Approach to vulvar skin disorders: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:19

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.

Focused H&P/Contact dermatitis0:19–1:25

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.

Lichen simplex chronicus1:25–2:48

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.

Lichen sclerosus2:48–4:18

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.

Lichen planus4:18–5:22

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.
If you see these findings, consider lichen planus and get a vulvar biopsy. If the biopsy reveals a lichenoid reaction pattern and a dermoepidermal junction with lymphocytic infiltrate, you have made your diagnosis of lichen planus.Now let's move on to condyloma acuminata.

Condyloma acuminata5:22–6:28

In this case, the patient will report single or multiple bumps on the vulva or perineum that may cause itching and irritation.
When performing the physical exam, you will find single or multiple lesions that might be flat or pedunculated; and either smooth, verrucous, or lobulated.
The lesions may vary in hue from skin-colored to erythematous or hyperpigmented. If you see these findings, consider condyloma acuminata.
Condyloma can be diagnosed by physical examination alone, but if they do not respond to standard treatment, consider an excisional biopsy which will show papillomatosis and koilocytosis.
This will confirm the diagnosis of condyloma acuminata. Here is a high-yield fact!
The majority of condylomas are associated with human papillomavirus, or HPV, types 6 and 11 which are of low oncogenic potential.

Vulvar dysplasia6:28–7:06

Alright, another important condition is vulvar dysplasia. The patient may present with risk factors such as prior HPV infection, tobacco use; or they could be immunocompromised.
They may report vulvar lesions that are associated with itching, a change in color or size, or bleeding. The physical examination will demonstrate elevated or flat lesions with variable colors such as white and gray; or red, black, and brown.
In this situation, consider vulvar dysplasia and perform a vulvar colposcopy with biopsies.The colposcopy may reveal lesions with leukoplakia and hyperpigmentation.

Vulvar low-grade squamous epithelial lesion7:06–7:28

If the biopsy demonstrates cytologic atypia in the upper third of the epithelium and the absence of atypia in the lower two-thirds of the epithelium, then the diagnosis is a vulvar low-grade squamous intraepithelial lesion or LSIL.

Vulvar high-grade squamous intraepithelial lesion7:28–8:39

Alternatively, the colposcopy might demonstrate leukoplakia and hyperpigmentation as well as an atypical vascular pattern.
If the biopsy reveals cytologic atypia from the middle third to the full thickness of the epithelium without invasion of the dermis, the diagnosis is vulvar high-grade squamous intraepithelial lesion or VIN.Here is a high-yield fact!
LSILs include vulvar LSIL and flat condyloma, and are associated with HPV. High-grade squamous intraepithelial lesions, or HSIL, are also known as usual-type VIN, and are secondary to persistent HPV with high oncogenic potential.
Usual-type VIN is a precancerous lesion that may evolve into squamous cell carcinoma. There is another type of VIN, differentiated-type VIN, that is not related to HPV but is associated with chronic dermatologic conditions such as lichen sclerosus.
Differentiated VIN is actually more likely to become squamous cell carcinoma than the usual type VIN.Lastly, the colposcopy might demonstrate leukoplakia, hyperpigmentation, or erythema, as well as an atypical vascular pattern with friability and ulcerated or warty lesions.

Vulvar squamous cell carcinoma8:39–9:03

If the biopsy shows cytologic atypia through the full thickness of the epithelium and invading into the dermis, the diagnosis is vulvar squamous cell carcinoma.Finally, let’s talk about vulvar melanoma.

Vulvar melanoma9:03–9:51

The history will reveal a darkly pigmented changing mole. Physical exam of moles should follow an ABCD assessment.
In melanoma, the lesion will reveal atypical features which include Asymmetry, Border irregularity, a Color that either is black or multicolored, and a Diameter of more than 6 millimeters.
In addition, friable, vascular nodules with or without dark pigmentation might be present. Consider melanoma and perform a vulvar biopsy.
If the biopsy reveals dysplastic melanocytes with positive staining for melanoma-specific antigen you have made the diagnosis of vulvar melanoma.After assessing for common causes of vulvar skin disorders, consider and assess for alternative diagnoses.

Consider alternative diagnoses9:51–10:07

These include Paget disease, vitiligo, vulvovaginal candidiasis, molluscum contagiosum, or condyloma lata.Alright, as a quick recap… Vulvar skin disorders often present with vulvar pruritus, itching, and pain.

Review10:07–10:45

There are a variety of vulvar skin disorders including contact dermatitis, lichen simplex chronicus, lichen sclerosus, and lichen planus.
Other common conditions include condyloma acuminata, vulvar low-grade and high-grade squamous intraepithelial lesions, vulvar squamous cell carcinoma, and melanoma.
Also consider other causes of vulvar skin disorders such as Paget disease, vitiligo, vulvovaginal candidiasis, molluscum contagiosum,