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 biopsy with skill and precision.  Perform basic interrupted suture insertion.

Comparative Anatomy  Variants of Normal 

Vulva Shaft of Fordyce spots Variants of Normal 

Benign papillae Variants of Normal 

Physiologic Algorithm for Diagnosis of Genital Disorders  Are there visible changes?  No, only symptoms  Pruritus  Pain  Yes  Lifted/removed epithelium  Pustules   Ulcers  Lesions are red, but epithelium is intact  Patches and plaques  and nodules  Lesions, but other than red  Skin colored  White  Brown/black/blue

Edwards & Lynch (2011) Genital Atlas, LWW Pruritus   Idiopathic  Atopic  Tissue appears normal  Allergic IgE reaction  Characterized by to common scratching or rubbing environmental  -scratch cycle allergens (eczema)   Probably a subclinical History of allergies or variant of atopic asthma dermatitis  Localized form: Red Plaques and Patches    Irritant Contact  dermatitis   Allergic contact  dermatitis  Extramammary Paget  Seborrheic dermatitis  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 fungi (tineas)  Diagnosis: Based on clinical findings  Biopsy helpful if there is loss of architectural  Biopsy not very helpful landmarks ( 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  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, rawness  Barriers: zinc oxide,  Urine, feces, soap, lubricants 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/   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  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, , immunocompromised patients Tinea Cruris  Tinea Cruris   Diagnose:  Management:  KOH prep from skin  Topical azoles 1-2x scraping day until clear  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  Wood’s light and crural crease fluorescence (coral-  , penis, pink) usually not affected  Negative KOH prep  minutissimum, bacteria Treat with 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:  : skin alcohol, smoking, obesity, folds (NSAIDs and  Genitals lithium)  Women: affects hair-  Rapid proliferation of bearing areas (vulva)  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 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, 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    Pyogenic granuloma  pilaris  Urethral caruncle  Bites & infestations  Vulvar endometriosis  Angiomas,  Hematoma  Kaposi nodularis

Keratosis Pilaris   Common in children, disappears in 4th decade  Clusters of papules  Excess keratinization of outer hair follicles  Noninfectious  Management  Bath soaks/loofah  Bites & Infestations   Insect bites on genitals are rare  Nodular  Almost exclusively in males  Presentation  Red-brown dome- shaped papules  Glans, shaft, scrotum  Diagnosis: biopsy  Management: scabicide Cherry Angiomas & Angiokeratomas  (Picker’s Nodules)   Increased  Results from chronic scratching, picking  May have underlying folliculitis  Diagnosis: Biopsy  Differential: Scabies  Treat:  Intralesional triamcinolone  Liquid nitrogen  Nighttime sedation  SSRIs

Pyogenic Granuloma   Benign  Cause unknown, may be second to trauma   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:   Epidermal cysts  Hidradenitis  Molluscum suppurativa contagiosum Folliculitis   Etiology: bacterial, fungal, or irritant inflammation of follicle  Superficial Folliculitis  Folliculitis   Irritant:  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  Bathing suits  Oral anti-  Hot tubs inflammatory antibiotics Furuncles   Involves deeper follicle  Red, painful nodules  Rupture and drain  More common in immunosuppression,  Usually S. aureas

Furuncles   Diagnosis:  Management  Clinical presentation  Oral antibiotics  Culture: S. aureus   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 of skin folds  Affects groin, axillae, inner , 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 estrogen  Wide range of severity contraceptives  Diagnosis (0.035mg), spironalactone  Clinical presentation  Oral  Chronicity  Isotretinoin

Epidermal Cysts   Obstructed hair follicles that are distended with keratin  White, skin colored, or yellow  Occasional inflammatory response from keratin  No treatment necessary   May be transmitted sexually  Genitals, thighs  Domed papules, may be umbilicated  May be inflamed, pruritic  Poxvirus  Resolve spontaneously  May use topical destruction, imiquimod Erosive and Vesicular Lesions    Hailey-Hailey disease  Bullous multiforme  Fixed drug eruptions  Trauma/artifact  Malignancies Herpes Simplex  Herpes Simplex   Clinical appearance can  Serology: be confusing  Consult CDC  Vesicular and erosive guidelines: Type 2 presentations  Conversion at 6 weeks  Differentiate from  Up to 80% of other ulcerative population with disorders, folliculitis positive IgG for HSV  Culture: false negatives  PCR: test of choice

CDC Guidelines on HSV 2 Serology  Appropriate for: Consider in:  Recurrent/atypical  STD visit, person with symptoms and negative multiple partners cultures  Person with HIV  Clinical fit, no lab  MSM with risk for HIV confirmation Inappropriate for:  Partner with genital  General screening herpes

CDC. STD Treatment Guidelines, 2010 (Dec.17, 2010) MMWR, vol.59, No. RR-12. Herpes Simplex  Impetigo  S. aureas  Fragile blisters  Round lesions with collarettes spp.  Erosion and crusting Diagnosis  Clinical suspicion  Culture Management  Antibiotic therapy (clindamycin) Pemphigus   Autoimmune intraepidermal disorder  Mucosal flaccid blisters and superficial erosions  Later stage: hyperkeratotic skin  Includes genitals & rectum  Cervix: Pap may show LGSIL  Penis: on glans, corona, distal shaft Diagnosis: biopsy Management: systemic steroids Pemphigus Vulgaris & Vegetans 

Large erosions heal without scarring Superficial crusting plaques of vegetans  Common autoimmune blistering disease  Intense pruritus precedes blisters  Rare genital involvement  On keratinized skin  Onset: elderly Diagnosis:  Biopsy Management:  Topical or systemic steroids Hailey-Hailey Disease  Familial pemphigus  Recurrent small blisters and crusted erosions  Sites: intertriginous zones, perianal area  Evolve into thickened macerated plaques Diagnosis: Shape, FHx, Bx Management: supportive  Topical/oral antibiotics  High-potency topical steroids

Hailey-Hailey Disease  Bullous   Stevens-Johnson Syndrome  Hypersensitivity reaction  Self-limiting  Blistering forms may affect mucosal surfaces  Rupture quickly leaving erosions  Heal quickly after inciting agent is removed  Scarring can be severe  Vaginal synechiae  Penile phimosis (uncircumcised) Fixed Drug Eruptions  On keratinized skin: Diagnosis:  Well-demarcated  History of recent drug  Edematous, erythematous, ingestion round  Biopsy On mucosal areas: Management:  and erode quickly  Identification and  Shape irregular elimination of offending  Burning medication  Supportive therapy

Fixed Drug Eruptions  Traumatic Lesions  Diagnosis:  History: event is immediately painful Typical insults:  Chemical burn  Chemicals in creams  Thermal   Zippers  Bites Management: soaks, infection  Miscellaneous control, pain treatment Traumatic Lesions  Erosive Malignant Lesions 

Basal Cell Carcinoma  5% of genital  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  Diagnosis: biopsy  Diagnosis: biopsy  Treat: local excision  Management: surgical

Erosive Malignant Lesions 

Basal Cell Carcinoma Squamous Cell Carcinoma Other Ulcerative Lesions 

Syphilis Other Ulcerative Lesions 

Granuloma Inguinale Other Ulcerative Lesions 

Aphthous Ulcers Behçet Disease Non-Red Lesions  White lesions Skin-colored lesions   Genital  Post-inflammatory hypopigmentation  Condyloma latum  Lichen sclerosis  Molluscum  Lichen planus  (acrochordon)  Lichen simplex chronicus  Intradermal nevi  White sponge  Intraepithelial neoplasia  Epidermal cysts  Basal and squamous  Molluscum contagiosum cell carcinomas

White Lesions  Post-inflammatory Vitiligo Hypopigmentation Lichen Sclerosis  Females Males  Childhood and post-  Childhood and later life menopausal  White papules and  Labia minora, , plaques on glans, labial sulci (hourglass) prepuce, shaft Lichen Sclerosis   Epidermal atrophy  4% chance of squamous  Crinkled appearance cell in long  Ecchymosis from easily damages vessels standing untreated LS  Scarring of and uncircumcised male prepuce  Shrinkage/loss of labia minora  Mucosa not affected  Extragenital sites: back, wrists, shoulders

Lichen Sclerosis  Etiology Management  Lymphocyte-mediated  Ultra-potent 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  White Sponge Nevus   Uncommon autosomal dominant condition  Affects mucosal surfaces (oral, esophageal, genital)  White, keratotic epithelium  Diagnosis: biopsy  Treatment: none for Oral lesion genital lesions Skin-Colored Lesions  External Genital Warts Condyloma Latum Skin Tags (Acrochordons)   Fibroepithelial polyps  Soft, skin-colored/tan  Inguinal folds, inner thigh, , rare on penis  Not on modified mucus membranes  Diagnosis: clinical  Treatment: none needed Lipomas   Rare  Soft, smooth, skin- colored, mobile  Labia majora and periclitoral areas  Diagnosis: clinical  Treatment: not needed unless bothersome Squamous Carcinoma 

HPV-Related Non-HPV Related  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 

Squamous Cell Cancer

Penile Intraepithelial Neoplasia “VIN” and Invasive Cancer 

HPV-Related Non-HPV Related  Flat topped papules,  Solitary lesions plaques  Pink, red, white  Multiple lesions  ,  Red, brown, skin-  Older women colored  Vestibule, labia minora  Younger women  Association with lichen  Vestibule, labia majora sclerosis and lichen and vulva, perianal planus VIN & SCC

VIN 

SCC Basal Cell Carcinoma   Older men and women  Solitary , plaque, or nodule  May be ulcerated  Only on keratinized skin  Women: labia majora  Men: scrotum, penis  Perianal: both  Diagnosis: biopsy Pigmented Lesions   Seborrheic keratoses  Pigmented warts  Intraepithelial neoplasia  Kaposi sarcoma  Genital melanosis  Pigmented nevus (mole) 

Seborrheic Keratoses   Sites: truck, genitals, lower limbs  Sharply marginated  Scale or waxy feel  Cause unknown  Biopsy to rule out malignancy Pigmented Warts  Intraepithelial Neoplasia   Vulva, penis, scrotum  Tan, brown, black  History  Biopsy for diagnosis Genital Melanosis   Flat, dark, smooth  More common on mucosa (labia minora, glans, prepuce)  Solitary or multifocal  Asymmetry  More common in middle age and older  Biopsy

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 Pigmented Nevus  Common nevus  No biopsy if no atypia Nevus from LS  Refer for biopsy Dysplastic nevus  Refer for biopsy Atypical nevus  Refer for biopsy

Melanoma  Presentation  Black exophytic mass  Very rare  Color variegation  Occurs in older age groups (50-80)  Location:  More common in  Labia, clitoris Caucasians  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  Dermatologic Procedures  Skin Scrapings for KOH 

 https://www.youtube.com/watch?v=FohwEA5byY M  https://www.youtube.com/watch?v=ZK-KsV1S7Y0 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

Biopsy Techniques 

Punch Biopsy: http://www.youtube.com/watch?v=7CzDEok8Wmo

Shave Biopsy: 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

Acknowledgements   Content from Edwards & Lynch, (2011) Genital Dermatology Atlas (2nd ed.). Wolters Kluwer/LWW  Photographs from Google Image Search, public domain  Videos from UTube as cited