City and Hackney Vulval Dermatoses Pathway Manages treatment of women age 12 onwards

PATIENT PRESENTS WITH 1 HISTORY 2  Vulval itch  Soreness  Itch, soreness, dyspareunia, dysuria, postcoital bleeding, anal itch/pain/bleeding  Irritation  Pain  Cervical screening history  Sexual health history  Recurrent thrush / bacterial vaginosis  Skin conditions / atopy?  Auto-immune conditions  Medication: HRT, tamoxifen, contraception, antibiotics, immunosuppressants

RED FLAG 4 3 Indication for 2WW referral for Vulvar itch suspected vulval carcinoma:  Vaginal ulceration  Irregular mass Abnormal architecture? Vaginal discharge? Suspicious features? Scarring / narrowing of introitus Or weeping of skin Persistent area of hyperkeratosis,  Bleeding from ulcer/mass Resorption of labia minora erosion or erythema Fusing in the midline with burying, but New wart or papular lesions  Enlarged inguinal lymph not loss of clitoris Swab nodes in absence of Is there candidiasis? obvious signs of infection No Yes Consider cancer / VIN Soreness, itch, thick white Refer for biopsy (via appropriate Please see here for more discharge cancer referral pathway) information Eczema/ Lichen sclerosus / psoriasis lichen planus Yes No Vulvar care regimen Vulvar care regimen Treat with moderate Treat if confident with super potency topical steroid potency topical steroid or combination steroid/ Refer for diagnosis, antifungal ongoing investigation Treat and treatment if not Treat primarily with antifungal creams Miconazole or nystatin ointment / clotrimazole confident cream applied to vulva twice a day According to the preparation used, courses of up to 14 days can be prescribed If not responded to Oral fluconazole 150mg single dose offer an treatment advantage when compliance is a problem

DIFFERENTIAL DIAGNOSES 5 Image 1. Lichen Sclerosus (LS): PIL Pale atrophic skin, midline fusion, loss of labial architecture. Take autoimmune history, do TFTs and DM

Image 2. Lichen Planus (LP): PIL Erosion of mucosal surfaces, Wickham striae, plaques, annular lesions on keratinised skin, vulval splitting – look in the mouth, less likely around anus, more likely in vagina than LS

3. Vulval Dermatitis (VD): Erythema, lichenification and fissuring

Image 4. Vulval Intraepithelial Neoplasia (VIN): Raised lesions - white, erythematous or pigmented, warty, moist/eroded, multifocal, with history of CIN, HIV

PIL 5. Vulval Pain Syndromes (VP): Vulval pain, no inflammatory change: Careful history to check for triggers. Consider OTC topical local anaesthetic (e.g. lidocaine 5% ointment or lidocaine 2% gel). Apply 15-20mins before sex, wash off just before sex/use condom to avoid numbness

Page 1 of 2 Authors: Anita Coutinho (GP Clinical Lead for Gynaecology) Publication date: Nov 2019 Sandra Watson (Consultant Gynaecologist) Review date: Nov 2022 EXAMINATION 6  Speculum and internal examination not always necessary if symptom is itch on its own  Anogenital inspection: look for pallor, lichenification, erythema, fissuring, ulceration, lumps, loss architecture  Check lymph nodes if appearance suggestive of malignancy e.g. ulceration

INVESTIGATION 7  Bloods if appropriate according to general condition  Bloods not normally necessary if diagnosis is dermatitis, if unsure ask for advice on eRS  Cervical screening if due, swabs for STIs, Candida and BV

MANAGEMENT 8 1. PRECIPITATING FACTORS PIL  Avoid tight fitting garments, soap, shampoo, bubble baths, douching, over the counter lubricants, spermicidally-lubricated condoms  If menopause-related atrophic vagina, advise oestrogen cream 2. EMOLLIENTS  Avoid contact with soap, shampoo and bubble bath. Simple emollients can be used as a soap/general moisturiser substitute  1st line - emulsifying ointment or Epimax cream  2nd line - ZeroAQS cream 3. STEROID THERAPY Vulval dermatoses often require treatment with moderately strong topical steroids. It is safe to prescribe topical steroid on a short-term basis and many conditions, such as recurrent dermatitis and lichen sclerosus require maintenance therapy

DO NOT USE STEROIDS FOR VULVAL PAIN SYNDROMES Lichen Sclerosus / Lichen Planus Clobetasol proprionate 0.05% ointment pea-sized amount: once daily for 1 month, then alternate days for 1 month, then twice a week for 1 month. Note 30g may be sufficient for 3 months.

Dermatitis Topical corticosteroid (apply once daily for 7–10 days until symptoms/signs settle and then used as needed for recurrent symptoms):  Mild cases: Hydrocortisone 1% ointment  Severe cases: Mometasone furoate 0.1% ointment or betamethasone valerate 0.025% ointment Treat any co-existing infection with a combination steroid/antifungal or steroid/ antibacterial:  Clobetasone butyrate 0.05% with nystatin and oxytetracyline cream (Trimovate)  Hydrocortisone 1% with fusidic acid cream  Hydrocortisone 1% with clotrimazole cream  Beclomethasone dipropionate 0.064% with clotrimazole 1.0% cream (Lotriderm)  Betamethasone 0.5% with neomycin cream

9 SPECIALIST REFERRAL: 10 ADVICE AND  No improvement after 3 months of clobetasol ointment GUIDANCE  Vulval pain syndromes unresponsive to initial treatment Available on e-RS  Suspicion of Vulval Intraeptithelial Neoplasia (VIN)

Page 2 of 2 Authors: Anita Coutinho (GP Clinical Lead for Gynaecology) Publication date: Nov 2019 Sandra Watson (Consultant Gynaecologist) Review date: Nov 2022