Meet the expert: Topical management of vulvar dermatoses

Vulvar dermatoses are often debilitating chronic skin conditions associated with pain and pruritus. In oncologic patients, cancer treatments can precipitate and exacerbate vulvar dermatoses. Cytotoxic chemotherapy, hormonal therapies, and local pelvic radiation therapy can lead to vulvar symptoms, and cancer treatment-induced vulvar conditions include graft-versus-host-disease and radiation dermatitis. There have also been reports of lichen sclerosus development or exacerbation secondary to hormonal therapy and immune checkpoint inhibitors, attributed to proposed hormonal and immunologic pathogenesis of lichen sclerosus. Early recognition and treatment of these conditions can significantly improve quality of life. In this review, we summarize the clinical features and management characteristics of six types of common vulvar dermatoses that may present in the oncologic patient.

Vulvar Pruritus and Lichen Simplex Chronicus

Vulvar pruritus and lichen simplex chronicus are common reasons for presentation to women's health practitioners, including gynecologists and dermatologists. Both conditions are multifactorial and are often confounded by other inflammatory, neoplastic, infectious, environmental, neuropathic, hormonal, and behavioral variables. Careful history taking and thorough physical examinations, including wet mount and potentially skin biopsy, are necessary for appropriate diagnosis. Treatment should focus on decreasing inflammation, reducing irritants, and providing symptomatic relief to achieve remission. Comprehensive treatment covering environmental, biological, and behavioral therapy can result in long-term cure for patients with these conditions.

Syringoma: A clinicopathological study of 244 cases

BACKGROUND

Syringomas are benign tumours of the sweat glands, the most familiar clinical presentation of which is the presence of multiple lesions on the eyelids. The aim of our study was to determine the clinical and histological characteristics of a large series of patients and to examine anatomoclinical correlations.

PATIENTS AND METHODS

This was a retrospective study conducted in all of the cases of syringoma analysed at the cutaneous histopathology laboratory in Strasbourg between 1970 and 2008. The clinical elements, patient history and diagnostic data were collated. All slides were re-read in order to determine the microscopic characteristics of the lesions.

RESULTS

Two hundred and forty-four lesions were included. The sex ratio was 0.27 and the mean age was 42 years (8 to 85 years). Multiple syringomas were noted in 76% of cases, of which 29.2% were eruptive, and one case occurred in a setting of metastatic melanoma. The sites of predilection were the face (56.7%, of which 36.3% on the eyelids), the chest (18.1%) and the neck (17.5%) for the multiple forms. The lesions were in the form of papules (67%), either brown (34.2%) or flesh-coloured (19.8%). Pruritus was reported in 14 cases, including 4 at vulvar sites (out of a total of 8). A diagnosis of syringoma was made by the clinician in only 30.2% of the multiple forms, with mastocytosis being proposed in 7.1% of cases. The clear-cell forms (18 cases) presented no special clinical features.

CONCLUSION

Syringomas are frequently multiple and are seen mainly in women. They are found predominantly on the face and trunk, and lesions are generally brown and pruritic, a little-known feature that accounts for the degree of diagnostic confusion with mastocytosis. The vulvar forms, which are often pruritic, are poorly known. The eruptive forms may include a hormonal component.

Resolution of Chronic Vulvar Pruritus With Replacement of a Neuromodulation Device

Vulvar pruritus is typically associated with fungal, bacterial, and/or dermatological conditions that routinely resolve with the use of topical medications. Pruritus rarely becomes chronic in nature without a definable pathological diagnosis. However, when this occurs, management is difficult and has limited treatment options. Few cases have reported resolution of vulvar pain or discomfort with sacral neuromodulation implantation. We report a case in which a patient experienced chronic vulvar pruritus that was refractory to medical treatments and did not have a pathological diagnosis. A neurological etiology was suspected, and upon replacement of the patient's sacral neuromodulation device, complete resolution of the vulvar symptoms occurred.