Anogenital skin diseases of childhood

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.

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.

Cutaneous signs of child abuse

Maltreatment of children is a major public health crisis, and it is estimated that each year more than 3 million children are victims of abuse. Safeguarding the welfare of children is a priority, and it is the moral and ethical responsibility of healthcare professionals to detect cases of abuse and intervene appropriately to prevent further harm. Clinicians are often challenged to differentiate signs of child abuse from skin conditions that mimic maltreatment. Because cutaneous injury represents the most recognizable and common form of abuse, dermatologists are often called upon to help distinguish signs of intentional injury from skin conditions that mimic maltreatment. However, few resources specific to dermatologic signs of abuse exist to aid in diagnosis. A review of the literature will provide an educational resource to assist dermatologists and other clinicians in differentiating cutaneous signs of child abuse, including physical and sexual abuse, from mimickers of inflicted injury.

LEARNING OBJECTIVE

After completing this learning activity, participants should be able to distinguish signs of intentional injury from skin conditions that mimic maltreatment and understand the clinician's role in the diagnosis and reporting of cases of suspected child abuse.

Guidelines for medical care of children who may have been sexually abused

BACKGROUND

Children who may have been sexually abused are examined in many different settings by medical providers with variable levels of education and experience in this special area of practice. Therefore, there is a need for a consistent evidence-based approach that is agreed upon by medical experts.

OBJECTIVES

To develop and provide guidelines and recommendations for performing and interpreting findings of the medical evaluation of children referred for sexual abuse medical evaluations, and to provide guidelines for the education, oversight, and peer review process for clinicians who provide assessments for suspected child sexual abuse.

METHODS

Participation from medical providers was solicited through postings on the Internet list-serves administered by Cornell University (Special Interest Group in Child Abuse), and by the Ray E. Helfer Society, an honorary society for physician specialists in child abuse diagnosis and treatment. The guidelines were developed through review and critique of published research studies, discussions in focus group meetings at child abuse medical conferences, and ongoing communication leading to revision of draft documents.

RESULTS

Groups of 10 to 40 physician experts met at child abuse conferences between January 2002 and January 2005 to revise the table summarizing the interpretation of physical and laboratory findings in suspected child sexual abuse and to develop guidelines for medical care for sexually abused children. Between January and December 2005, the guidelines were expanded and revised.

CONCLUSIONS

The guidelines presented here reflect the current knowledge, recommended clinical approaches, and required competencies in the field of child sexual abuse medical evaluation.

Human Papillomavirus Infections of the Genital and Respiratory Tracts in Young Children

Human papillomavirus (HPV) causes papillomas (warts) on the skin and respiratory mucosal surfaces (laryngeal and oral papillomas) in addition to condyloma acuminata (anogenital warts). HPV has become one of the most common sexually transmitted diseases in adults. Vertical transmission from mother to infant during birth is well recognized. Laryngeal papillomas are the most common tumors of the larynx in children worldwide, and recurrent lesions are common occurrences. Anogenital warts in children are problematic in that child sexual abuse is a potential means of acquisition, but many cases are acquired perinatally. Postnatal acquisition by nonsexual means also can occur. The likelihood of sexual abuse as the mode of acquisition increases with increasing age in childhood. The virus infects primarily epithelial cells, where it can exist as a long-term latent infection that can reactivate or persist actively (even subclinically), with resultant accumulation of host chromosomal mutations. The latter accounts for the oncogenic potential of a number of HPV types, and childhood infections may lead to neoplasia later in life. Regression of papillomas over the course of months to years is the usual natural course. Numerous treatments are available, but most do not prevent persistent infection or problematic recurrences. Multivalent HPV vaccines have been developed, and early results of clinical trials appear to be very promising.

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.

Pruritus vulvae in prepubertal children

BACKGROUND

Vulvar pruritus is a common complaint in females of all ages. However, little has been published on pruritus vulvae in children as a primary symptom.

OBJECTIVE

Our purpose is to review the causes and treatments of vulvar pruritus in prepubertal girls and to retrospectively evaluate the causes and outcomes of the premenarchal children we studied.

METHODS

The records of 44 premenarchal girls with vulvar pruritus were reviewed, and follow-up interviews were performed by telephone.

RESULTS

Thirty-three patients (75%) had nonspecific pruritus. Lichen sclerosus, bacterial infections, yeast infection, and pinworm infestation were seen in a minority of patients. At follow-up, pruritus had cleared in 15 patients, been alleviated in 13, and remained the same in 4.

CONCLUSION

Most of our patients had nonspecific pruritus, which was alleviated by or cleared with better hygiene and avoidance of irritants. In prepubertal girls, poor hygiene and irritants such as soap are major contributors to pruritus vulvae. All patients may benefit from following hygienic measures and irritant precautions in addition to specific therapy directed at underlying causes.

Examination for sexual abuse in prepubertal children: an update

The complete physical examination of prepubertal children should always include a genital examination. Most children, even those who have been sexually abused, will have a normal genital examination. A child's acceptance and tolerance for this aspect of the examination will be enhanced by use of the techniques described. Sexually abused children may be identified through routine review of systems and history, including behavioral and psychosocial, and open-ended questions regarding sexual abuse. Regular genital examinations will also help to identify sexually abused children. Although the diagnosis of sexual abuse can never rely solely on physical findings, abnormal findings suspicious for sexual abuse are significantly more useful if there have been prior documented normal examinations. When sexually abused children initially present to their medical practitioner, the practitioner should obtain a complete medical and psychosocial history and perform a thorough examination. The practitioner need not be an expert in the interpretation of the possible legal significance of specific genital findings but should recognize normal, abnormal, and suspicious findings. Reassurance from a trusted practitioner relating to a normal body can be the most valuable treatment for a child's emotional healing. Practitioners need to be aware of the resources in their community for medical evaluations for sexual abuse, legal investigations, and mental health referrals. If there is a local center for child abuse evaluations, such as a Child Advocacy Center or Center of Excellence for child protection, practitioners should consider referrals to and consultations with these resources.