Vulvar skin disorders (benign): Clinical sciences

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Introduction0:00–0:26

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.

History and Physical exam0:26–2:37

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.

Contact dermatitis2:37–4:40

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.

Lichen simplex chronicus4:40–5:58

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.Next, let’s talk about lichen sclerosus.
The exact etiology is unknown, but it’s thought that genetic, autoimmune, environmental, and hormonal factors play a role.

Lichen sclerosus5:58–8:32

Patients with lichen sclerosus present with chronic vulvar pruritus, irritation, burning, dyspareunia or pain with intercourse, and tearing.
Lichen sclerosus is associated with chronic scarring and it’s seen most often in the prepubertal and postmenopausal populations.
Here’s a clinical pearl! Lichen sclerosus should be differentiated from genitourinary syndrome of menopause.
This condition results from low levels of local estradiol, and may also appear with some atrophic changes to the vulva. However, there’s preservation of anatomical structures, unlike some cases of lichen sclerosus with abnormal scarring, where anatomical landmarks may become obliterated.On physical exam, you’ll typically see white papules and plaques along with thinned, crinkling, and whitened skin in a figure eight distribution from the superior vulva to the perianal tissue.
You may also see scarring, fusion of the labia minora, phimosis of the clitorial hood, fissures, and tears. Here’s a high-yield fact!
Lichen sclerosus is associated with a small increase in the risk of vulvar squamous cell cancer. Long term follow-up with routine examinations is indicated in patients with lichen sclerosus to monitor for signs of disease progression.
Now, when it comes to treatment, a topical medium to high potency corticosteroid ointment is used frequently and then tapered down based on symptoms.
A 3-month follow-up is recommended to monitor for both improvement of symptoms and vulvar appearance. Once lichen sclerosus is in remission, long term maintenance consists of continued topical corticosteroid ointment titrated to the lowest dose needed to maintain symptom resolution.
If treatment failure occurs, be sure to obtain a vulvar biopsy, unless previously completed, to confirm your diagnosis. If the diagnosis is confirmed and treatment still fails, your patient may need intralesional corticosteroid injections, often performed via a vulvar specialist.
Alright, let’s go over the final benign vulvar skin disorder called lichen planus. This disorder typically presents with chronic vulvar burning and pruritus along with dyspareunia, vulvar soreness, and increased vaginal discharge.The hallmark feature on examination is the presence of Wickman striae, which are white, lacy striae.

Lichen planus8:32–10:39

You might also observe erosions in the posterior vestibule, agglutination, and resorption of the labia, and the presence of oral lesions.
As before, treatment of lichen planus begins with the application of a topical high-potency corticosteroid ointment and a 3 month follow-up to monitor symptoms.
After the symptoms are stable, long term maintenance is achieved with the lowest dose of corticosteroid ointment needed to manage symptoms.
One key thing to keep in mind is that visualization of erosive disease on either initial or subsequent examinations requires referral to a vulvar specialist.
This is because erosive disease can cause significant scarring of the vaginal canal to the point of complete obliteration!
When present, Intravaginal corticosteroids and vaginal dilators may be needed. Additionally, the majority of patients with erosive disease have oral involvement and will require a dental provider on their care team.Here’s a high-yield fact!
Although the exact etiology is unknown, lichen planus is believed to be associated with dysfunction of cell-mediated immunity, and concomitant autoimmune disorders have been seen in approximately one third of patients with lichen planus.
This condition most commonly affects perimenopausal and menopausal patients.And one last clinical pearl! While these 4 diseases are the most common benign vulvar skin disorders there are others you might see in clinical practice including psoriasis, eczema, and seborrheic dermatitis.
Alright, as a quick recap… The most common benign vulvar skin disorders include contact dermatitis, lichen simplex chronicus, lichen sclerosus, and lichen planus.

Review10:39–11:12

The diagnosis is usually a clinical one. Treatment includes topical corticosteroid ointment along with optimizing vulvar care, including removal of vulvar irritants and allergens.
Lichen sclerosus and lichen planus require long term maintenance with the lowest dose of corticosteroid ointment needed to manage symptoms.