Approach to vulvar skin disorders: Clinical sciences

Many vulvar skin disorders are chronic and may adversely affect sexual function and the patient’s overall sense of well-being. There are a wide variety of skin conditions associated with vulvar skin disorders that can be related to infectious, inflammatory, or neoplastic processes.

When a patient presents with a vulvar skin disorder, the first step is to perform a focused history and physical examination. Let’s start with contact dermatitis. The patient will present with the acute onset of vulvar itching, burning, and irritation. They will also report exposure to a vulvar irritant or allergen such as scented soaps or body wash, laundry detergent, condoms, topical medications, or vaginal hygiene products.

The physical examination will reveal varying degrees of erythema, and might show excoriations of the vulva or vaginal discharge. In this case, consider contact dermatitis. Then perform potassium hydroxide and saline wet mount microscopy of the vaginal discharge.

If the microscopy demonstrates mature squamous cells and lactobacilli and is negative for motile trichomonads or pseudohyphae, you have ruled out vulvovaginal candidiasis or vaginal trichomoniasis and have made a diagnosis of contact dermatitis.

Next up is lichen simplex chronicus. Patients typically report symptoms of intense pruritus with scratching and rubbing that may even cause sleep disturbance. They might also have a history of an allergic condition such as seasonal allergies, asthma, or childhood eczema. In addition, they may reveal an exposure to a vulvar irritant or allergen.

The physical exam will show erythematous, lichenified plaques; possibly scaling and excoriation; thickened, leathery skin; erosions; ulcers; and vaginal discharge. With these findings, consider lichen simplex chronicus.

Perform potassium hydroxide microscopy and perhaps a vulvar biopsy. The microscopy may reveal pseudohyphae, indicating underlying vulvovaginal candidiasis, and if the vulvar biopsy demonstrates hyperkeratosis and parakeratosis, the diagnosis is lichen simplex chronicus.

Here is a clinical pearl! Lichen simplex chronicus is characterized by intense itching and scratching and is associated with the “itch, scratch, itch” cycle. It often begins with an acute event such as contact dermatitis or vulvovaginal candidiasis, and evolves into a chronic skin condition.

Now let’s talk about lichen sclerosus. Most patients with this condition are premenarchal or postmenopausal. The cause of this condition is unclear, though genetic and autoimmune factors likely play a role. Your patient will describe vulvar itching, irritation, and burning; and perhaps dyspareunia.

The physical exam will show white papules that often coalesce to form plaques. The skin is thinning, crinkling, and hypopigmented with a tissue paper appearance, which assumes an hourglass or figure-eight shape around the perivaginal and perianal areas. There may also be evidence of involution of the labia minora, phimosis of the clitoral hood, and skin fissures.

Next, consider lichen sclerosus and order a vulvar biopsy. If the biopsy demonstrates a lichenoid inflammatory pattern and hyperkeratosis, this is consistent with lichen sclerosus.

Here is another clinical pearl! Vulvar skin disorders could be diagnosed by history and physical examination alone, but a biopsy is indicated if the diagnosis is uncertain, there is a concern for malignancy, or standard treatment is unsuccessful. The biopsy can be performed as a punch, shave or excisional procedure, which is determined by the characteristics of the lesion, physician preference, and resource availability.

Okay, time to move on to another inflammatory skin condition, lichen planus. This primarily affects patients who are perimenopausal or postmenopausal. They will report burning and itching as well as dyspareunia and post-coital bleeding. They may also have oral symptoms such as burning and pain when eating.

The physical examination will reveal Wickham striae which are white, lacy, or fern-like striae adjacent to erythematous epithelium. Vulvar erosions and scarring will be present and there might be loss of vulvovaginal architecture, vaginal discharge, and possibly oral striae and erosions.