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

Phenylacetic acid, an anti-vaginitis metabolite produced by the vaginal symbiotic bacterium Chryseobacterium gleum

The human microbiome contains genetic information that regulates metabolic processes in response to host health and disease. While acidic vaginal pH is maintained in normal conditions, the pH level increases in infectious vaginitis. We propose that this change in the vaginal environment triggers the biosynthesis of anti-vaginitis metabolites. Gene expression levels of Chryseobacterium gleum, a vaginal symbiotic bacterium, were found to be affected by pH changes. The distinctive difference in the metabolic profiles between two C. gleum cultures incubated under acidic and neutral pH conditions was suggested to be an anti-vaginitis molecule, which was identified as phenylacetic acid (PAA) by spectroscopic data analysis. The antimicrobial activity of PAA was evaluated in vitro, showing greater toxicity toward Gardnerella vaginalis and Candida albicans, two major vaginal pathogens, relative to commensal Lactobacillus spp. The activation of myeloperoxidase, prostaglandin E2, and nuclear factor-κB, and the expression of cyclooxygenase-2 were reduced by an intravaginal administration of PAA in the vaginitis mouse model. In addition, PAA displayed the downregulation of mast cell activation. Therefore, PAA was suggested to be a messenger molecule that mediates interactions between the human microbiome and vaginal health.

Pregnancy, parturition and postpartum considerations among patients with vulvar lichen sclerosus: A retrospective cross-sectional online survey

OBJECTIVE

Characterise VLS and obstetric considerations among women during pregnancy, parturition and postpartum.

DESIGN

Retrospective cross-sectional online survey, 2022.

SETTING

International, English-speakers.

POPULATION

Self-identified individuals aged 18-50 diagnosed with VLS with symptom onset prior to pregnancy.

METHODS

Participants recruited from social media support groups and accounts, completed a 47-question survey including yes/no, multiple answer, and free-text responses. Data were analysed with frequency, means and the Chi-square test.

MAIN OUTCOME MEASURES

VLS symptom severity, mode of delivery, perineal laceration, source and sufficiency of information provided about VLS and obstetrics, anxiety about delivery, and postpartum depression.

RESULTS

Of 204 responses, 134 met inclusion criteria, encompassing 206 pregnancies. Mean respondent age was 35 years (SD 6) and mean age of VLS symptom onset, diagnosis and birth, was 22 (SD 8), 29 (SD 7) and 31 (SD 4) years, respectively. Symptoms decreased in 44% (n = 91) of pregnancies and increased during the postpartum period in 60% (n = 123). In all, 67% (n = 137) of pregnancies resulted in vaginal birth and 33% (n = 69) in caesarean birth. Anxiety for delivery due to VLS symptoms was reported by 50% (n = 103); 31% (n = 63) experienced postpartum depression. Of respondents previously diagnosed with VLS, 60% (n = 69) used topical steroids prior to pregnancy, 40% (n = 45) were treated during pregnancy and 65% (n = 75) postpartum. In all, 94% (n = 116) reported receiving an insufficient amount of information on the topic.

CONCLUSION

In this online survey, we found reported symptom severity remained unchanged or decreased during pregnancy, but increased postpartum. Use of topical corticosteroids decreased during pregnancy compared with before and after pregnancy. Half of the respondents reported anxiety regarding VLS and delivery.

Evaluation and treatment of vulvovaginal itching in postmenopausal women

Vulvovaginal itching, a commonly reported symptom in postmenopausal women, may be because of the genitourinary syndrome of menopause but has a broad differential including dermatologic, infectious, and autoimmune causes. Comprehensive evaluation is important to avoid inappropriate treatments that may delay the correct diagnosis. In many cases, no clear cause can be identified, and the goal of management is simply to control symptoms.

In a Pinch: An Unusual Case of Zoon's Vaginitis, a Plasma Cell Disorder

Plasma cell, or Zoon's, vulvitis (PCV) is a rare inflammatory disorder of the female genital tract. Clinically, it is characterized by erythematous mucosal lesions associated with burning, pruritus, and dyspareunia. Histologically, it is characterized by the thinning of the epithelium with the infiltration of plasma cells in the underlying dermis. There are few case reports describing predominantly vaginal symptoms. Our patient is a 53-year-old postmenopausal female presenting for the gynecologic evaluation of a vaginal pinching sensation and vulvar irritation for three months. On examination, vaginal mucosa was notable for erythematous macules and papules with focal tenderness. Initial evaluation was significant for bacterial vaginosis. This was treated, but it did not improve the patient's presenting symptoms. Our preliminary working diagnosis was vulvovaginal atrophy. Biopsies showed plasmacytosis mucosae consistent with Zoon's vaginitis. The patient was treated with external clobetasol ointment and hydrocortisone 25 mg vaginal suppositories with improvement in symptoms. Female genital tract lesions engender a range of differential diagnoses, including infectious, immunologic, and malignant causes. In this patient, our initial working diagnosis of genitourinary syndrome of menopause suggested that local hormonal treatment was indicated. However, histological diagnosis directed the use of steroid treatment, ultimately improving the patient's symptoms.

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.