52 Women’s Health FAMILY P RACTICE N EWS • September 1, 2005 Desquamative Vaginitis: Not an Infectious Entity

Condition may be a range of blistering disorders; as pus erythematosus, cicatricial pem- and focal or diffuse. Also consider whether phigoid, Stevens-Johnson syndrome, graft- it involves the vestibule and/or the vagina such, no one treatment is always appropriate. versus-host disease, pemphigus of the and whether the patient has a local estra- mouth and skin, and a local drug reaction diol deficiency, oral mucosal or ocular dis- BY ELIZABETH MECHCATIE Dr. Haefner said, noting that in studies de- such as contact dermatitis. ease, or any iatrogenic topical etiology. Senior Writer scribing DIV in the 1950s and 1960s infec- Like other experts in this area, Dr. As for the use of dilators, Dr. Haefner tious organisms were detected in associa- Haefner believes that DIV can be an ex- said that for patients with chronic lichen B ETHESDA, MD. — Most experts now tion with DIV but have since been ruled pression of erosive lichen planus, which planus, prophylactic dilation is important, believe that desquamative inflammatory out as a cause. can have the same wet smear, pH, cytol- because those patients often present with vaginitis is not a diagnosis of one condi- Other forms of vulvovaginitis caused by ogy, and biopsy results. However, not all “shut” vaginas. However, prophylactic di- tion, but may represent a range of blis- trichomonas and other infections can be DIV is lichen planus, she pointed out. lation is not necessary and would be con- tering disorders, such as lichen planus, confused with DIV, as can noninfectious Vulvovaginal symptoms of erosive sidered overtreatment if used for all pa- mucous membrane pemphigoid, and causes of erosive vulvovaginitis, such as lichen planus include burning; pruritus; tients with DIV. pemphigus vulgaris, Hope K. Haefner, lichen planus and graft-versus-host dis- dyspareunia that can be mild to severe, To distinguish whether a patient has M.D., said at a conference on vulvovagi- ease, she said. Other noninfectious causes preventing coitus at times; bleeding spon- DIV or lichen planus, consider performing nal diseases. of erosive vulvovaginitis include collagen taneously after coitus; and vaginal dis- a biopsy and immunofluorescent studies With descriptions in the medical litera- vascular diseases and a local toxic effect of charge, she said, noting that erosions are to rule in or out some of the conditions ture dating to the 1950s, the signs and a drug. The cause also may be idiopathic. very painful. The difference with lichen in the differential diagnosis. symptoms of desquamative inflammatory Distinguishing DIV from atrophy can be planus is that it often is associated with Because DIV is not a single disease, no vaginitis (DIV) include dyspareunia and difficult, since lab findings are similar to erosive changes in the mouth, with a white one treatment will be effective in all cas- exudative, chronic vaginitis, with yellow- those found with atrophic vaginitis, with a reticulated border, adhesions, and atrophy, es. Treatment with 2% clindamycin cream watery, purulent discharge that is occa- nonspecific histology and parabasal cells probably related to T-cell autoimmunity. for 2 weeks is a first-line therapy for most sionally blood-tinged, said Dr. Haefner, di- and many polymorphonuclear leukocytes “When you see patients with DIV, think patients. Although DIV is not considered rector of the University of Michigan (PMNs) on cytology. Atrophic vaginitis has about looking in the mouth,” she advised. an infection, clindamycin is still useful be- Center for Vulvar Diseases, Ann Arbor. serosanguineous or watery discharge simi- In lichen planus, erosions may be found cause it has an anti-inflammatory effect. Patients with DIV also may have a spot- lar to that seen with DIV, as well as an ele- in the conjunctivae, external ear canal, Those who need a second course of ted rash on the vagina and cervix, massive vated vaginal pH, with a thin vagina and red esophagus, and anus. treatment may respond to treatment with vaginal cell exfoliation, and an increased petechiae, Dr. Haefner said at the confer- In some cases, histology can help in di- hydrocortisone at a dose of 100 mg/g in vaginal pH, she said. ence, sponsored by the American Society agnosing lichen planus, but in Dr. Haef- a clindamycin 2% emollient cream base. A Previous terms used to describe this for Colposcopy and Cervical Pathology. ner’s experience, this has not been very 5-g applicator should be inserted every condition include exudative or membra- Atrophic vaginitis and erosive lichen helpful because lab and cytologic changes other day for a total of 14 doses. This treat- nous vaginitis, and hydrorrhea vaginalis. planus are among the noninfectious con- are nonspecific and may be similar to ment regimen is expensive, however, and DIV can occur at any age, and although ditions that are high on Dr. Haefner’s list those found with atrophic vaginitis. is not recommended for a first episode, it has been considered rare, it is being seen of differential diagnoses in a patient she In diagnosing patients with DIV, she said Dr. Haefner, who stated that she has more frequently than in the past. suspects may have DIV. Lower on the list recommended considering what is hap- no relevant financial relationships with “Although we don’t know what it is ... are other noninfectious causes of these pening with the whole patient, and any commercial interest relative to the we don’t think it is an infectious process,” symptoms, including lichen sclerosus, lu- whether the condition is acute or chronic subject of this presentation. ■ Consider Patient Age, Lesion Location When Diagnosing VAIN

BY ELIZABETH MECHCATIE Some of these risk factors were associ- same,” he added. And on histopathology, va needs to be examined, he said, adding Senior Writer ated with VAIN in a 2001 study of 121 VAIN looks “exactly the same” as CIN, that “a fair number of patients” will have women with biopsy-confirmed VAIN, VIN, or anal intraepithelial neoplasia. VIN, CIN, and VAIN at the same time. B ETHESDA, MD. — An older age, a which found that 41% smoked, 39% had a He advised caution about the diagnosis On colposcopy, VAIN “frequently appears history of cervical intraepithelial neoplasia, history of human papilloma virus (HPV), of VAIN-1. “A lot of us are trying not to as slightly raised, acetowhite lesions,” which and the presence of multifocal lesions in the 22% had undergone surgery for CIN, and make low-grade diagnoses of VIN or can be subtle, especially in postmenopausal upper third of the vagina are among the 23% had undergone a total abdominal hys- VAIN,” and instead, “classify the majority patients with low estrogen levels, he said. features associated with vaginal intraep- terectomy. The mean age of the patients of these lesions as flat condylomas, because In the vagina, with high-grade lesions, ithelial neoplasia, Thomas C. Wright Jr. said was 35 years, and the majority had VAIN- the natural history of these low-grade le- vascular patterns such as mosaicism in the at a conference on vulvovaginal diseases. 1, a diagnosis Dr. Wright said he is “very sions is not really well characterized.” vagina usually are not present as they are Vaginal intraepithelial neoplasia (VAIN) leery” about classi- It is unclear with cervical lesions. These lesions usually is not common, accounting for only 0.4% fying “as true VAIN VAIN is not whether a flat, low- are not acetowhite and are identified only of intraepithelial lesions of the lower gen- lesions.” common, grade–appearing le- after the application of Lugol’s solution. ital tract, according to Dr. Wright, director Most of the pa- accounting for sion in a 60-year-old On colposcopy, conditions that can of obstetrics, gynecology, and pathology tients he sees with only 0.4% of has any premalig- mimic VAIN are congenital transforma- at Columbia University College of Physi- VAIN are in their intraepithelial nant potential, he tion zones that extend into the vagina and cians and Surgeons, New York. 40s to late 60s. lesions of the added. Low-grade leukoplakia, which can appear on the vagi- Women at higher risk include those VAIN is rare among lower genital tract. VAIN has many fea- na, not just the cervix, he said. with vulvar intraepithelial neoplasia women in their 20s tures of a flat Vaginal ulcers or trauma and granula- (VIN), cigarette smokers, and those who and 30s, but when it DR. WRIGHT condyloma, com- tion tissue also can look like VAIN lesions have had radiation therapy. A woman who does occur among pared with VAIN-3, on colposcopy. Inflammation caused by tri- has had radiation therapy for endometri- younger women, there usually is a history which is more clearly a high-grade lesion. chomonas, candida, atrophic vaginitis, or al cancer and presents with an abnormal of immunosuppression or CIN, Dr. Wright As for the location of VAIN lesions, most radiation atrophy can obscure VAIN le- Pap smear exemplifies one clinical sce- said. are found in the upper third of the vagina, sions, he added. nario in which the index of suspicion for The sensitivity of cytology in diagnos- usually contiguous with CIN, if a cervix is Treatments for VAIN include excisional VAIN should be high, he noted. ing VAIN remains uncertain. Most VAIN present. Most cases are multifocal, often biopsy in the office, intravaginal 5-fluo- Another typical VAIN case is a post- patients are postmenopausal, raising the with lesions found in the “dog-ears of the rouracil, laser ablation or electrofulguration, menopausal patient who has been treated question of whether a patient has high- vault after hysterectomy,” which makes and partial vaginectomy. Cryosurgery is for cervical intraepithelial neoplasia (CIN), grade VAIN or “severe atrophy, which is colposcopy very difficult. Colposcopy is not used very much now, he added. VAIN- even 10 years earlier, often with a hys- causing the cytology to mimic high-grade required to diagnose VAIN, but is difficult, 1 usually is not treated aggressively, but fol- terectomy, and has been considered cured. VAIN,” he said at the conference, spon- especially in postmenopausal women who lowed, except in women suspected of hav- She then unexpectedly has a high-grade sored by the American Society for Col- have had a hysterectomy, because it is nec- ing a higher-grade lesion, such as those squamous lesion on cytology, with no le- poscopy and Cervical Pathology. essary to look inside the folds and “dog- who have had a hysterectomy for CIN 2 or sion on the vagina that is visible to the On cytology, squamous intraepithelial ears,” he said. 3 or cancer, or a conization for CIN 2 naked eye. neoplasia and VAIN “look exactly the VIN may be present as well, so the vul- or 3, Dr. Wright said. ■