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Benign vulvar disorders march 2012 ghatage
This document discusses benign lesions of the vulva, including definitions, classifications, symptoms, histology, and management. It covers several common conditions - lichen sclerosus, lichen planus, squamous cell hyperplasia, seborrheic dermatitis, and psoriasis. For each condition, it describes the etiology, symptoms, histological findings, and treatment approaches, which commonly involve topical steroids, soaks, moisturizers, and occasionally oral steroids or surgical denervation for severe cases. The conclusion emphasizes the importance of ruling out cancer with biopsy before treatment, and managing symptoms by drying wet lesions and moisturizing dry ones.
In this document
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Overview of benign lesions of the vulva presented by Dr. Prafull Ghatage at the Tom Baker Cancer Centre.
Explains the anatomy of the vulva, physiology of itching, definitions, classification (ISSVD), and management of benign lesions.
Defines itch and its sensory pathways involving C fibers, pain control, and itch reflex mechanisms.
Definitions and differences between lotions, ointments, and creams; potency ranking of topical steroids from Class I to VII.
Categorizes vulvar lesions into non-neoplastic, infectious, and neoplastic based on ISSVD 2004 classification.
Discusses vitiligo, seborrheic dermatitis, and contact dermatitis's characteristics and common occurrences.
Details on psoriasis prevalence (2% of population), symptoms, and characteristics of skin plaques.
Describes lichen planus as an inflammatory, mucocutaneous eruption with multiple symptoms like soreness and itch.
Diagnosis methods for lichen planus including skin examination and biopsy techniques.
Focus on the condition of erosive lichen planus.
Histological findings in lichen planus including basal cell liquefaction and lymphocyte infiltration.
Outlines treatments for lichen planus, including corticosteroids, hydrocortisone acetate, and other therapies.
Explains etiology and characteristics of lichen sclerosus, its prevalence, associations, and effects on vulvar tissues.
Histological features and various treatment options for lichen sclerosus, including steroids and supportive care.
Management strategies for lichen sclerosus and the associated risk of developing squamous cell carcinoma.
Describes squamous cell hyperplasia, its symptoms, etiology, and relation to chronic itching and scratching.
Management of squamous cell hyperplasia focusing on breaking the itch-scratch cycle and using potent steroids.
Comparison chart highlighting differences in symptoms and characteristics among lichen sclerosus, lichen planus, and squamous cell hyperplasia.
Details about the nerve supply relevant to vulvar conditions and treatment.
Descriptions of medical denervation methods involving alcohol injections.
Introduction to vulvar edema as a clinical condition.
Outline of the surgical denervation procedures for managing vulvar issues.
Final notes emphasizing the need to rule out cancer in skin disorders, the importance of biopsy, and hygiene recommendations.
Message of thanks to the audience at the conclusion of the presentation.
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Similar to Benign vulvar disorders march 2012 ghatage
Benign vulvar disorders march 2012 ghatage
- 1. Benign lesions ofthe vulva Dr Prafull Ghatage Tom Baker Cancer Centre, Calgary, Canada March 2012
- 2. Learning objectives n Anatomyof the vulva n Physiology of vulvar itching n Definitions n Classification – ISSVD n Management
- 4. Itch is anunpleasant sensation which evokes the desire to scratch-Samuel Hafenreffer,Nosodochium,in Quo Cutis,1660 n Itching – exteroceptive sensation elicited only by stimulation of the skin or skin-to-mucosa transitional surfaces. n Stratification of receptors limits itching to the epidermis and epidermis/dermis transition. Maximal sensitivity at the basal layer n Itching induces a scratch reflex
- 5. Pruritis n Fine unmyelinatedC fibers n Also control pain, touch ,temperature n Subepidermal to lateral spinothalamic tract thalamus sensory cortex
- 6. Definitions n Lotion Oil mixedwith water. Can be drying as it may have alcohol n Ointment Oil base. Greater penetration. More abrasive. However, very moisturizing. n Cream Water-soluble. Moderately moisturizing. Least abrasive
- 7. Potency ranking oftopical steroids Class Generic Name I Very high Clobetasol proprionate 0.05% ointment / cream II High Betamethasone diproprionate 0.05% ointment III Betamethasone diproprionate 0.05% cream IV Mild Triamcinalone 0.1% cream V Betamethasone Valerate 0.1% cream VI Low Clobetasol butyrate 0.05% cream VII Hydrocortisone 1% cream / ointment
- 8. Benign and MalignantLesions of the Vulva n Non-neoplastic n Infectious n Neoplastic
- 9. Epithelial Vulvar Disease(ISSVD),2004 n Nonepithelial disorders of the vulva n Lichen sclerosus n Sqamous cell hyperplasia n Other dermatoses n Mixed neoplastic and nonneoplastic disorders n Intraepithelial neoplasia n Squamous n Non-squamous n Invasive
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- 11. Vitiligo n Psoralen photochemotherapy( PUVA) n Treatment with narrow band ultraviolet B phototherapy
- 12. Seborrheic dermatitis n Commonin neonates n Cause unknown n Often occurs in areas of sebaceous glands
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- 15. Psoriasis n 2% ofpopulation n Silver white plaques n Check elbows ,knees , forearms
- 16. Psoriasis n Rarely welldemarcated n Can be annular n Steroids
- 17. Lichen Planus An inflammatory,mucocutaneous eruption with a distinctive pattern on: - skin, scalp, nails - mucous membranes - oral, genital, esophageal
- 18. Lichen Planus -Etiology Unknown ? Autoimmune triggered by exogenous antigens, possibly - viral - bacterial (superantigen) - chemical - drug - trauma
- 19. Symptoms LP n irritationwith burning and soreness n Can be very itchy, and scratching flares it n thickening of the vulva n dyspareunia n Symptoms depend on extent of disease - e.g. when vagina is involved with erosions, there is discharge and burning
- 22. Diagnosis LP n Lookat rest of skin and mucous membranes n Look in the mouth n Biopsy - regular histopathology (H&E) - immunofluorescence
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- 25. Lichen Planus -histology n Basal cell liquification n Subepidermal lymphocyte infiltration
- 26. Treatment LP n Treatsecondary infection n Restore barrier function with Sitz bath or tub bath 1- 2 times a day n Reduce inflammation with topical superpotent corticosteroids halobetasol or clobetasol 0.05% ointment 1- 2 times a day
- 27. Treatment LP n Forthe vagina - hydrocortisone acetate foam (80 mg) at night or in a compounded suppository 100 mg n For localized disease consider intralesional steroids n Consider dilators for vaginal narrowing
- 28. Severe LP n OralPrednisone 1 - 1.5 mg / kg / day for 2 weeks and tapering over 2-4 months n +/- Cyclosporine 4 mg per kg per day and continue until the patient is clear n Plaquenil 200 mg bid and / or hydrocortisone acetate vaginally n Doxycycline, metronidazole, n Acitretin, n Tacrolimus
- 29. Prognosis LP 1/3rd completeresolution 1/3rd significant resolution 1/3rd ongoing problems
- 30. Etiology of LS n Unknown n Multifactorial - genetic n - autoimmune n - environmental factors n NOTE: Often associated with autoimmune conditions, e.g. thyroid disease, vitiligo, etc. n Familial cases have been reported
- 31. Lichen Sclerosus n Acommon chronic vulvar disease n An inflammatory skin condition n Prevalence 1 in 300 to 1 in 1,000 n Most commonly found in middle-age women, but it can be seen in very young children and the elderly n Recognized familial association and certain HLA subtypes occur more often in affected families
- 32. Lichen sclerosus n Benignepithelial disorder n Epithelial thinning with edema and fibrosis of dermis n Shrinkage and agglutination of labia n Typically does not involve vagina and urethra
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- 37. Lichen sclerosis histology n Thin epithelium with loss of rete edges n Hyperkeratosis, fibrin deposition and loss of vascularity n Chronic inflammatory cell infiltrate of lymphocytes in deeper layer
- 38. Lichen sclerosis- treatment n High potency steroids n 0.05% clobetasol propionate n Applied bid X 2-3 weeks for 12 weeks. Resolution can take several months n Treat secondary infection
- 39. Lichen sclerosis-treatment cont’d n 2% Testosterone ointment. Testosterone propionate in sesame oil 100mg/ml mixed in petrolatum base n 2% Progesterone ointment 100mg in oil per oz of aquaphor cream base n Topical Tacrolimus 0.1% ointment
- 40. Lichen sclerosis- treatment n Mineral oil , hydrogenated vegetable oil good for symptomatic relief n Soaks in Sitz bath or Burows solution helpful if used infrequently n Non-medicated moisturing soap n Cotton underwear n Avoid perfumes and scented pads
- 41. Lichen sclerosis- treatment n Vaginal dilators may reduce stenosis n 3-9% of women with LS develop sqamous cell carcinoma
- 42. Squamous cell hyperplasia n Chronic, intense itching that results in repetitive scratching and rubbing n The skin responds by thickening (lichenification). The thickening of the skin is caused by the scratching n An itch-scratch-itch cycle starts and perpetuates the problem
- 43. Squamous cell hyperplasia-Etiology n Develops in several itchy skin conditions: Atopic dermatitis (eczema) Contact dermatitis Lichen sclerosus n Contact dermatitis can start this condition or be the main long-term promoting factor
- 44. Squamous Cell Hyperplasia n Benign epithelial disorder n vulvar pruritus n localized nonspecific vulvar skin thickening
- 48. Squamous cell hyperplasia- histology n thick epithelium n broad rete ridges n no significant inflammation
- 49. Treatment n Stop theitch-scratch-itch cycle n Sitz baths and soaks, no irritants n Reduce inflammation with superpotent steroids, i.e., clobetasol or halobetasol ointment - bid for two weeks, - once a day for four weeks n Intralesional steroids if severe. 5 mg of triamcinolone suspension in 2 ml of saline subcutaneously
- 50. Lichen Sclerosus LichenPlanus SCH Itch or burn Itch or burn Severe itch Scars Scars No scarring On the vulva On vulva and On the vulva in vagina Oral lesions frequently seen
- 51. Nerve supply andsites of steroid injection
- 52.
- 53. n 0.1 ml95% alcohol
- 54.
- 55. Surgical denervation ofthe vulva n Under GA n Use Drains
- 56. Conclusion n Skin disordersnot uncommon n Rule out cancer n Biopsy essential for diagnosis prior to treatment
- 57. Conclusion cont’d n Soap n Underwear n Avoid public pools / baths A dermatologic cliché is to dry wet lesions (soaks and compresses) and moisturize dry lesion (creams and ointments) n Rarely, medical and/or surgical denervation may be necessary
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