Vulvar skin disorders (benign): Clinical sciences

There are several benign skin disorders of the vulva, including contact dermatitis, lichen simplex chronicus, lichen sclerosus, and lichen planus. These skin disorders are often chronic and can cause significant discomfort, decreased sense of well-being, and adversely affect sexual function.

When evaluating a patient with a chief concern suggesting a benign vulvar skin disorder your first step is to obtain a focused history and physical. The first thing you should ask about is symptom…onset, duration, location, and nature.

Other factors that will aid in your diagnosis include the timing of symptoms in relation to the patient’s menstrual cycle and a review of any possible precipitating or known risk factors. The vulva is particularly sensitive to irritants including cleansers, fragrances, lubricants, and other topical products such as antibiotics and local anesthetics, bathing, shaving, and the use of incontinence pads, or menstrual products.

Now, for patients with acute concerns of vulvar pruritus, especially for those with concomitant vaginal discharge, first consider possible alternative diagnoses, such as vulvovaginal infections and conditions like bacterial vaginosis, candidiasis, trichomoniasis, or molluscum contagiosum. On the other hand, for those whose symptoms are more chronic, consider a benign vulvar skin disorder.

Here’s a clinical pearl! History and physical examination are typically enough to make your diagnosis. However, when the diagnosis is not clear or treatment does not improve your patient’s symptoms, be sure to obtain additional labs. These may include wet mount microscopy, yeast culture, screening for sexually transmitted infections, and vulvar biopsy.

A vulvar biopsy is a powerful diagnostic test for vulvar skin disorders as it can definitively confirm your diagnosis. A biopsy is indicated if you are unsure about the diagnosis or if on physical exam you see any of the following; an atypical lesion such as one with new pigmentation, concern for malignancy, a lesion in an immunocompromised patient, a lesion that is not responding to standard treatment, or a lesion that worsens with treatment.

Okay, let’s discuss the common benign vulvar skin disorders, starting with contact dermatitis. Symptoms include chronic vulvar pruritus or burning. Remember to ask about exposure to vulvar irritants or allergens as those are common causes of contact dermatitis. These may include new laundry detergents, soaps, sanitary products, adult or baby wipes, condoms, semen, dyes, and hygiene products.

Physical exam is characterized by mild to marked vulvar erythema and swelling. You might also note excoriations, fissures, erosions, or ulcers.

Here’s another clinical pearl! There are many over-the-counter hygiene products including vaginal sprays, washes, douches, perfumes, and deodorants. In general, they are not recommended by health care providers as they can cause significant vulvar irritation.

Treatment for contact dermatitis starts with vulvar care counseling. This includes educating your patient on the sensitive nature of the vulva and the importance of removing any current vulvar irritants or allergens along with avoiding them in the future.

For irritation, counsel your patient on general vulvar care including sitz baths in lukewarm water. Be sure to let them know that following their sitz bath they should pat the area dry and apply an emollient, like vaseline, to lock in moisture and create a barrier.

Additionally, prescribe a topical high-potency corticosteroid ointment, such as clobetasol, which is better suited than over-the-counter options. Ointments are preferred over other formulations because creams and lotions often contain alcohol or preservatives which can cause or exacerbate irritation. You can also offer an oral antihistamine medication to help with itching.

Now let’s move on to lichen simplex chronicus. This is also known as the “itch that rashes” as it presents with chronic, unrelenting vulvar pruritus followed by scratching. Lichen simplex chronicus typically occurs secondary to prolonged contact dermatitis. This is due to the chronic mechanical irritation from scratching and rubbing an already irritated area.

On examination, the classic findings include one or more erythematous, scaling or lichenified plaques along with excoriations. Depending on how long the disease has been present the skin may appear thickened or “bark-like”.

As before, treatment of lichen simplex chronicus includes counseling on proper vulvar care, with a primary focus on breaking the itch-scratch cycle. One aspect of this counseling is raising awareness about potential nighttime scratching, which should be avoided. Additionally, a prescription topical medium to high-potency corticosteroid ointment is indicated, and again, you can consider an oral antihistamine to help with itching. A fungal culture can also be considered to rule out underlying vulvovaginal candidiasis.