condition. As a result of our review, we discuss several potential mechanisms, molecules, and pathways that have been recognized in this disease. The purpose of our review was also to summarize what we can induce in further studies, which will ultimately help to identify the mechanism responsible for the disease and aid in the development of new, more effective treatment strategies for diagnosis and treatment by clinicians and researchers.

Profile of Nonvenereal Female Genital Dermatoses: A Cross-Sectional Study From Eastern India

OBJECTIVE

Nonvenereal genital dermatoses may be a reason for considerable concern to the patient and often pose diagnostic dilemma to the treating physicians. The objective of the present study was to find out the demographical and clinical profile of nonvenereal genital dermatoses including systemic comorbidities in a tertiary care hospital.

MATERIALS AND METHODS

This was an observational study, carried out at the outpatient department of dermatology of a tertiary care hospital of Eastern India over a period of 12 months. Female patients with genital lesions were included in the study after excluding venereal disease. Results were tabulated and analyzed.

RESULTS

A total of 189 female patients were evaluated having 39 different dermatoses. The age ranged from 2 months to 72 years with most patients belonged to the fourth decade and 70.4% patients were from reproductive age group. Most of the patients were literate (81%) and hailing from rural areas. Most of them were homemakers and belonged to lower socioeconomic status (42.3%). Itching (77.3%) was the most common presenting complaint followed by burning sensation (9.5%). Common dermatoses encountered were vulval candidiasis (40.7%), lichen sclerosus (15.3%), tinea cruris (13.8%), lichen planus (4.2%), vitiligo (3.2%), irritant contact dermatitis (2.6%), psoriasis (2.6%), lichen simplex chronicus (2.1%), among others. Most common associated comorbidity was diabetes mellitus.

CONCLUSIONS

This study provides important data on the spectrum of vulvar diseases in Eastern Indian patients and emphasizes the importance of proper and timely diagnosing nonvenereal vulvar dermatoses.

Cutaneous Mimics of Child Abuse & Neglect: Part II

Given that some cutaneous mimics of child abuse result from rare disease, they may be more prone to misdiagnosis. For possible child abuse cases in which diagnosis remains uncertain at time of initial dermatologic evaluation, it is important that dermatologists are prepared to distinguish true dermatologic conditions in cases of ambiguous skin findings. Additionally, this review will aid clinicians in recognizing the possibility of concurrent true dermatologic disease and skin findings related to abuse with the acknowledgement that they are not mutually exclusive. Proper recognition of mimics of abuse may prevent unnecessary stress and child protective service investigation.

Prevalence and risk factors of vulvar dermatoses: A hospital-based study

Background:

The overall prevalence of vulvar diseases in the literature is low because of underreporting and is often neglected; thus, its impact on a female's life is often underestimated.

Objectives:

This study is aimed to determine the prevalence of vulvar diseases and their associated risk factors in patients attending a tertiary care hospital.

Materials and Methods:

This is a descriptive, cross-sectional, and case–controlled study wherein all female patients attending the dermatology outpatient department (OPD) were screened for the signs and symptoms of vulvar dermatoses and were enrolled after obtaining informed consent and institutional ethics committee approval for 21 months. Out of them, 200 patients who consented and had signs and symptoms of vulvar diseases were selected as cases, and the same number of age-matched females were enrolled as controls with no signs and symptoms of vulvar dermatoses.

Results:

During the study period, 9431 females attended the dermatology OPD, of which the prevalence was 2.12% (200 patients). The most common infection was genital infection without sexually transmitted infection (57%) (tinea cruris [33.5%]), followed by inflammatory dermatoses (21%) (lichen sclerosus et atrophicus [6%]). The most common risk factor found statistically significant (P ≤ 0.005) were homemakers (49%) and the use of undergarments of mixed fabric (70.68%), followed by nonmenopausal females (63.15%).

Conclusion:

Our study findings indicated that the prevalence was low, which reflects the tip of an iceberg. Further clinical and population-based studies, a multidisciplinary approach including gynecological consult for diagnostic and therapeutic approach is needed for the optimal management of vulvar diseases.

Localised childhood vulvar pemphigoid: a rare case study

In this case report we present a young patient with localised childhood vulvar pemphigoid. It is a rare variant of bullous pemphigoid with mostly a favourable prognosis and prompt response to potent topical corticosteroids. She presented with relapsing vulvar pain and lesions. Our case enlightens the recognition of this unusual subtype and the importance of performing a cutaneous biopsy.

Vulvar vitiligo and lichen sclerosus in children: A clinical challenge

Vulvar vitiligo (VV) and vulvar lichen sclerosus (VLS), both feature skin and mucosal hypo-/depigmentation. The aim of this study was to describe the clinical and dermoscopic features of VV and VLS in the pediatric population, providing diagnostic clues, and to define their association. We performed a systematic literature review of the clinical and dermoscopic features of pediatric VV and VLS. An observational study was conducted on children affected by VLS associated with VV, referred to the Dermatology Unit of the Sant'Orsola Polyclinic in Bologna, Italy. Medical history, age at diagnosis, ethnicity, clinical and dermoscopic features, and symptoms were recorded for all patients. 124 cases of VLS and 10 cases of VV were reviewed. Clinical manifestations included hypo-/depigmented patches in both conditions, while ecchymosis/purpura and fissures/erosion were observed in VLS. Symptoms including pruritus, pain, or burning were reported only by VLS patients. In our study five patients with VLS associated with VV were retrieved. Clinical features included well-demarcated depigmented patches in VV and translucent areas, erythema, ecchymoses/purpura, and labial fusion in VLS. Dermoscopy showed white structureless areas with a whipped cream-like appearance, linear or dotted vessels, white chrysalis-like structures, erosion and red-purpuric blotches in VLS and reduced pigment network or pigment absence, intralesional spots of residual pigmentation and telangiectasias in VV. Symptoms were present in all patients. Both VV and VLS show hypo-/depigmented patches. In the presence of associated symptoms, possible VLS should be investigated with clinical and dermoscopic examination to achieve a prompt diagnosis.

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.

[Paediatric vulval clinic]

In 2008 a vulval clinic was established at the University Clinic of Schleswig Holstein, Campus Luebeck, Department of Dermatology. A total of 1227 patients were referred to the clinic between 2008 and October 2020, including 91 children (age range 1-13 years) and 17 adolescents (age range 14-17 years). The most common paediatric vulval conditions encountered were lichen sclerosus (33%), vulvitis (23%) and vulval psoriasis (7%). Quality of life was measured in 81 children using the paediatric version of the Dermatology Life Quality Index (DLQI). Of a maximum 30 points, the mean score was 7.2, confirming the association between vulval diseases and impaired quality of life in children and adolescents.

Anogenital Papular Lesions in Children Five Year Old and Younger: Gender Differences

Introduction:

Anogenital area is a small compartment in the human body. Recognition of various dermatological conditions affecting this area in children is essential for any physician involved in pediatric examination and evaluation.

Aim:

To assess the nature, diagnoses, and gender differences of Anogenital lesions in pediatric patients presented to Royal Medical Services (RMS) general dermatology clinics, who were five year old and younger.

Methods:

The authors reviewed patients’ medical records in the period between September 2015 and September 2018. The inclusion criteria were children of both genders who were five year old or younger and presented with papular lesions in the Anogenital area. Those patients visited the general dermatology clinics of The Royal Medical Services Hospitals from the Eastern and Southern regions of Jordan.

Results:

Over a period of 3 years, a total of 514 patients were five year old or younger presented with various Anogenital papular lesions were evaluated and treated in general dermatology clinics. 35% of the patients presented with Perianal Psuedoverrucous Papules and nodules, 21% presented with Anogenital warts, 16% presented with Molluscum Contageosum. Moreover, 10% were presented with Epidermal nevi, 6% presented with Pearly Penile Papules, 7% presented with Infantile Perineal Pyramidal Protrusion, 4% presented with Vulvar Vestibular Papillomatosis, 0.2% presented with Juvenile Xanthogranuloma, 0.2% presented with lymphangioma Circumscriptum, and 0.2% presented with median raphe cyst. In addition, gender differences were noticed among Genital Warts, Mollascum Contageosum, Pearly Penile Papules, and Vulvar Vestibular Papillomatosis.

Conclusion:

Anogenital papules in children have variable clinical presentations and can be caused by multiple number of infectious and non-infectious factors. The presence of such lesions can be a source of a major concern for parents, and might be mistakenly assumed as a result of sexual assaults. Proper recognition of these papules is of paramount importance for all physicians involved in children examination, to appropriately reassure parents and avoid unnecessary investigations and psychological distress.

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.

The long-term clinical consequences of juvenile vulvar lichen sclerosus: A systematic review

BACKGROUND

Vulvar lichen sclerosus (VLS) occurring in children and adolescents may have repercussions throughout life.

OBJECTIVE

We sought to assess the evidence available on the long-term consequences of juvenile VLS.

METHODS

Multiple databases were searched for studies containing long-term follow-up information on children or adolescents up to age 18 years with VLS. Articles were classified by level of evidence and the specific aspects of VLS studied.

RESULTS

In all, 37 studies met the inclusion criteria, giving information on the long-term consequences of VLS, of which 13 were cohort studies and 24 were case reports or series. These publications show that signs and symptoms persist after puberty and beyond, scarring and permanent architectural changes occur, treatment is effective with regard to symptoms, and long-term quality of life is affected. Findings suggest a possible relationship with risk of malignancy. The included publications had low-level evidence.

LIMITATIONS

Meta-analysis was not possible because the studies had different focuses. Very few patients were followed into adulthood.

CONCLUSIONS

There is low-level evidence suggesting long-term repercussions of juvenile VLS. Studies following children and adolescents with VLS into adulthood are needed to better understand the course of this disease and its repercussions on adult vulvar health.

Localized vulvar bullous pemphigoid of childhood: A rare cause of persistent vulvar erosions in children

Localized vulvar bullous pemphigoid of childhood is an excessively rare variant of bullous pemphigoid and affects almost exclusively young girls of 7-12 years of age. In contrast to adult-onset bullous pemphigoid, a prompt response to potent topical corticosteroids is observed in the majority of cases, with a favorable prognosis and rare relapses. We report the case of a 7-year-old girl who presented with this condition. Our case reinforces the recognition of this rare subtype of childhood bullous pemphigoid as a distinct entity and enlightens the importance of performing a cutaneous biopsy when clinically indicated.

Histopathology of Cutaneous Inflammatory Disorders in Children

Inflammatory dermatoses encompass a variety of histologic patterns that affect different portions of the skin. In spongiotic, psoriasiform, lichenoid, pityriasiform, and blistering disorders, there are predominately epidermal and junctional activities with variable superficial dermal inflammation. Hypersensitivity reactions can show either epidermal or mostly dermal changes depending on whether the exposure of the exogenous allergen occurs through an external or internal route, respectively. Exceptions include erythema multiforme and Stevens-Johnson syndrome/toxic epidermal necrolysis, where the etiology is often due to infection or ingested medications, but the histologic features are almost exclusively confined to the epidermis and dermoepidermal junction. Autoimmune disorders are unique in that lesions typically incorporate a mixture of epidermal and dermal inflammatory patterns with periadnexal inflammation, while the vast majority of vasculitis/vasculopathy and alopecia have changes limited to only the vessels and hair follicles, respectively. It is critical to recognize that a relatively limited number of histologic patterns are seen in a large array of clinical entities. Therefore, clinicopathologic correlation and careful examination of histologic details are of the utmost importance when evaluating skin biopsies for inflammatory disorders.

Streptococcus pyogenes as the cause of vulvovaginitis and balanitis in children

BACKGROUND

Streptococcus pyogenes (group A Streptococcus) is the etiological agent of perineal infection in children, consisting of perianal infection, vulvovaginitis and balanitis. If it is not properly diagnosed and treated, it can persist for many months and can cause severe complications. Furthermore, treatment with penicillin can be followed by failures and recurrences.

METHODS

We report here the prevalence of S. pyogenes isolates in genital tract specimens from girls (n = 1692) with symptoms of vulvovaginitis and from boys (n = 52) with balanitis in the municipality of Nis, Southeast-Serbia (the Western Balkans) in a 10 year period, and the seasonal distribution, patient age and sensitivity to bacitracin and antimicrobial drugs used in the treatment of streptococcal infection.

RESULTS

Streptococcal vulvovaginitis was diagnosed in 2.30% of examinees. Of those cases, 64.10% were detected from April to September, and it was most common (71.79%) in girls aged 3-7 years. Streptococcal balanitis was diagnosed in two instances: in a 4-year-old boy and in a 7-year-old boy. S. pyogenes strains resistant to bacitracin were identified in five girls. Two isolates with M phenotype and five isolates with cMLS_B phenotype were identified.

CONCLUSIONS

Streptococcal vulvovaginitis was diagnosed less often in the present study, but it was still far more common than streptococcal balanitis in childhood. Bacitracin resistance of S. pyogenes strains should be taken into account in routine microbiological identification, and the detection of S. pyogenes isolates resistant to erythromycin requires surveillance in the present geographical territory.

Atypical infantile genital Molluscum contagiosum

Genital molluscum contagiosum is rare in children. We report a molluscum contagiosum around the vulva and anus of 9-year-old girl, which has atypical presentations and was finally confirmed by histopathological and electron microscopy findings.

Acute penile pain and swelling in a 4-year-old child with Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is the most common vasculitis found in children. It usually affects the small vessels of the skin, joints, gastrointestinal tract and, more rarely, kidneys, brain, lungs and genitalia. Apart from classical presentation with purpuric rashes around buttocks and lower extremities, features such as arthralgia, abdominal pain, haematuria and proteinuria as well as scrotal swelling have been described in the literature. Penile involvement is rare and is not commonly described. We describe a child with HSP who developed penile involvement. We review the literature of all the cases reported in detail, in order to highlight useful clinical presentation, management and prognosis of this rare manifestation.

Paediatric vulvar disease

Paediatric vulvar skin conditions are relatively common but often cause diagnostic difficulties for clinicians, which can lead to anxiety within the children's families. Vulvar skin conditions can be caused by various underlying aetiologies. Most are general dermatologic conditions that occur in the vulvar area, such as eczema, psoriasis, skin lesions or infections. However, other conditions such as lichen sclerosus and napkin dermatitis ('nappy rash') only affect the genital region. Every affected child needs a sensitive evaluation of the complaint including an assessment of the impact of the condition on the patient and her family. Paediatric vulvar disease often influences bowel and bladder habits and may lead to behavioural problems. General measures such as avoidance of irritants or soap substitution and regular use of emollients are helpful for all patients. Specific therapy depends upon the underlying diagnosis. Time spent reassuring the families, reinforcing regimens and providing written documentation can all be very helpful in successful management of paediatric vulvar skin conditions.

Extragenital bullous lichen sclerosus in a pediatric patient: a case report and literature review

A 14-year-old girl presented with a 1-year history of a pruritic, bullous lesion on her posterior neck. A biopsy revealed bullous lichen sclerosus. Although unusual, this bullous variant of lichen sclerosus is well recognized in the adult literature, but extragenital bullous and hemorrhagic lesions are rare in children. A review of this case and the literature describes the clinical features, pathophysiology, and treatment options for this extragenital bullous variant in an effort to raise awareness of this rare clinical presentation.

Bacterial vaginosis in the context of lichen sclerosus in a prepubertal girl

Group A beta-hemolytic streptococcus cause most vulvovaginal infections seen in prepubertal girls. Bacterial vaginosis is a common cause of abnormal vaginal discharge in women of childbearing age but is rare in children. Data are insufficient to suggest that bacterial vaginosis is an exclusively sexually transmitted disease. We report a 10-year-old girl with no history or suspicion of sexual abuse who developed bacterial vaginosis in the context of a lichen sclerosus being treated with tacrolimus ointment. Secondary bacterial infection in lichen sclerosus is uncommon. We speculate that the immunosuppressive effect of topical tacrolimus could have triggered the infection.

Microbiological findings of vulvovaginitis in prepubertal girls

OBJECTIVE

To compare vaginal culture results between prepubertal girls with and without vulvovaginitis, and obtain an overview of the most commonly encountered microbes.

DESIGN

Prospective descriptive study.

SETTING

Outpatient clinic of Vilnius University Hospital Santariskiu Klinikos during September 2011-December 2012.

PATIENTS

115 prepubertal girls with vulvovaginitis symptoms and additionally 20 age-matched asymptomatic girls.

METHODS

Each girl had a vaginal smear carried out using a sterile swab from the introitus or lower third of the vagina. All samples were referred to the microbiology laboratory where standard microbiological diagnostic procedures were performed.

RESULTS

Positive microbiological findings were seen in all 115 (100%) symptomatic girls and in 12 (60%) control group girls (p<0.001). Pathogenic bacteria were found only in symptomatic girls. Statistically significant differences in bacteria culture results (pure or mixed) and growth of isolated bacteria colonies between patients versus healthy girls were found (p<0.05). The dominant bacteria in the target group, accounting for 66% of all isolated microbes, were Escherichia coli, Enterococcus faecalis, Staphylococcus coagulase negative, Streptococcus α haemolyticus and A group Streptococcus β haemolyticus. The bacteria of faecal origin were isolated from 61 (53%) girls with vulvovaginitis and from 5 (25%) girls without vaginal inflammation (p<0.05). Instances of Candida species were extremely rare (2.6%).

CONCLUSIONS

Positive microbiological findings, mixed bacteria cultures and a high growth of bacteria colonies are found significantly more often in girls with vulvovaginitis. The main causative premenarchal vulvovaginitis agents are faecal in origin.

Inverse psoriasis involving genital skin folds: successful therapy with dapsone

Introduction

Inverse psoriasis is a rare form of psoriasis that affects between 3% and 7% of the patients with psoriasis. It can comprise genital skin folds as part of genital psoriasis, and it is one of the most commonly seen dermatoses of this area. There are few evidence-based studies about the treatment of intertriginous psoriasis involving genital skin folds.

Case Presentation

The authors present a 42-year-old female patient with erythematous plaques in the vulva, groin, and perianal region. The patient had previously received a broad range of topical and systemic therapies that had to be discontinued due to ineffectiveness or side effects. She was treated with 100 mg dapsone daily for 10 months, showing a significant improvement of her cutaneous and mucous lesions. Complete clearance of psoriatic lesions was observed after 4 weeks of treatment. She has remained in remission for up to 2 years, using only topical therapy with tacrolimus 0.1% and calcipotriol.

Discussion

Genital psoriasis is a skin disease that causes great discomfort. It is important to include examination of the genital region and to adopt this conduct in daily clinical practice. Research in this field is still poor, making no discrimination between flexural and genital psoriasis, and is based on case series and expert opinion; therefore, empirical recommendations for the treatment of genital psoriasis remain. Dapsone has been shown to be an effective and convenient alternative for the treatment of inverse psoriasis in genital skin folds, which can provide effective control of the disease. Further studies are required to determine the efficacy and safety of current therapies, and to decide whether dapsone therapy should be considered in the management of this form of psoriasis when topical and other systemic agents are not effective.

Microbiological aspects of vulvovaginitis in prepubertal girls

This study aimed to establish the vaginal introitus microbial flora in girls with and without symptoms of vulvovaginitis, and to present the distribution of isolated microorganisms by age groups in girls with vulvovaginitis. We enrolled 500 girls with vulvovaginitis symptoms, aged 2-12 years, referred by their pediatricians for microbiological examination of the vaginal introitus swabs, and 30 age-matched asymptomatic girls. Similar microbial flora was isolated in both groups, but the symptomatic girls had significantly more common positive microbiological findings compared to controls (p < 0.001). In symptomatic girls, the following pathogenic bacteria were isolated: Streptococcus pyogenes (4.2%), Haemophilus influenzae (0.4%), and Staphylococcus aureus (5.8%). Bacteria of fecal origin were found in vaginal introitus swabs in 33.8% of cases, most commonly Proteus mirabilis (14.4%), Enterococcus faecalis (12.2%), and Escherichia coli (7.0%). The finding of fecal flora was more common compared to controls, reaching a statistical significance (p < 0.05), as well as in girls aged up to 6 years (p < 0.001). Candida species were found in 2.4% of girls with vulvovaginitis symptoms.

CONCLUSION

The microbial ecosystem in girls with clinical signs of vulvovaginitis is complex and variable, and the presence of a microorganism does not necessarily imply that it is the cause of infection. The diagnosis of vulvovaginitis in prepubertal girls requires a complex and comprehensive approach, and microbiological findings should be interpreted in the context of clinical findings.

Urogenital symptoms in premenarchal girls: parents' and girls' perceptions and associations with irritants

OBJECTIVES

Premenarchal girls commonly seek care for urogenital symptoms, yet little is published about parents' and girls' perceived causes of symptoms or associations with irritant exposures. We sought to describe urogenital symptoms, perceived causes, and associations between symptoms and genital irritant exposures.

DESIGN

Descriptive study. Parents/girls interviewed; medical records reviewed.

PARTICIPANTS

Five- to 12-year-old well, premenarchal girls and their parents.

SETTING

One urban and 1 suburban pediatric practice.

OUTCOME MEASURES

Prevalence of histories of urogenital symptoms and perceived causes; association between symptoms and exposure to genital irritants in a well population.

RESULTS

Of 191 parent/girl dyads, 33% of parents and 48% of girls reported girls' histories of urogenital symptoms not attributed to urinary tract infections or trauma. Perceived causes: poor hygiene (29% of parents vs 14% of girls); soap products (20% of parents and girls); none identified (24% of parents vs 53% of girls). Analysis of symptoms versus irritant exposures demonstrated these associations: dysuria and genital soreness with poor genital hygiene, tight garments, or exposure to soap products; genital pruritus with poor hygiene (all P < .05). No symptoms were associated with nylon underwear, tights, or bike or horseback riding. Vaginal discharge was not associated with any irritants.

CONCLUSION

Almost half the girls had histories of urogenital symptoms. Poor hygiene and soap exposure were perceived causes of most symptoms. When no cause for urogenital symptoms is identified, treatment should be focused on hygiene, soap exposure, and tight-fitting clothes, not on bike or horseback riding or wearing nylon underwear or tights. Vaginal discharge warrants further evaluation.

Chronic vulvitis in pre-pubertal girls

Pre-pubertal girls with inflammatory chronic vulval disease excluding lichen sclerosus are often described as having 'non-specific vulvovaginitis'. The aim of this retrospective case series was to determine the aetiology of chronic vulvovaginitis in pre-pubertal (Tanner Stage 1) girls, with particular reference to candidiasis. A chart review recorded and compared the characteristics of 38 girls and 68 post-menarchal adolescents and pre-menopausal women with chronic vulvitis. Nineteen (50%) of the pre-pubertal children had been previously diagnosed with candidiasis and 21 (55%) had been treated unsuccessfully with topical antifungal agents. Candida albicans was isolated in two (5%) of the children and 37 (54%) of the adults (P < 0.001). A positive Candida culture was causally associated with chronic vulvovaginitis in 50% of the adults but in none of the children (P < 0.001). In 28 (74%) of the children and 28 (41%) of the adults, no pathogens were isolated on microbiological testing. General skin examination of the girls revealed signs of psoriasis in 27 (71%) and atopic dermatitis in nine (24%). Symptoms were controlled with topical anti-inflammatory treatment and environmental modification, including cessation of topical antifungals. Pre-pubertal girls with chronic vulvitis are likely to have either psoriasis or atopic dermatitis. Chronic vulvovaginal candidiasis is not seen in Tanner Stage 1 girls.

Erosive diseases of the vulva

Vesicobullous and inflammatory diseases produce vulvar erosions that may exhibit nonspecific morphology and represent a diagnostic challenge. An approach to arriving at the correct diagnosis is presented. Most common etiologies are reviewed.

Abdominal wall and labial edema presenting in a girl with Henoch-Schönlein purpura: a case report

Introduction

Henoch-Schönlein purpura is a common immunoglobulin A-mediated vasculitic syndrome in children, characterized by purpuric rash, arthritis and abdominal pain. Renal involvement, manifested by the presence of hematuria and/or proteinuria, is also frequently seen. In most cases, patients with this disease achieve complete recovery, but some progress to renal impairment. Gastro-intestinal manifestations are present in two-thirds of affected patients and range from vomiting, diarrhea, and peri-umbilical pain to serious complications such as intussusception and gastrointestinal hemorrhage.

Case presentation

We report the case of a 7-year-old Caucasian girl who presented with abdominal pain, labial swelling, and a large abdominal ecchymosis two weeks after having been diagnosed with Henoch-Schönlein purpura. A computed tomography scan revealed abdominal wall edema extending to the groin, without any intra-abdominal pathology. She was successfully treated with intravenous steroids.

Conclusion

Circumferential anterior abdominal wall edema and labial edema have never been reported previously, to the best of our knowledge, as a complication of Henoch-Schönlein purpura. These findings further contribute to the wide spectrum of manifestations of this disorder in the literature, aiding in its recognition and management.

Pediatric vulvovaginal disorders: a diagnostic approach and review of the literature

Vulvovaginal complaints in the prepubertal child are a common reason for referral to the health care provider. The Cochrane Library and Medline databases were searched for articles published in English from 1980 to December 2004 relating to vulvovaginal conditions in girls. The following search terms were used: vulvovaginitis, prepubertal, pediatric, lichen sclerosis, labial fusion, labial adhesion, genital ulcers, urethral prolapse, psoriasis, and straddle injuries. The objectives of this article are to review the normal vulvovaginal anatomy, describe how to perform an age-appropriate examination, and discuss common vulvovaginal disorders and their management in young girls.

Vulvovaginitis in childhood

Symptoms related to vulvitis and vulvovaginitis are a frequent complaint in the paediatric age. Knowledge of the risk factors and the pathogenetic mechanisms, combined with thorough clinical examination, helps to distinguish between dermatological diseases, non-specific vulvitis and vulvovaginitis proper. On the basis of microbiological data, the most common pathogens prove to be Streptococcus pyogenes, Haemophilus influenzae and Enterobius vermicularis; fungal and viral infections are less frequent. The possibility of isolating opportunistic pathogens should also be considered. In rare situations, the isolation of a micro-organism normally transmitted by sexual contact should prompt a careful evaluation of possible sexual abuse. Current treatments for specific and non-specific forms are outlined, together with pointers for the evaluation of recurrence.

The missing "Bratz" doll: a case of vaginal foreign body

Young female patients with gynecologic complaints, including vaginal discharge, commonly seek care in the emergency department. Prepubertal vaginal discharges have various potential etiologies including nonspecific vulvovaginitis, infections, inflammatory or dermatologic processes, precocious puberty, malignancy, anatomical anomaly, trauma, sexual abuse, and foreign body. We present the case of a 4-year-old girl with vaginal odor and discharge secondary to a foreign body. The foreign body was part of a toy, the lower half of the patient's missing "Bratz" (MGA Entertainment) doll. Although it is well known that a vaginal foreign body can cause a vaginal discharge, the unusual nature of the foreign body in this case and the revealing radiograph made this a case of particular interest.

Anogenitaldermatosen - allergische und irritative Auslosefaktoren Analyse von Daten des IVDK1 und Literaturubersicht. Anogenital dermatoses - allergic and irritative causative factors Analysis of IVDK2 data and review of the literature

BACKGROUND

Anogenital dermatoses (AGD) are common and often very distressing. Clinically it is often unclear if allergic contact dermatitis or irritant dermatitis is involved. In order to optimize therapy and prophylaxis, it is essential to identify relevant allergens or irritants.

PATIENTS AND METHODS

Data of the Information Network of Departments of Dermatology (IVDK, data center in Göttingen) collected between 1999 and 2003 were analyzed. The anogenital area was involved in 1 168 patients with suspected allergic contact dermatitis. Clinical variables and patch test results were statistically compared with the remaining IVDK patch test population, the latter standardized for age and sex.

RESULTS

Allergic contact dermatitis had been suspected prior to patch testing in 39.5 %, while in 24.6 % this diagnosis was eventually confirmed. Irritant contact dermatitis was diagnosed in 11.8 %. Other diagnoses, included balanitis, lichen sclerosus et atrophicus and herpes genitalis. Positive reactions to cinchocaine (6.6 %), bufexamac (3.5 %) and benzocaine (2.4 %) were observed significantly more often among patients with anogenital dermatitis. Among those in whom co-factors were considered important (n = 422), wetness (38.4 %), occlusion (30.3 %), mechanical strain (4.7 %) and heat (3.6 %) were mentioned as irritation factors.

CONCLUSION

Because of the significantly higher frequency of sensitization to cinchocaine, benzocaine and bufexamac in patients with anogenital dermatitis, these ingredients should be used only with caution. According to the literature, ingredients of toiletries, cosmetics and contraceptives of any kind seem to cause allergic contact dermatitis rarely although there are several case reports. Comprehensive patch test including the standard series plus major sensitizers such as cinchocaine, benzocaine and bufexamac, and in particular patients' own skin care products, is recommended.

[Pigmented lesions of the genital mucosa]

Pigmented lesions of the genital mucosa are more frequent in women than in men. They represent a spectrum of different benign entities. A biopsy is always recommended when the diagnosis cannot be made with certainty on clinical examination and dermatoscopy. Differential diagnostic considerations include melanocytic nevi, blue nevi and syndromes featuring lentigines. Malignant melanomas of the penis and vulva are uncommon tumors which usually appear in elderly patients. They frequently present as painless palpable nodules at routine examination. The treatment consists of excision with histological control of the margins. An aggressive surgical approach has not been shown to prolong the poor 5-year survival. Cooperation with gynecologists and urologists is essential for the optimal management of such patients.

Lower genital tract disease in children and adolescents--a review

Conditions affecting the lower genital tract of female children and adolescents are often significantly different than those seen in the adult. The purpose of this review is to provide an overview of vulvar, vaginal, and cervical conditions that may be encountered only rarely by the more generalized practitioner.