How to navigate vulvar dermatology

It is important to know what is normal and what is abnormal when it comes to the vulva, especially when diagnosing and treating vulvar-afflicted diseases, according to a recent presentation.

This presentation focused on vulvar dermatology and was given by Jean Marino, APRN-CNP, NCMP, IF, at the ­25th Annual Premier Women's Healthcare Conference held in Houston, Texas, from September 29 to October 2, 2022.

Marino began her presentation by stating that the default is for the genitals to develop into females, but the introduction of androgens is how it differentiates. When it comes to females, the vulvovaginal area is made up of 3 embryological layers, including: the vulva (ectoderm), vestibule (endoderm), and vagina (mesoderm).

Both estrogen and androgen play a role in the vulvovaginal area by maintaining blood flow, protecting against harmful pathogens, and supporting the tissue and microbiome. Additionally, Marino said both androgens and estrogen are integral for vascular health and signaling sexual responses. Different embryological layers responding to different hormone groups. For example, the vulva and vestibule respond to androgen, while the vagina responds to estrogen.

Marino then presented a few cases that demonstrated normal vulvovaginal areas vs scenarios that required further exploration. One such case demonstrated prolonged pruritus, multiple doses of fluconazole, and burning pain after intercourse.

Marino stated that some common reasons for vulvovaginal pruritus include contact dermatitis, trichomonas, vulvovaginal candidiasis, lichen sclerosus, lichen simplex chronicus, and genitourinary syndrome of menopause. She added that when diagnosing your patients with complaints of vulvovaginal pruritus, to ask if they have any concern for STI exposure, if they have self-treated, and what their vulvar and vaginal hygiene is like.

If you suspect vulvovaginal candidiasis, Marino said to watch out for fissures, erythema and edema, no change in pH levels, vaginal discharge or lack thereof, as well as itching, irritation. Pain. Itching, and dysuria.

When it comes to treatment, Marino suggested either azoles (fluconzazole and terconazole), which inhibit fungal growth, or ibrexafungerp, which kills candida species.

Other cases were presented that covered a wide variety of symptoms including diseases associated with pruritus such as genitourinary syndrome of menopause, contact dermatitis, lichen sclerosus, lichen simplex chronicus. Cases on pain-related diseases such as vulvodynia and vestibulodynia, and erythema-related disease like genital psoriasis and vulvar lichen planus were also presented.

Marino concluded her presentation with some valuable key takeaways for the audience:

• The disease is not ruled out if the biopsy does not confirm what you expect.
• A thorough history and physical exam that includes hygiene and treatment is crucial.
• A little clobetasol goes a long way and consider the likelihood of yeast
• Before you refer to pelvis floor physical therapy or dilator use, ensure the tissue is healthy.
• Potential negative body image and the patient’s sexual health is important to keep in mind.
• Vaginal estrogen is great, especially in menopause.
• Follow-ups are essential.

Disclosures: Jean Marino, APRN-CNP, NCMP, IF, is on the advisory board for Scynexis and is a partial owner of The Menopause Retreat.

Reference:

1. Marino J. Vulvar Dermatology. Presented at: 25th Annual Premier Women's Healthcare Conference. Houston, Texas. September 29 to October 2, 2022.