Disclosures The Older Woman with Vulvar Mark Spitzer, MD Itching and Burning Merck: Advisory Board, Speakers Bureau Mark Spitzer, MD QiagenQiagen:: Speakers Bureau Medical Director SABK: Stock ownership Center for Colposcopy Elsevier: Book Editor Lake Success, NY Old Adage Does this story sound familiar? A 62 year old woman complaining of vulvovaginal itching and without a discharge self treatstreats with OTC miconazole.miconazole. If the only tool in your tool Two weeks later the itching has improved slightly but now chest is a hammer, pretty she is burning. She sees her doctor who records in the chart that she is soon everyyggthing begins to complaining of itching/burning and tells her that she has a look like a nail. yeast infection and gives her teraconazole cream. The cream is cooling while she is using it but the burning persists If the only diagnoses you are aware of She calls her doctor but speaks only to the receptionist. She that cause vulvar symptoms are Candida, tells the receptionist that her yeast infection is not better yet. The doctor (who is busy), never gets on the phone but Trichomonas, BV and atrophy those are instructs the receptionist to call in another prescription for teraconazole but also for thrthreeee doses of oral fluconazole the only diagnoses you will make. and to tell the patient that it is a tough infection. A month later the patient is still not feeling well. She is using cold compresses on her vulva to help her sleep at night. She makes an appointment. The doctor tests for BV. The Desperate to get rid of an annoying and frustrating test comes back positive for Gardnerella and beta Strep. patient, her doctor refers her to me. The doctor treats her with vaginal clindamycin cream for a “bacterial infection”. I see these patients every day After a few more phone calls to the doctor resulting in When the patient comes into my office she lists as her “telephone treatment for self diagnoses” she returns to the chief complaint ‘chronic yeast infection’ doctor. The first thing I tell her is that in order to get to the The doctor sees nothing except atrophy that would be typical for a woman of this age, so he treats her with bo ttom o f her pro blem, we w ill fi rst h ave t o di scard vaginal estrogen cream. every diagnosis she has had in the past and that she The patient is now worse than ever. She Googles ‘yeast may not have a yeast or bacterial infection at all. infections’ and finds all sorts of books, articles and chat She asks me “if it is not a yeast infection, what else rooms full of horror stories. She goes on a restrictive diet could it be?” and begins to lose weight. She washes her vulva with antibacterial soap twice daily to keep it clean and uninfected. She begins to down acidophilus pills by the fist full. She now begins to experience a little itching and a slight cheesy That is what this lecture will be about discharge in addition to her burning (which is worse than ever). 1 Learning Objectives Vulvodynia Often a silent disease At the conclusion of this lecture the participant should be able to: 30% of women with these conditions will suffer without seeking medical care Describe the main differential diagnosis of vulvar burning irritation , rawness , stinging Many doctors are unfamiliar with other causes or pain in an older woman. vulvar itching, burning and pain so they treat Describe the main differential diagnosis of what they know vulvar itching in an older woman Typically, these women are told they have: Know the treatment of conditions that Yeast infection cause itching and burning of the vulva in Bacterial vaginosis an older woman Vaginal atrophy Before We Start, Some Before We Start, Some Foundational Principles of Candida Foundational Principles of BV in the in the Older Woman Older Woman Candida thrives in a well estrogenized,estrogenized, glycogenated BV is estrogen dependent. Postmenopausal women who vagina and absent certain risk factors, Candida is quite are not on HRT or vaginal estrogen rarely get BV unusual in women with vaginal atrophy The symptoms are a vaginal discharge with a foul or Risk factors: fishy odor . Itching and/or irritation are less common. Hormone replacement (especially vaginal estrogen) Because G. vaginalis is normally found in the vagina, a Immune suppression (steroids, immune suppressive “detected” result using a nucleic acid probes for G. medications, HIV) Vaginalis (Affirm VPIIIVPIII),), although suggestive, is not DM (especially poorly controlled DM) definitive proof of BV. ResultsResults should be interpreted in conjunction with other test results and clinical findings. In older women, Candida is often not associated with a creamy or cheesy discharge and is much more likely to Amsel’s criteria areare useful teststests to support a diagnosis of be nonnon--albicansalbicans yeast that may be resistant to BV. fluconazole. Candidiasis Differential diagnosis Differential diagnosis Trichomoniasis for symptoms for symptoms including: including: Bacterial vaginosis DISCHARGE DISCHARGE ITCHING ITCHING Atrophic vaginitis BURNING BURNING 2 Herpes Aphthosis Group A IBD - Crohns genitalis (complex) streptococcus Contact Chlamydia Gonorrhea An Approach to the Evaluation dermatitis Psoriasis Candidiasis of Vulvar Pain and Burning (and Lichen Differential diagnosis Trichomoniasis Itching) simplex chronicus for symptoms Dry skin including: Bacterial vaginosis Causes Eczema DISCHARGE Lichen ITCHING Atrophic On the skin sclerosus vaginitis BURNING Of the skin Paget’s Desquamative Inflammatory disease vaginitis Neither (diagnosis of exclusion) Vulvar intraepithelial Erosive Lichen neoplasia / Neoplasia Planus Vulvodynia Vulvodynia Abscess - Hidradenitis localized general MRSA Suppurativa On the Skin Candida Contact Dermatitis Trichomoniasis (usually burning and irritation) The unestrogenized vulva is more HSV (usually pain, burning or irritation) susceptible to irritants and allergens ?Strep vulvovaginitis? than the estrogenized vulva of Contact dermatitis (irritants or allergens) someone who is of reproductive age No matter how the patient describes her symptoms, irritative symptoms are almost always vulvar (not vaginal) and treating the vagina will not be as effective as treating the vulva directly Vulvar Eczema: Allergic Contact Dermatitis Allergic or Irritant Dermatitis Much less common than irritant contact Thickened or red excoriated skin dermatitis Skin changes may be minimal Usually very itchy When no other cause of itching can be found, assume May have previous exposure without an the cause is eczema allergic reaction Distinction between irritants May happen hours to days after the exposure and allergens is difficult and not necessary Findings in acute allergic contact dermatitis Thin skin is more easily irritated In keratinized skin (diaper rash/post menopausal Well demarcated edema, papules, vesicles skin) and crusts Irritated skin is more easily irritated In mucous membrane Less well demarcated edema and erosion 3 Approach to ‘On the Skin’ Vulvar Care Measures Vulvar Care Measures Use very mild soap for bathing the rest of the body. No Avoid contact with potential irritants soap on the vulva. Frequent baths with soaps may increase the irritation Soap Sanitary products, especially panty Adult or baby wipes liners, incontinence pads You cannot wash away your symptoms antiseptics Conditioners Colored or scented toilet Tea tree oil Vaginal odor and vulvar symptoms are rarely a hygiene pppaper Topical anesthetics (e. g. problem and will not get better by washing more or Condoms (lubricant or benzocainebenzocaine,, lidocainelidocaine,, dibucainedibucaine)) spermicide containing) Topical antibacterials (e.g. washing more vigorously. Contraceptive creams, jellies, neomycin, bacitracin,bacitracin, polymyxinpolymyxin)) Wear white 100% cotton underwear; No underwear at foams, nonoxynolnonoxynol--9,9, Topical antifungal preparations lubricants, (e.g. imidazolesimidazoles,, nystatinnystatin)) night; washed only in hypoallergenic detergent with no Dyes Topical corticosteroids fabric softeners or dryer sheets. Emollients (e.g. lanolin, jojoba Other topical medications, oil, glycerin) including trichloroaceticacid, 5-5- No pantyhose or other tight-tight-fittingfitting clothes. Laundry detergents, fabric fluorouacil, Podofilox or softeners, and dryer sheets podophyllinpodophyllin)) Put underwear through an extra plain water rinse Rubber products (including Vaginal hygiene products latex) (including perfumes and deodorants) Lichen Simplex Chronicus Of the Skin (Hyperplastic Dystrophy, Squamous Hyperplasia) Lichen simplex chronicus /squamous cell hyperplasia (end stage of vulvar eczema) End stage of the Lichen sclerosus itchitch--scratchscratch--itchitch Lichen planus cycle of vulvar Psoriasis eczema VIN Years of relentless Paget's disease chronic itching: Fissuring “nothing helps” Any acute or chronic condition that causes edema or thickening of the skin can cause fissuring Lichen Simplex Chronicus Lichen Simplex Chronicus Skin is thick (and often red) Caused by intense repetitive rubbing and scratching May exhibit erosions or fissuring 4 LSC and Treatment of LSC Squamous Eliminate irritants Cell Cancer Steroid creams (ointments if the skin is broken) Triamcinolone 0.1% BID for mild changes, fluocinonide 0.05% or clobetasol 0.05% for severe changes RhkiRecheck in one month thfi for signs of ft atrop hy, super infection or steroid rebound dermatitis Treat/suppress