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Disclosures/Conflicts of Interest Vulvar Disease Hope K. Haefner, MD and Management • Advisory Board Prestige Consumer Health Care, Inc.

Hope K. Haefner, MD Professor, Michigan Medicine Ann Arbor, MI September 28, 2019

Learning Objectives Additional Information At the conclusion of this activity, the participant should https://medicine.umich.edu/dept/obgyn/patient‐care‐ be able to: services/womens‐health‐library/center‐vulvar‐ diseases/resources‐providers 1. Identify the clinical features of various vulvovaginal conditions seen in the menopausal or search Google for population Resources for Providers University of Michigan 2. Learn tips on medical treatments for some frustrating vulvovaginal conditions 3. Become familiar with surgical procedures used for some of these vulvovaginal conditions

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Test Format Make Your Selection The image shown represents which vulvar condition?

Test Format Beef Tongue The image shown represents which vulvar condition?

A Erosive lichen planus B Paget’s disease C Eczematous dermatitis D None of the above

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Anatomy Can Be Confusing Vulvar Education

Use diagrams, pictures and handouts Look Carefully See www.issvd.org ‐ patient education

Light ‐ Extra Hands Magnification ‐Time

Vulvar Conditions in Menopausal Women Vulvar Conditions in Menopausal Women

• Genitourinary Syndrome of Menopause (GSM) • Lichen planus (atrophic vulvovaginitis) • Squamous cell • Genitourinary Syndrome of Menopause (GSM) • Lichen planus • Candidiasis in diabetics or with HRT carcinoma (atrophic vulvovaginitis) • Squamous cell • Contact dermatitis – irritant vs. allergic • Malignant melanoma • Candidiasis in diabetics or with HRT carcinoma • Intertrigo • Extramammary Paget’s • Contact dermatitis – irritant vs. allergic • Malignant melanoma • Lichen sclerosus • Intertrigo disease • Extramammary Paget’s • Lichen sclerosus disease Nyirjesy P, Leigh RD, Mathew L, Lev‐Sagie A, et al. Chronic vulvovaginitis in women older than 50 years: analysis of a prospective database. J Low Genit Tract Dis. 2012 Jan;16(1):24‐29.

Matthews N, Wong V, Brooks J, et al. Genital diseases in the mature woman. Clin Dermatol. 2018 Mar ‐ Apr;36(2):208‐221.

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Vulvar Contact Dermatitis Irritant Contact Dermatitis

Irritant Immediate

Common in menopause due to loss of barrier function Prolonged or repeated exposure to caustic or physically irritating agent - a “chemical burn” Causes: Hygiene habits – soap, wipes, pads Moisture - urine, feces, sweat Topicals – lotions, antifungals Allergic Delayed 24 to 48 hours Usually itchy From sanitary pads From “wipes” for diarrhea Allergy to perfumes, preservatives, or chemicals

Severe Contact Dermatitis Allergic Contact Dermatitis

Type IV delayed hypersensitivity reaction Witch Hazel e.g. Neomycin, fragrance, benzocaine, poison ivy

Not common in menopause

From 20% Benzocaine itch cream – “a chemical burn”

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Perianal Dermatitis Treatment Vulvar Contact Dermatitis Contact Dermatitis Constipation in older • Feces women is common Stop Contact – Find Irritants or Allergens and STOP Them • Hygiene • Educate patient Trauma • Straining Worse due to diet and - Stop scratching - Treat infection – yeast, bacteria • Cleaning inactivity, medications - Patch Test as indicated for allergic contact dermatitis • Secondary infection Control inflammation -Staph -Strep Perianal fissures - Triamcinolone 0.1% oint twice a day for 7-10 days producing and worsened If severe - Systemic corticosteroids (prednisone 40 mg po q am x 5 by constipation days, then 20 mg po q am x 10 days)

Anal / Perianal / Fecal Dermatitis Vulvar Conditions in Menopausal Women

Treatment • Genitourinary Syndrome of Menopause (GSM) • Lichen planus - Control diet, diarrhea, constipation (atrophic vulvovaginitis) • Squamous cell “wipes” use Water Wipes® only • Candidiasis in diabetics or with HRT carcinoma - No facecloths, sponges etc - use bare hands only or white flannel • Contact dermatitis – irritant vs. allergic • Malignant melanoma - Rinse with hand held shower or squirt bottle • Intertrigo - If very raw – tub or sitz bath 5-7 min AM and PM • Extramammary Paget’s • Lichen sclerosus then pat dry and coat with plain petrolatum disease -For very sticky feces or fecal soiling Use plain mineral oil on a tissue

- If irritated use 2.5% HC ointment +/- 25 mg HC suppository HS - Sundown Natural Mg- 500 to 1000 mg nightly

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Intertrigo

Intertrigo Treatment Vulvar Conditions in Menopausal Women

• Stop hot, tight clothing • Gentle cleanse (hypoallergenic unscented bar) and pat dry • Treat infection – yeast, bacteria • Genitourinary Syndrome of Menopause (GSM) • Lichen planus • Keep folds dry with a powder or a thin strip of white flannel (atrophic vulvovaginitis) • Squamous cell placed into skin fold • Candidiasis in diabetics or with HRT carcinoma • Medications • Contact dermatitis – irritant vs. allergic • Malignant melanoma • Intertrigo • 1 to 2 1/2 % hydrocortisone cream bid with an • Extramammary Paget’s • Lichen sclerosus imidazole cream bid disease or • 1% hydrocortisone /1% iodoquinol with in a cream base bid for 1-2 weeks

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Lichen Sclerosus Clinical Findings Symptoms

• Often asymptomatic • Most common symptom is pruritus – Can be severe, intolerable – Can interfere with sleep – Pruritus ani

Other Symptoms Signs

• Hypopigmentation • Burning • Ivory white papules or plaques • Soreness • Cigarette paper appearance • Dysuria • Cellophane-like sheen to surface • Dyspareunia • Hour glass-figure of eight appearance • Apareunia • Patchy or generalized • Pain with defecation – Vulva, perineum, perianal • Constipation (children) – No vaginal involvement

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Signs Cigarette Paper Appearance Secondary Changes

• Fusion of labia minora • Scratching yields open areas causing erosions • Urinary retention • Tearing

Figure of Eight – Hour Glass Office Procedures

Biopsy (4 mm)

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Histopathology Treatment of Lichen Sclerosus Thinned epidermis +/- hyperkeratosis

Band of homogenized collagen • Superpotent steroid ointment (clobetasol propionate 0.05%) – Twice daily in a thin, invisible film for 1 month then daily for two months – Maintain 3x weekly Class 1 VERSUS – Decrease to Class IV steroid

Lymphocytic infiltrate under the band

After 3 Months Intralesional Triamcinolone Class 4 Steroid Medications

Triamcinolone acetonide ointment 0.1% Sig: apply to vulva qd to bid Disp: 80 gms 40 mg max on entire vulva

Consider decreasing gradually to triamcinolone acetonide ointment 0.025% qd to bid

Mazdisnian F, Degregorio F, Mazdisnian F, Palmieri A. Intralesional injection of triamcinolone in the treatment of lichen sclerosus. J Repro Med 1999;44:332-4.

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Intramuscular Triamcinolone Surgical Treatment

• Limited role (high rate of recurrence) • Surgical division of mucosal adhesions helpful in clitoral phimosis, introital narrowing

1 mg per kg (up to 80 mg max) into gluteus muscle

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DO NOT DO THIS ON LICHEN PLANUS PATIENTS IN CLINIC!

Other Treatments for Lichen Sclerosus Other Treatments for Lichen Sclerosus

• Hydrodissection with • Use of acellular human • Hydrodissection with • Use of acellular human reverse V plasty dermal allograft reverse V plasty dermal allograft technique • Role of adipose technique • Role of adipose • Cryosurgery derived mesenchymal • Cryosurgery derived mesenchymal • Ultrasound therapy cells and platelet rich • Ultrasound therapy cells and platelet rich • Use of split thickness plasma in tissue • Use of split thickness plasma in tissue skin grafts or full regeneration skin grafts or full regeneration thickness skin grafts • Stem cell lift thickness skin grafts • Stem cell lift • Release of urethral • Release of urethral strictures (oral mucosa strictures (oral mucosa grafts) grafts)

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Question Differentiated VIN

A patient with vulvar/buttock whitening that is symmetric and has no loss of the labia minora most likely has: A. Lichen sclerosus B. Lichen planus C. Vitiligo D. Graft versus host disease

V‐to‐Y Flap V‐to‐Y Flap

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V‐to‐Y Flap V‐to‐Y Flap

Double V‐Y Flaps V‐to‐Y Flap

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Vulvar Conditions in Menopausal Women ErosiveVery Lichen Early LP Planus

• Genitourinary Syndrome of Menopause (GSM) • Lichen planus (atrophic vulvovaginitis) • Squamous cell • Candidiasis in diabetics or with HRT carcinoma • Contact dermatitis – irritant vs. allergic • Malignant melanoma • Intertrigo • Extramammary Paget’s • Lichen sclerosus disease

Signs and Symptoms of Lichen Planus Question

Signs Symptoms Erosive lichen planus can occur in the – Lacy pattern (Wickham’s striae) – Dyspareunia – Erosions – Apareunia A. Ear – Vaginal scarring (complete – Pruritus B. Esophagus closure at times) – Rawness C. Mouth – Loss of labia minora – Burning – Esophageal strictures D. All of the above

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Lichen Planus (LP) Treatments

• Topical steroid ointments/tacrolimus • Methotrexate, hydroxychloroquine, cyclosporine, cyclophosphamide, azathioprine, etanercept, mycophenolate mofetil • Surgery for lichen planus (lysis of vulvovaginal adhesions) consists of opening the vagina under anesthesia, followed by long term vaginal dilation and intravaginal steroids

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What is this? Soft Type Backer Rods

• Ideal for irregular joints, particularly where free flowing A. Pool noodle and self leveling sealants are employed B. Backer rod for building houses • Google C. Speedway Motors Racer's Crash Repair Kit

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Video Available

Fairchild PS, Haefner HK. Surgical management of vulvovaginal agglutination due to lichen planus. Am J Obstet Gynecol 2016;214;289.e1-2.

Lysis of Vulvovaginal Adhesions in Lichen Planus • Surgical lysis of adhesions – Goal • Improve urine flow, decrease risk of UTI • Allow intercourse, reduce dyspareunia – Best if disease controlled (koebnerization) – Results N=22, 11 patients who underwent surgery for vulvovaginal adhesions and 11 age matched controls • 6 months to 6 years post-lysis of adhesions • 91% satisfied with procedure • 75% of patients with decreased urinary difficulties • 55% able to have intercourse • 50% continued to fear pain – Post op dilator 48-72 hours, long term dilation and steroids

Suzuki et al. Postoperative Sexual Concerns and Functioning in Patients Who Underwent Lysis of Vulvovaginal Adhesions. J Low Genit Tract Dis. 2013 Nov;17(1):33-37

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Lubricants Use Water Based Lubricants in Shower Water Based Silicone based Hypoallergenic • Astroglide • Astroglide X • Good Clean Love • Astroglide Gel Just Like Me • Gun Oil • Just like Me • Astroglide Silken Secret • ID Millennium • K‐Y Liquid Personal • Jo Premium • K‐Y SILK‐E • K‐Y Intrigue • K‐Y Ultra Gel • Lubrin (Suppository) • Liquid Silk • Pink Silicone • Me Again • Pjur Silicone • Pink Water • Sliquid Silver • Pjur Water Based • Wet Platinum Premium Lubricant • Pre‐Seed • Probe • Slippery Stuff Gel • Sliquid H20 • Sweet Seduction • System Jo H20

Vaginal Moisturizers Vulvar Conditions in Menopausal Women

• Emerita Personal • Luvena • Genitourinary Syndrome of Menopause (GSM) • Lichen planus Moisturizer • Me Again (atrophic vulvovaginitis) • Squamous cell • Feminease • Moist Again • Candidiasis in diabetics or with HRT carcinoma • Contact dermatitis – irritant vs. allergic • Malignant melanoma • Hyalo Gyn • Replens • Intertrigo • Extramammary Paget’s • Lichen sclerosus • Juvagyn • Silken Secret disease • K‐Y Liquibeads • Vitamin E capsules, oil, • K‐Y Silk‐E and suppositories • Luvena • Coconut oil

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86 year old woman complains of vulvar soreness and itching that has recurred in the last year. CHF, recent stroke, DVT

She thinks she had a problem like this 10 years ago but has no records. Topical steroids had made no difference.

A biopsy is performed.

In this patient, is this a preinvasive or an invasive condition?

A. Preinvasive B. Invasive

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Recurrent Paget’s Disease

Which treatment do you not recommend for her recurrent Paget’s?

A. Triamcinolone ointment B. Laser therapy C. 5% imiquimod cream D. Wide local excision

5% imiquimod cream 9 months

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What is the rate of primary Paget’s Surgery for Primary Paget’s Disease disease of the vulva being associated with an underlying adenocarcinoma?

A. 1% to 25% B. 26% to 50% C. 51% to 75% D. 76% to 100%

Take Home Messages

• Don’t forget to listen to your patients • Touch the skin • Do not hesitate to re-biopsy if the results are not consistent with the whole picture • You are vital for vulvovaginal care • Thousands of women will thank you

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