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Vulvovaginal Disorders: 4 Challenging Conditions How to Identify and Treat Candidiasis, Contact Dermatitis, Lichen Sclerosus, and Vestibulodynia

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Vulvovaginal Disorders: 4 Challenging Conditions How to Identify and Treat Candidiasis, Contact Dermatitis, Lichen Sclerosus, and Vestibulodynia OBGM_0306_Stewart.Final 2/17/06 9:17 AM Page 35 Dr. Stewart is the author (with Paula Spencer) of the bestselling book, The V Book: A Doctor’s Guide to Complete Vulvovaginal Health, OBGMANAGEMENT New York: Bantam Books; 2002 Vulvovaginal disorders: 4 challenging conditions How to identify and treat candidiasis, contact dermatitis, lichen sclerosus, and vestibulodynia he symptoms are recited every day in mislead the clinician into thinking appropri- gynecologists’ offices around the ate therapy “doesn’t work.” And it is impor- world: itching, irritation, burning, tant to remember that any genital complaint Elizabeth G. Stewart, MD T Director, Vulvovaginal Service, rawness, pain, dyspareunia. The challenge has the potential to dampen a woman’s self- Harvard Vanguard Medical is tracing these general symptoms to a spe- esteem and hamper sexual function. Associates, and Assistant Professor cific pathology, a task harder than one This article covers the fine points of of Obstetrics and Gynecology, ® Dowden Health Media Harvard Medical School, Boston might expect, because vulvovaginal condi- diagnosis and treatment of 4 common vul- tions often represent a complex mix of sev- vovaginal problems: eral problems. Candida andCopyright bacterial inva-For personal1. Candidiasis use only sion frequently complicate genital 2. Contact dermatitis dermatologic conditions. Atrophy and loss 3. Lichen sclerosus of the epithelial barrier worsen the problem. 4. Vestibulodynia Over-the-counter (OTC) and prescription Could all 4 problems coexist in 1 IN THIS ARTICLE remedies can lead to contact dermatitis. patient? They frequently do. As always, a Vulvodynia may be the ultimate outcome, careful history and physical examination ❙ 9 essential steps possibly from central sensitization after with appropriate use of yeast cultures make for treatment chronic inflammation, which in turn can it possible to manage the complexity. of contact dermatitis Page 37 1. CANDIDIASIS ❙ Telephone and self-diagnosis are a waste of time Lichen sclerosus: Why lifelong follow-up n vulvovaginal candidiasis (VVC), parapsilosis, krusei, lusitaniae, and tropi- is a must Isymptoms can range from none to calis are more difficult to treat. Page 38 recurrent. VVC can complicate genital dermatologic conditions and interfere Not all episodes are the same ❙ Tricyclic with the treatment of illnesses that call VVC is uncomplicated when it occurs spo- antidepressants for steroids or antibiotics. Because the radically or infrequently in a woman in good symptoms of VVC are nonspecific, diag- overall health and involves mild to moderate for persistent pain nosis necessitates consideration of a long symptoms; albicans species are likely. VVC Page 46 list of other potential causes, both infec- is complicated when it is severe or recurrent tious and noninfectious. or occurs in a debilitated, unhealthy, or preg- Candida albicans predominates in 85% to nant woman; non-albicans species often are 90% of positive vaginal yeast cultures. involved. Proper classification is essential to Non-albicans species such as C glabrata, successful treatment.1 CONTINUED www.obgmanagement.com March 2006 • OBG MANAGEMENT 35 For mass reproduction, content licensing and permissions contact Dowden Health Media. OBGM_0306_Stewart.Final 2/17/06 9:17 AM Page 36 ▲ Vulvovaginal disorders: 4 challenging conditions Phone diagnosis TABLE 1 is usually inaccurate CDC guidelines Although phone diagnosis for treatment of candidiasis is unreliable,2 it is still fair- Any of these intravaginal or oral ly common, and fewer regimens may be used offices use microscopy and DOSE vaginal pH to diagnose (NUMBER OF DAYS) vaginal infections because INTRAVAGINAL AGENTS of the tightened (though still Butoconazole simple) requirements of the 2% cream* 5 g (3) Clinical Laboratory Improve- Butoconazole-1 ment Amendment. (Clinicians sustained-release cream 5 g (1) who do wet mounts and KOH are Clotrimazole required to pass a simple test each year 1% cream* 5 g (7–14) to continue the practice.) 100 mg 1 tablet (7) Women are poor self-diagnosticians when it comes to Candida infection; only one third 2 tablets (3) of a group purchasing OTC antifungals 500 mg 1 tablet (1) had accurately identified their condition.3 Miconazole Clinicians are not exempt from error, either. 2% cream* 5 g (7) About 50% of the time, Candida is mis- 100 mg* 1 suppository (7) 4 diagnosed, largely because of the 200 mg* 1 suppository (3) assumption that the wet mount is more Nystatin specific than it actually is (it is only 40% 100,000 U 1 tablet (14) specific for Candida). Tioconazole Ask about sex habits, douching, 6.5% ointment* 5 g (1) drugs, and diseases Terconazole FAST TRACK Accurate diagnosis requires a careful his- 0.4% cream 5 g (7) The wet mount tory, focusing on risk factors for 0.8% cream 5 g (3) Candida: a new sexual partner; oral sex; 80 mg 1 suppository (3) is only 40% douching; use of antibiotics, steroids, or ORAL AGENT specific for Candida exogenous estrogen; and uncontrolled Fluconazole diabetes. Look for signs of vulvar and vaginal 150 mg 1 tablet (1) erythema, edema, and excoriation. * Over-the-counter Classic “cottage cheese” discharge may not be present, and the amount has no cor- Azole antifungals are usual treatment relation with symptom severity. For uncomplicated VVC, azole antifungals Vaginal pH of less than 4.5 excludes bacter- are best (TABLE 1). For complicated VVC, ial vaginosis, trichomoniasis, atrophic follow this therapy with maintenance flu- vaginitis, desquamative inflammatory conazole (150 mg weekly for 6 months), vaginitis, and vaginal lichen planus. which clears Candida in 90.8% of cases.5 Blastospores or pseudohyphae are diagnostic Non-albicans infection can be treated with (on 10% KOH microscopy). If they are boric acid capsules (inserted vaginally at IMAGE: absent, a yeast culture is essential and will bedtime for 14 days) or terconazole cream (7 allow speciation. A vaginal culture is espe- days) or suppositories (3 days). A culture to KIMBERLY cially important in women with recurrent or confirm cure is essential, since non-albicans refractory symptoms. infection can be difficult to eradicate. MARTENS Always consider testing for sexually trans- Note that boric acid is not approved for mitted diseases. pregnancy. 36 OBG MANAGEMENT • March 2006 OBGM_0306_Stewart.Final 2/17/06 9:17 AM Page 37 Vulvovaginal disorders: 4 challenging conditions ▲ 2. CONTACT DERMATITIS Nine essentials of treatment ontact dermatitis, the most common and edema; scaling is possible. Severe Cform of vulvar dermatitis, is inflam- cases manifest as erosion, ulceration, or mation of the skin caused by an external pigment changes. Secondary infection, if agent that acts as an irritant or allergen. any, may involve pustules, crusting, and The skin reaction may escape notice fissuring. The dermatitis may be local- because changes ranging from minor to ized, but often extends over the area of extreme are often superimposed on com- product spread to the mons, labiocrural plex preexisting conditions such as lichen folds, and anus. C albicans often compli- simplex chronicus, lichen planus, and cates genital dermatologic conditions. lichen sclerosus.6 Contact dermatitis occurs readily in 9-step treatment the vulvar area because the skin of the 1. Stop the offending product and/or vulva reacts more intensely to irritants practices. than other skin, and its barrier function 2. Restore the skin barrier with sitz baths COMMON VULVAR is easily weakened by moisture, friction, in plain lukewarm water for 5 to 10 IRRITANTS urine, and vaginal discharge. The 3 main minutes twice daily. Compresses or a CAUSTIC AGENTS types of irritant dermatitis are7: handheld shower are alternatives. Bichloracetic acid • A potent irritant, which may produce 3. Provide moisture. After hydration, Trichloroacetic acid the equivalent of a chemical burn. have the patient pat dry and apply a 5-Fluorouracil • A weaker irritant, which may be thin film of plain petrolatum. Lye (in soap) applied repeatedly before inflamma- 4. Replace local estrogen if necessary. Phenol Podophyllin tion manifests. 5. Control any concomitant Candida Sodium hypochlorite • Stinging and burning, which can occur with oral fluconazole 150 mg weekly, Solvents without detectable skin change, avoiding the potential irritation caused WEAK CUMULATIVE due to chemical exposure. by topical antifungals. IRRITANTS Many products can cause dermatitis. 6. Treat itching and scratching with Alcohol Even typically harmless products can cause cool gel packs from the refrigerator, Deodorants Diapers dermatitis if combined with lack of estro- not the freezer (frozen packs can Feces gen or use of pads, panty hose, or girdles. burn). Stop involuntary nighttime Feminine spray scratching with sedation: doxepin or Pads Perfume No typical pattern hydroxyzine (10–75 mg at 6 PM). Povidone iodine Patients complain of varying degrees of itch- 7. Use topical steroids for dermatitis: Powders ing, burning, and irritation. Depending on • Moderate: Triamcinolone, 0.1% Propylene glycol the agent involved, onset may be sudden or ointment twice daily. Semen gradual, and the woman may be aware or • Severe: A super-potent steroid such Soap Sweat oblivious of the cause. New reactions to as clobetasol, 0.05% ointment, Urine “old” practices or products are also possible. twice daily for 1 to 3 weeks. Vaginal secretions Ask about personal hygiene, care during • Extreme: Burst and taper pred- Water menses and after intercourse, and about nisone (0.5–1 mg/kg/day decreased Wipes soap, cleansers, and any product applied to over 14–21 days) or a single dose of PHYSICALLY ABRASIVE the genital skin, as well as clothing types intramuscular triamcinolone CONTACTANTS Face cloths and exercise habits. Review prescription (1 mg/kg). Sponges and OTC products, including topicals, and 8. Order patch testing to rule out or THERMAL IRRITANTS note which products or actions improve or define allergens. Hot water bottles aggravate symptoms. A history of allergy 9. Educate the patient about the many Hair dryers and atopy should heighten suspicion. potential causes of dermatitis, to pre- Source: Lynette Margesson, MD26 The physical exam may reveal erythema vent recurrence.
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