8/3/2014
Wendy Grube, PhD, CRNP University of Pennsylvania School of Nursing
Disclosure Comparative Anatomy
No conflicts of interest
Objectives Variants of Normal Identify common genital dermatological conditions. List appropriate diagnostic approaches to common genital dermatological conditions. Describe appropriate management of common genital dermatologic disorders. Demonstrate good local anesthetic perfusion technique. Perform a skin biopsy with skill and precision. Perform basic interrupted suture insertion.
Vulva Shaft of Penis Fordyce spots
1 8/3/2014
Variants of Normal Pruritus Idiopathic Atopic dermatitis Tissue appears normal Allergic IgE reaction Characterized by to common scratching or rubbing environmental Itch-scratch cycle allergens (eczema) Probably a subclinical History of allergies or variant of atopic asthma dermatitis Localized form: Lichen Simplex Chronicus
Benign papillae
Variants of Normal Red Plaques and Patches Atopic dermatitis Psoriasis Contact dermatitis Tinea cruris Irritant Contact Erythrasma dermatitis Candidiasis Allergic contact Lichen planus dermatitis Extramammary Paget Seborrheic dermatitis disease Intraepithelial neoplasia Physiologic hyperpigmentation
Algorithm for Diagnosis of Lichen Simplex Chronicus Genital Disorders Are there visible changes? No , only symptoms Pruritus Pain Yes Lifted/removed epithelium Pustules Blisters Ulcers Lesions are red, but epithelium is intact Patches and plaques Papules and nodules Lesions, but other than red Skin colored White Brown/black/blue
Edwards & Lynch (2011) Genital Dermatology Atlas, LWW
2 8/3/2014
Lichen Simplex Chronicus Allergic Contact Dermatitis Cause: not known, Consider: Immunological probably genetic Wet mounts : rule out response predisposition candidiasis Cell-mediated delayed Heat, sweat triggers KOH : for dermatophyte hypersensitivity fungi (tineas) reaction Diagnosis : Based on Biopsy helpful if there OTC preparations: clinical findings benzocaine, bacitracin, is loss of architectural Biopsy not very helpful landmarks (labia spermicides, parabens, in finding underlying fragrances minora) in women to problem rule out lichen sclerosis Latex: IgE response, immediate reaction
Seborrheic Lichen Simplex Chronicus Dermatitis/Intertrigo Management Goals: Breathable fabrics Located where Diagnosis: Clinical Reduce triggers in local Weight loss moisture is retained Can have superimposed (sweat, urine) candida environment Manage fecal, urinary, vaginal secretions Maceration Management Restore normal barrier Stop excessive bathing Skin folds Reduce heat and layer function Lubricant/barrier moisture Crural folds Topical corticosteroids Reduce inflammation Topical steroids Axillae (ointment, high potency) Hydrocortisone 1-2.5% Stop itch-scratch cycle Umbilicus for a month or until Triamcinolone 0.1% clinical improvement Indistinct margins Topical ketoconazole cream BID Antihistamines Red patches and scale
Seborrheic Irritant Contact Dermatitis Dermatitis/Intertrigo Eczematous reaction to a Identify and eliminate substance on the skin irritants Most data on women Mid-potency topical Irritation, soreness, steroid rawness Barriers: zinc oxide, Urine, feces, soap, lubricants antifungal creams, panty liners, spermicides Tepid soaks TCA, imiquimod, podophyllin products
3 8/3/2014
Candidiasis Tinea Cruris Diagnose: Management: KOH prep from skin Topical azoles 1-2x scraping day until clear Hair follicle involvement: oral therapy (i.e. fluconazole 100- 200mg/day for 1-2 weeks) Topical triamcinolone 0.1% first few days
Candidiasis Erythrasma Diagnose with KOH Management: Mimics tinea cruris Diagnosis: prep Eliminate heat, Found mostly in men Clinical exam moisture Proximal, medial thigh Wood’s light Topical azoles BID and crural crease fluorescence (coral- until clear Scrotum, penis, vulva pink) Attention to DM, usually not affected Negative KOH prep obesity, Corynebacterium immunocompromised minutissimum, bacteria Treat with Erythromycin patients prevalent in warm 500 mg BID for 1-2 weeks environments
Tinea Cruris Erythrasma
4 8/3/2014
Psoriasis Psoriasis Affects 2-3% of people Plaques and silvery scales Diagnosis: Management: Onset: young adults on scalp, elbows, knees, gluteal cleft, genitals Other psoriatic Potent topical Etiology: genetic, autoimmune, 20% with Koebner’s lesions? corticosteroids with environmental phenomenon Biopsy helpful, but tapering doses Contributing factors: Inverse psoriasis: skin can be nonspecific in Triamcinolone 0.1% alcohol, smoking, obesity, folds older lesions Ultraviolet light of medications (NSAIDs and Genitals lithium) Women: affects hair- Negative fungal little use to genitalia Rapid proliferation of bearing areas (vulva) scrapings/cultures Oral methotrexate epidermis Men: glans, shaft, No response to scrotum, groin Immunosuppressant Associated arthritis antifungal medication agents
Psoriasis Lichen Planus Different clinical presentations Autoimmune disorder, cell-mediated Usually self-limiting Resolves in few years
Psoriasis Lichen Planus
5 8/3/2014
Extramammary Paget’s Lichen Planus Disease Primary or secondary forms Diagnosis: Management: Onset: usually >50 Clinical findings Topical corticosteroids More common in women Biopsy (clobetasol 0.05% and 10-20% with underlying taper down) GU/GI malignancy Differential: Bowen Short burst of oral Initial symptom: pruritus disease, candidiasis, Presentation: prednisone if needed psoriasis, herpes Well demarcated red plaque Rough, scaling or moist surface White thickened islands Erosions
Extramammary Paget’s Plasma Cell Mucositis Disease Poorly understood Diagnosis by biopsy Diagnosis Management: excision Onset after puberty Management: Clinical suspicion <1 mm invasion: good Resembles benign prognosis Deep red solitary No good therapy skin disorders and Laser, radiation, plaque Circumcision Bowen’s disease imiquimod May erode, bleed Potent topical Biopsy >1mm invasion: node evaluation Related to lichen steroids? Determine primary or planus? Imiquimod? secondary CO2 or YAG laser? Evaluate for GU/GI malignancy
Plasma Cell Mucositis Intraepithelial Neoplasia Non-invasive but full thickness dysplasia Many types HPV-related Bowen’s disease: older Presentation Well-demarcated plaques, scaling, hyperkeratosis
6 8/3/2014
Intraepithelial Neoplasia Bites & Infestations Bowen Disease/VIN/PIN Lesions may be Insect bites on genitals are accentuated with 5% rare Undifferentiated: acetic acid Nodular scabies HPV 16, 18, 31, 33 Almost exclusively in 2/3 – full thickness White, red, skin colored males Differentiated: plaques Presentation Red-brown dome- Lower 1/3 of Diagnosis: biopsy shaped papules epithelium Management: surgical, Glans, shaft, scrotum No HPV link imiquimod, laser Diagnosis: biopsy Management: scabicide
Cherry Angiomas & Red Papules and Nodules Angiokeratomas Folliculitis Pyogenic granuloma Keratosis pilaris Urethral caruncle Bites & infestations Vulvar endometriosis Angiomas, Hematoma angiokeratomas Kaposi Sarcoma Prurigo nodularis
Prurigo Nodularis Keratosis Pilaris (Picker’s Nodules) Increased keratin Common in children, th Results from chronic disappears in 4 decade scratching, picking Clusters of papules May have underlying folliculitis Excess keratinization of Diagnosis: Biopsy outer hair follicles Differential: Scabies Noninfectious Treat: Intralesional Management triamcinolone Liquid nitrogen Bath soaks/loofah Nighttime sedation Moisturizer SSRIs
7 8/3/2014
Pyogenic Granuloma Hematoma Benign neoplasm Cause unknown, may be second to trauma Pregnancy Management: shaved excision
Urethral Caruncle & Prolapse Kaposi Sarcoma
Vulvar Endometriosis Crohn’s Disease Cyclic enlargement and Asymmetrical edema pain with menses Linear ulcers Implantation may occur Fistulae during parturition Diagnosis: presumptive, Also: skin tags, by clinical presentation papules, nodules Management: refer for surgical excision May require hormonal suppression
8 8/3/2014
Pustular Lesions Folliculitis Folliculitis Solid lesions that appear Irritant: shaving Diagnosis Furuncles pustular: Fungal: middle aged Clinical presentation Culture Epidermal cysts and older men (tinea) Carbuncles Management Hidradenitis Molluscum Bacterial: Bacterial: oral, topical suppurativa contagiosum Staphylococcus antibiotics No known risk factor Fungal: oral antifungal Irritant: avoid shaving Pseudomonas Loose, cool clothing Bathing suits Oral anti- Hot tubs inflammatory antibiotics
Folliculitis Furuncles Etiology: bacterial, fungal, or irritant inflammation of Involves deeper follicle follicle Red, painful nodules Superficial Rupture and drain More common in immunosuppression, diabetes Usually S. aureas
Folliculitis Furuncles Diagnosis: Management Clinical presentation Oral antibiotics Culture: S. aureus Clindamycin Clinical confusion: Warm soaks Hidradenitis Incision and draining Limited to genital and axillary areas Has comedones and scarring Cultures: normal skin flora
9 8/3/2014
Carbuncles Hidradenitis Supperativa Presentation Management Fluctuant, draining I&D of fluctuant lesions nodules Oral antibiotics Location Surgical excision of Sinus tracts and scars affected areas Comedones Hormonal: high estrogen Wide range of severity contraceptives Diagnosis (0.035mg), spironalactone Clinical presentation Oral retinoids Chronicity Isotretinoin
Hidradenitis Supperativa Epidermal Cysts Cystic acne of skin Obstructed hair follicles folds that are distended with Affects groin, axillae, keratin inner thighs, vulva, White, skin colored, or scrotum yellow Occurs after puberty Occasional Strong association with inflammatory response smoking from keratin No treatment necessary
Hidradenitis Supperativa Molluscum Contagiosum May be transmitted sexually Genitals, thighs Domed papules, may be umbilicated May be inflamed, pruritic Poxvirus Resolve spontaneously May use topical destruction, imiquimod
10 8/3/2014
CDC Guidelines on HSV 2 Erosive and Vesicular Lesions Serology Herpes Simplex Appropriate for: Consider in: Impetigo Recurrent/atypical STD visit, person with Pemphigus symptoms and negative multiple partners Hailey-Hailey disease cultures Person with HIV Bullous erythema Clinical fit, no lab MSM with risk for HIV multiforme confirmation Inappropriate for: Fixed drug eruptions Partner with genital General screening Trauma/artifact herpes Malignancies
CDC. STD Treatment Guidelines, 2010 (Dec.17, 2010) MMWR, vol.59, No. RR-12.
Herpes Simplex Herpes Simplex
Herpes Simplex Impetigo Clinical appearance can Serology: S. aureas be confusing Consult CDC Fragile blisters Vesicular and erosive guidelines: Type 2 Round lesions with collarettes presentations Conversion at 6 weeks Streptococcus spp. Erosion and crusting Differentiate from Up to 80% of other ulcerative population with Diagnosis disorders, folliculitis positive IgG for HSV Clinical suspicion Culture Culture: false negatives Management PCR: test of choice Antibiotic therapy (clindamycin)
11 8/3/2014
Pemphigus Hailey-Hailey Disease Pemphigus vulgaris Familial pemphigus Autoimmune intraepidermal Recurrent small blisters disorder and crusted erosions Mucosal flaccid blisters and Sites: intertriginous superficial erosions zones, perianal area Later stage: hyperkeratotic skin Includes genitals & rectum Evolve into thickened Cervix: Pap may show LGSIL macerated plaques Penis: on glans, corona, distal Diagnosis: Shape, FHx, Bx shaft Management: supportive Diagnosis: biopsy Topical/oral antibiotics Management: systemic High-potency topical steroids steroids
Pemphigus Vulgaris & Vegetans Hailey-Hailey Disease
Large erosions heal without scarring Superficial crusting plaques of vegetans
Bullous Pemphigoid Bullous Erythema Multiforme Common autoimmune Stevens-Johnson Syndrome blistering disease Hypersensitivity reaction Intense pruritus precedes Self-limiting blisters Blistering forms may affect Rare genital involvement mucosal surfaces On keratinized skin Rupture quickly leaving Onset: elderly erosions Diagnosis: Heal quickly after inciting Biopsy agent is removed Scarring can be severe Management: Topical or systemic Vaginal synechiae steroids Penile phimosis (uncircumcised)
12 8/3/2014
Fixed Drug Eruptions Traumatic Lesions On keratinized skin: Diagnosis: Well-demarcated History of recent drug Edematous, erythematous, ingestion round Biopsy On mucosal areas: Management: Blister and erode quickly Identification and Shape irregular elimination of offending Burning medication Supportive therapy
Fixed Drug Eruptions Erosive Malignant Lesions
Basal Cell Carcinoma Squamous Cell Carcinoma 5% of genital cancers 90% of genital cancers Increased incidence in fair- Sites of chronic skinned, older inflammation or HPV Itching Ages >65 more common Rolled edges, telangiectasias Red or skin colored plaques Local invasion and necrosis that erode Rare metastases May be lymphadenopathy Diagnosis: biopsy Diagnosis: biopsy Treat: local excision Management: surgical
Traumatic Lesions Erosive Malignant Lesions Diagnosis: History: event is Basal Cell Carcinoma Squamous Cell Carcinoma immediately painful Typical insults: Chemical burn Chemicals in creams Thermal Surgery Zippers Bites Management: soaks, infection Miscellaneous control, pain treatment
13 8/3/2014
Other Ulcerative Lesions Non-Red Lesions White lesions Skin-colored lesions Syphilis Chancroid Vitiligo Genital warts Post-inflammatory hypopigmentation Condyloma latum Lichen sclerosis Molluscum Lichen planus Skin tag (acrochordon) Lichen simplex chronicus Intradermal nevi White sponge nevus Lipomas Intraepithelial neoplasia Epidermal cysts Basal and squamous Molluscum contagiosum cell carcinomas
Other Ulcerative Lesions White Lesions Post-inflammatory Granuloma Inguinale Lymphogranuloma Venereum Vitiligo Hypopigmentation
Other Ulcerative Lesions Lichen Sclerosis Females Males Aphthous Ulcers Behçet Disease Childhood and post- Childhood and later life menopausal White papules and Labia minora, clitoris, plaques on glans, labial sulci (hourglass) prepuce, shaft
14 8/3/2014
Lichen Sclerosis White Sponge Nevus Epidermal atrophy 4% chance of squamous Uncommon autosomal Crinkled appearance dominant condition cell cancer in long Ecchymosis from easily Affects mucosal damages vessels standing untreated LS surfaces (oral, Scarring of clitoral hood and uncircumcised male esophageal, genital) prepuce White, keratotic Shrinkage/loss of labia epithelium minora Diagnosis: biopsy Mucosa not affected Extragenital sites: back, Treatment: none for Oral lesion wrists, shoulders genital lesions
Lichen Sclerosis Skin-Colored Lesions Etiology Management External Genital Warts Condyloma Latum Lymphocyte-mediated Ultra-potent topical steroid inflammation (clobetasol) Autoimmune disorder? Apply nightly Diagnosis Reduce frequency with symptom improvement Clinical presentation Men: usually require Biopsy of crinkled or circumcision ecchymotic area Careful long term follow up
Intraepithelial Neoplasia Skin Tags (Acrochordons) Fibroepithelial polyps Soft, skin-colored/tan Inguinal folds, inner thigh, buttocks, rare on penis Not on modified mucus membranes Diagnosis: clinical Treatment: none needed
15 8/3/2014
Lipomas “VIN” and Invasive Cancer Rare HPV-Related Non-HPV Related Soft, smooth, skin- colored, mobile Flat topped papules, Solitary lesions plaques Pink, red, white Labia majora and Multiple lesions Nodule, ulcer periclitoral areas Red, brown, skin- Older women Diagnosis: clinical colored Vestibule, labia minora Treatment: not needed Younger women Association with lichen unless bothersome Vestibule, labia majora sclerosis and lichen and vulva, perianal planus
Squamous Carcinoma VIN & SCC
VIN
HPV-Related Non-HPV Related SCC Variegated appearance Less variegated Pink Red Red White Brown Skin-colored Black More rapid progression Skin-colored from in-situ to invasive Longer stage from in-situ to Older men invasive Solitary lesions Younger men Glans, corona, prepuce Multiple lesions Association with lichen Shaft, perianal sclerosis
“PIN” and Invasive Cancer Basal Cell Carcinoma Older men and women Squamous Solitary papule, plaque, Cell or nodule Cancer May be ulcerated Only on keratinized skin Women: labia majora Men: scrotum, penis Perianal: both Diagnosis: biopsy Penile Intraepithelial Neoplasia
16 8/3/2014
Pigmented Lesions Intraepithelial Neoplasia Seborrheic keratoses Vulva, penis, scrotum Pigmented warts Tan, brown, black Intraepithelial neoplasia History Kaposi sarcoma Biopsy for diagnosis Genital melanosis Pigmented nevus (mole) Melanoma
Seborrheic Keratoses Genital Melanosis Sites: truck, genitals, Flat, dark, smooth lower limbs More common on Sharply marginated mucosa (labia minora, Scale or waxy feel glans, prepuce) Cause unknown Solitary or multifocal Biopsy to rule out Asymmetry malignancy More common in middle age and older Biopsy
Pigmented Warts Pigmented Nevus Common nevi: 90% Tan, brown, even color Dysplastic nevi Brown, asymmetry, speckling of color (with red, white, blue) Atypical nevi Like common, but larger (>6 mm) May have bumpy surface Nevi associated with lichen sclerosis Black, smooth Macule, papule, patch
17 8/3/2014
Pigmented Nevus Dermatologic Common nevus No biopsy if no atypia Procedures Nevus from LS Refer for biopsy Dysplastic nevus Refer for biopsy Atypical nevus Refer for biopsy
Melanoma Skin Scrapings for KOH Presentation Black exophytic mass Very rare Occurs in older age Color variegation https://www.youtube.com/watch?v=FohwEA5byY groups (50-80) Location: M More common in Labia, clitoris Caucasians https://www.youtube.com/watch?v=ZK-KsV1S7Y0 Glans, prepuce, shaft DDX: atypical nevi Anus 20% are multifocal May be nodular or Genetic etiology? ulcerated Relation to HPV? 50% are localized disease
Melanoma Local Anesthesia 1% lidocaine May add epinephrine for vulva 0.5 to 1.0 mL 30 gauge needle
http://www.youtube.co m/watch?v=Uxav0kAW U14&feature=results_vid eo&playnext=1&list=PLB F100062B46E56A7
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Biopsy Techniques Acknowledgements Content from Edwards & Lynch, (2011) Genital nd Punch Biopsy: Dermatology Atlas (2 ed.). Wolters Kluwer/LWW http://www.youtube.com/watch?v=7CzDEok8Wmo Photographs from Google Image Search, public domain Shave Biopsy: Videos from UTube as cited https://www.youtube.com/watch?v=nbdmmukko4s
Basic Suture Technique
http://www.youtube.com/watch?v=6P0rYS6LeZw
http://www.youtube.com/watch?v=bXqvo2St8lE
Clinical Resources
http://dermatologymadesimple.blogspot.com/2008_10_0 1_archive.html
Biopsy of the Vulva http://emedicine.medscape.com/article/1998133-overview Biopsy of the Penis http://emedicine.medscape.com/article/1997665-overview
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