SECOND OF 2 PARTS ON OFFICE MANAGEMENT OF BENIGN VULVAR CONDITIONS Chronic vulvar irritation, itching, and pain. What is the diagnosis? Five cases of dermatoses, vaginal abnormalities, and pain syndromes that may masquerade as infection Libby Edwards, MD, and Beth E. Goldbaum, MD hronic irritation, itching, and pain CASE 1 Introital burning and a fear are only rarely due to infection. of breast cancer C These symptoms are more likely to A 56-year-old woman visits your office for be caused by dermatoses, vaginal abnormali- management of recent-onset introital burn- ties, and pain syndromes that may be difficult ing during sexual activity. She reports that to diagnose. Careful evaluation should in- her commercial lubricant causes irritation. clude a wet mount and culture to eliminate Topical and oral antifungal therapies have not infection as a cause so that the correct diag- been beneficial. She has a strong family his- IN THIS nosis can be ascertained and treated. tory of breast cancer. ARTICLE In Part 2 of this two-part series, we focus On examination, she exhibits small, When a woman on five cases of vulvar dermatologic disrup- smooth labia minora and experiences pain is reluctant to use tions: when a cotton swab is pressed against the local estrogen • atrophic vagina vestibule. The vagina is also smooth, with page 32 • irritant and allergic contact dermatitis scant secretions. Microscopically, these • complex vulvar aphthosis secretions are almost acellular, with no • desquamative inflammatory vaginitis increase in white blood cells and no clue A teenager • inverse psoriasis. cells, yeast forms, or lactobacilli. The pH is with vulvar pain greater than 6.5, and most epithelial cells are and sores parabasal (FIGURE 1, page 32). page 34 You prescribe topical estradiol cream Dr. Edwards is Chief of for vaginal use three nights per week, but Dermatology at Carolinas Medical A case of inverse Center, Charlotte, North Carolina. when the patient returns 1 month later, her psoriasis condition is unchanged. She explains that page 36 she never used the cream after reading the package insert, which reports a risk of breast cancer. Dr. Goldbaum is Clinical Instructor of Obstetrics and Gynecology Diagnosis: Atrophic vagina (not atrophic vag- at Harvard Medical School, initis, as there is no increase in white blood Boston, Massachusetts. cells). ›› Read Part 1: Chronic Treatment: Re-estrogenization should relieve vulvar symptoms her symptoms. and dermatologic disruptions (May 2014), The authors report no financial relationships relevant to this article. at obgmanagement.com Several options for local estrogen replace- ment are available. Creams include estradiol CONTINUED ON PAGE 32 30 OBG Management | June 2014 | Vol. 26 No. 6 obgmanagement.com Benign vulvar conditions CONTINUED FROM PAGE 30 FIGURE 1 Atrophic vagina When a woman is reluctant to use local estrogen We counsel women that small doses of vagi- nal estrogen used for limited periods of time are unlikely to influence their breast cancer risk and are the most effective treatment for symptoms of atrophy. Usually, this explana- tion is sufficient to reassure a woman that topical estrogen is safe. Otherwise, use of commercial personal lubricants (silicone- based lubricants are well tolerated) and moisturizers such as Replens and RePhresh can be comforting. The topical anesthetics lidocaine 2% jelly or lidocaine 5% ointment (which sometimes burns) can minimize pain with sexual activity for those requiring more than lubrication. Ospemifene (Osphena) is used by some clinicians in this situation, but this medica- This wet mount of an atrophic vagina shows many parabasal cells with no tion is labeled as a risk for all of the same lactobacilli and no increase in white blood cells. Figure courtesy of Libby Edwards, MD. contraindications as systemic estrogen, and it is much more expensive than topical es- trogen. Ospemifene is an estrogen agonist/ (Estrace) and conjugated equine estrogen antagonist. Although it is the only oral (Premarin), the latter of which is arguably medication indicated for the treatment of The risk of vaginal slightly more irritating. These are prescribed menopause-related dyspareunia, the long- candidiasis is fairly at a starting dose of 1 g in the vagina three term effects on breast cancer risk are un- high during the first nights per week. After several weeks, they known. Also, it has an agonist effect on the 2 or 3 weeks of can be titrated to the lowest frequency that endometrium and, again, the long-term risk re-estrogenization controls symptoms. is unknown. The risk of vaginal candidiasis is fair- Fluconazole use is contraindicated ly high during the first 2 or 3 weeks of re- with ospemifene, as is the use of any estro- estrogenization, so patients should be gen products. warned of this possibility. Also consider prophylactic weekly fluconazole or an CASE 2 Recalcitrant itching, burning, azole suppository two or three times a week and redness for the first few weeks. Estradiol tablets A 25-year-old woman reports anogenital itch- (Vagifem) inserted in the vagina are effec- ing, burning, and redness, which have been tive, less messy, and more expensive, as is present for 3 months. She says she devel- the estradiol ring ( Estring), which is insert- oped a yeast infection after antibiotic therapy ed and changed quarterly. for a dental infection; the yeast infection was It is not unusual for a woman to avoid treated with terconazole. She reports an aller- use of topical estrogen out of fear, or to use gic reaction to the terconazole, with immedi- insufficient amounts only on the vulva, or to ate severe burning, redness, and swelling. use it for only 1 or 2 weeks.1 The clobetasol cream she was given to use Women should be scheduled for a re- twice daily also caused burning, so she dis- turn visit to ensure they have been using the continued it. Her symptoms improved when estrogen, their wet mount has normalized, she tried cool soaks and applied topical ben- and discomfort has cleared. zocaine gel as a local anesthetic. However, 32 OBG Management | June 2014 | Vol. 26 No. 6 obgmanagement.com FIGURE 2 Contact dermatitis exposed to an irritating substance in suf- ficient quantity or frequency. Irritant con- tact dermatitis is characterized mostly by sensations of rawness or burning and generally is caused by urine, feces, perspi- ration, friction, alcohols in topical creams, overwashing, and use of harsh soaps. • Allergic contact dermatitis—This form is characterized by itching, although second- ary pain and burning from scratching and blistering can occur as well. Common aller- gens in the genital area include benzocaine, diphenhydramine (Benadryl), neomycin in triple antibiotic ointment (Neosporin), and latex. Allergic contact dermatitis occurs after 1 or 2 weeks of initial exposure or 1 or 2 days after re-exposure. The diagnosis of an irritant or allergic contact dermatitis can be based on a history of incontinence, application of high-risk sub- stances, or inappropriate washing. Manage- Redness and erosions are typical of an acute contact ment generally involves discontinuation of dermatitis, and eroded papules are especially all panty liners and topical agents except for common in contact dermatitis of benzocaine. Figure courtesy of Libby Edwards, MD. water, with a topical steroid ointment used twice a day and pure petroleum jelly used as often as necessary for comfort. Nighttime se- 2 weeks later, she experienced increasing red- dation to allow a reprieve from rubbing and Diagnosis of an ness, itching, and burning. Although the ben- scratching may be helpful, and narcotic pain irritant or allergic zocaine relieved these symptoms, it required medications may be useful for the first 1 to contact dermatitis almost continual reapplication for comfort. 2 weeks of treatment. can be based A physical examination of the vulva Women who fail to respond to treatment on a history of reveals generalized, poorly demarcated should be referred for patch testing by a incontinence, redness, edema, and superficial erosions dermatologist. application of high- (FIGURE 2). risk substances, Diagnosis: Irritant contact dermatitis (as CASE 3 Teenager with vulvar pain and sores or inappropriate opposed to allergic contact dermatitis) asso- A woman brings her 13-year-old daughter washing ciated with the use of terconazole and clo- to your office for treatment of sudden-onset betasol. This was followed by allergic contact vulvar pain and sores. The child developed a dermatitis in association with benzocaine. sore throat and low-grade fever 3 days ear- Treatment: Withdrawal of benzocaine, with lier, with vulvar pain and vulvar dysuria the reinitiation of cool soaks and a switch to clo- next day. The pediatrician diagnosed a her- betasol ointment rather than cream. Night- pes simplex virus infection and prescribed time sedation allows the patient to sleep oral acyclovir, but the girl’s condition has through the itching and gradually allows her not improved, and the mother believes her skin to heal. daughter’s claims of sexual abstinence. The girl is otherwise healthy, aside from Contact dermatitis is a fairly common cause a history of trivial oral canker sores without of vulvar irritation, with two main types: arthritis, headaches, abdominal pain, eye • Irritant contact dermatitis—The most pain, or vision changes. common form, it occurs in any individual Physical examination of the vulva reveals obgmanagement.com Vol. 26 No. 6 | June 2014 | OBG Management 33 Benign vulvar conditions FIGURE 3 Vulvar aphthae transmitted disease, but the large, well- demarcated, painful, nonindurated deep nature of the ulcer is pathognomonic for an aphthous ulcer. The presence of oral and genital aphthae does not constitute a diagnosis of Behçet disease, an often-devastating systemic in- flammatory condition occurring almost ex- clusively in men in the Middle and Far East. The diagnosis of Behçet disease requires the identification of objective inflammatory dis- ease of the eyes, joints, gastrointestinal tract, or neurologic system.