Wendy Grube, PhD, CRNP University of Pennsylvania School of Nursing Disclosure No conflicts of interest Objectives 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. Comparative Anatomy Variants of Normal Vulva Shaft of Penis Fordyce spots Variants of Normal Benign papillae Variants of Normal Physiologic hyperpigmentation Algorithm for Diagnosis of 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 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 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 Lichen Simplex Chronicus Lichen Simplex Chronicus Cause: not known, Consider: probably genetic Wet mounts: rule out predisposition candidiasis Heat, sweat triggers KOH: for dermatophyte fungi (tineas) Diagnosis: Based on clinical findings Biopsy helpful if there is loss of architectural Biopsy not very helpful landmarks (labia in finding underlying minora) in women to problem rule out lichen sclerosis Lichen Simplex Chronicus Management Goals: Breathable fabrics Reduce triggers in local Weight loss environment Manage fecal, urinary, vaginal secretions Restore normal barrier Stop excessive bathing layer function Lubricant/barrier Reduce inflammation Topical steroids Stop itch-scratch cycle (ointment, high potency) for a month or until clinical improvement Antihistamines Irritant Contact Dermatitis 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 Allergic Contact Dermatitis Immunological response Cell-mediated delayed hypersensitivity reaction OTC preparations: benzocaine, bacitracin, spermicides, parabens, fragrances Latex: IgE response, immediate reaction Seborrheic Dermatitis/Intertrigo Located where Diagnosis: Clinical moisture is retained Can have superimposed (sweat, urine) candida Maceration Management Skin folds Reduce heat and moisture Crural folds Topical corticosteroids Axillae Hydrocortisone 1-2.5% Umbilicus Triamcinolone 0.1% Indistinct margins Topical ketoconazole Red patches and scale cream BID Seborrheic Dermatitis/Intertrigo Candidiasis Candidiasis Diagnose with KOH Management: prep Eliminate heat, moisture Topical azoles BID until clear Attention to DM, obesity, immunocompromised patients Tinea Cruris 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 Erythrasma Mimics tinea cruris Diagnosis: Found mostly in men Clinical exam Proximal, medial thigh Wood’s light and crural crease fluorescence (coral- Scrotum, penis, vulva pink) usually not affected Negative KOH prep Corynebacterium minutissimum, bacteria Treat with Erythromycin prevalent in warm 500 mg BID for 1-2 weeks environments Erythrasma Psoriasis Affects 2-3% of people Plaques and silvery scales Onset: young adults on scalp, elbows, knees, Etiology: genetic, gluteal cleft, genitals autoimmune, 20% with Koebner’s environmental phenomenon Contributing factors: Inverse psoriasis: skin alcohol, smoking, obesity, folds medications (NSAIDs and Genitals lithium) Women: affects hair- Rapid proliferation of bearing areas (vulva) epidermis Men: glans, shaft, Associated arthritis scrotum, groin Psoriasis Psoriasis Psoriasis Diagnosis: Management: Other psoriatic Potent topical lesions? corticosteroids with Biopsy helpful, but tapering doses can be nonspecific in Triamcinolone 0.1% older lesions Ultraviolet light of Negative fungal little use to genitalia scrapings/cultures Oral methotrexate No response to Immunosuppressant antifungal medication agents Lichen Planus Different clinical presentations Autoimmune disorder, cell-mediated Usually self-limiting Resolves in few years Lichen Planus Lichen Planus Diagnosis: Management: Clinical findings Topical corticosteroids Biopsy (clobetasol 0.05% and Differential: Bowen taper down) disease, candidiasis, Short burst of oral psoriasis, herpes prednisone if needed Plasma Cell Mucositis Poorly understood Diagnosis by biopsy Onset after puberty Management: Deep red solitary No good therapy plaque Circumcision May erode, bleed Potent topical Related to lichen steroids? planus? Imiquimod? CO2 or YAG laser? Plasma Cell Mucositis Extramammary Paget’s Disease Primary or secondary forms Onset: usually >50 More common in women 10-20% with underlying GU/GI malignancy Initial symptom: pruritus Presentation: Well demarcated red plaque Rough, scaling or moist surface White thickened islands Erosions Extramammary Paget’s Disease Diagnosis Management: excision Clinical suspicion <1 mm invasion: good Resembles benign prognosis skin disorders and Laser, radiation, Bowen’s disease imiquimod Biopsy >1mm invasion: node evaluation Determine primary or secondary Evaluate for GU/GI malignancy Intraepithelial Neoplasia Non-invasive but full thickness dysplasia Many types HPV-related Bowen’s disease: older Presentation Well-demarcated plaques, scaling, hyperkeratosis Intraepithelial Neoplasia Bowen Disease/VIN/PIN Lesions may be Undifferentiated: accentuated with 5% HPV 16, 18, 31, 33 acetic acid 2/3 – full thickness White, red, skin colored Differentiated: plaques Lower 1/3 of Diagnosis: biopsy epithelium Management: surgical, No HPV link imiquimod, laser Red Papules and Nodules Folliculitis Pyogenic granuloma Keratosis pilaris Urethral caruncle Bites & infestations Vulvar endometriosis Angiomas, Hematoma angiokeratomas Kaposi Sarcoma Prurigo nodularis Keratosis Pilaris Common in children, disappears in 4th decade Clusters of papules Excess keratinization of outer hair follicles Noninfectious Management Bath soaks/loofah Moisturizer Bites & Infestations Insect bites on genitals are rare Nodular scabies Almost exclusively in males Presentation Red-brown dome- shaped papules Glans, shaft, scrotum Diagnosis: biopsy Management: scabicide Cherry Angiomas & Angiokeratomas Prurigo Nodularis (Picker’s Nodules) Increased keratin Results from chronic scratching, picking May have underlying folliculitis Diagnosis: Biopsy Differential: Scabies Treat: Intralesional triamcinolone Liquid nitrogen Nighttime sedation SSRIs Pyogenic Granuloma Benign neoplasm Cause unknown, may be second to trauma Pregnancy Management: shaved excision Urethral Caruncle & Prolapse Vulvar Endometriosis Cyclic enlargement and pain with menses Implantation may occur during parturition Diagnosis: presumptive, by clinical presentation Management: refer for surgical excision May require hormonal suppression Hematoma Kaposi Sarcoma Crohn’s Disease Asymmetrical edema Linear ulcers Fistulae Also: skin tags, papules, nodules Pustular Lesions Folliculitis Solid lesions that appear Furuncles pustular: Carbuncles Epidermal cysts Hidradenitis Molluscum suppurativa contagiosum Folliculitis Etiology: bacterial, fungal, or irritant inflammation of follicle Superficial Folliculitis Folliculitis Irritant: shaving Diagnosis Fungal: middle aged Clinical presentation Culture and older men (tinea) Management Bacterial: Bacterial: oral, topical Staphylococcus antibiotics No known risk factor Fungal: oral antifungal Irritant: avoid shaving Pseudomonas Loose, cool clothing Bathing suits Oral anti- Hot tubs inflammatory antibiotics Furuncles Involves deeper follicle Red, painful nodules Rupture and drain More common in immunosuppression, diabetes Usually S. aureas 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 Carbuncles Hidradenitis Supperativa Cystic acne of skin folds Affects groin, axillae, inner thighs, vulva, scrotum Occurs after puberty Strong association with smoking Hidradenitis Supperativa 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