UPDATE ON GENITAL DERMATOSES Sangeetha Sundaram Consultant GUM/HIV Southampton 07/11/2018 Normal variants • Fordyce spots • Vestibular papillae • Pearly penile papules • Angiokeratoma • Epidermal cysts • Skin tags Inflammatory dermatoses • Irritant dermatitis • Lichen sclerosus • Lichen simplex chronicus • Lichen planus • Seborrhoeic dermatitis • Psoriasis History • Itching? Where exactly? Waking up at night scratching? • Soreness/burning/raw? Where exactly? When? • Pain with sex? Where exactly? When exactly? • Discharge? • Skin trouble elsewhere? • Mouth ulcers? • Irritants in lifestyle Examination Irritants • Soap and shower gel (even Dove, Simple and Sanex…) • Sanitary pads and panty liners (especially when worn daily) • Moistened wipes • Synthetic underwear • Tight clothing • Feminine washes • Topical medication (creams and gels) • Urine, faeces, excessive vaginal discharge • Lubricants • Spermicides Basic vulval toolkit • Stop soap/shower gel (even Dove and Simple and Sanex!) • Stop pads/ panty liners (except during menses) • Loose cotton pants • Emollient soap substitute and barrier ointment Lichen simplex chronicus • Itching wakes her at night • Scratches in her sleep • Always same place(s) Lichen simplex chronicus - management • Stop soap/shower gel • Stop pads/ panty liners (except during menses) • Loose cotton pants • Emollient soap substitute and barrier ointment • Identify underlying condition(s), if any • Dermovate ointment every night for 2 weeks, then alternate nights for 2 weeks, then twice weekly for 2 weeks, then stop • Iron supplements if low ferritin levels Lichen sclerosus - management • Stop soap/shower gel • Stop pads/ panty liners (except during menses) • Loose cotton pants • Emollient soap substitute and barrier ointment • Clobetasol propionate 0.05% ointment (Dermovate ointment) – Every night for one month, alternate nights for one month, twice weekly for one month • 60% will go into remission – Thereafter a regular regimen, eg two nights per week and more often during flares: 30g tube lasting 12 weeks minimum – usually lasting for at least 6 months – Children: every night for 12 weeks Erosive lichen planus - management • Stop soap/shower gel • Stop pads/ panty liners (except during menses) • Loose cotton pants • Emollient soap substitute and barrier ointment • Speculum examination • Clobetasol propionate 0.05% ointment (Dermovate ointment) – Every morning and night for one month, every night for one month, alternate nights for one month….decreasing as possible, increasing as needed – Prednisolone (Predsol) 5mg suppository as pessary every night for one month, decreasing as possible Manangement of Seborrhoeic dermatitis • Milder preparations eg Daktacort • 2% Ketoconazole or selenium sulphide shampoo • Itraconazole 200mg od for 1/52 • Consider screening for HIV if severe Psoriasis - management • Stop soap/shower gel • Stop pads/ panty liners (except during menses) • Loose cotton pants • Emollient soap substitute and barrier ointment • Eumovate ointment nocte or Trimovate cream nocte as required VIN • Usual type • Differentiated type • Undifferentiated • Older women • Grades 1,2 & 3 • Solitary plaque • Young women • Background of Lichen • Often multifocal sclerosus • Associated with • No link with HPV HPV 16 • High risk of SCC • Low risk of progression to SCC Differential diagnosis of vulval ulcers • Herpes simplex • Aphthous ulceration • Trauma including scratching • Infective (other than herpes) eg syphilis • Lipschutz ulcer • Part of inflammatory disease (LS, LP) • Cancer Management of recurrent aphthous ulceration - vulva • Stop soap/shower gel • Stop pads/ panty liners (except during menses) • Loose cotton pants • Emollient soap substitute and barrier ointment • Consider underlying systemic conditions (history) • Exclude HSV • Clobetasol propionate 0.05% ointment (Dermovate ointment) daily from earliest onset to resolution • 5% lignocaine ointment PRN • Oral prednisolone eg 30mg for 5 days • Prophylaxis with colchicine Management • Low threshold for biopsy as pre-cancerous conditions can mimic Zoon’s • Hygiene measures • Barrier emollient • Topical steroids with antibacterial eg trimovate • Circumcision Key messages • Take a good history and examine • Basic principles: Avoid irritants, recommend emollients • Dispel myths around topical steroid use • Red flags: - Rapidly growing lumps/bumps - Ulcers that are not typical of herpes - Warts not responding to treatment - Pigmented lesions.