Vulvar irritation in a 27-year-old woman

Appearance of the vulva in this case

Appearance of the vulva, detail

Case 3

A 27-year-old woman presents with an 18-month history of vulvar irritation. She is otherwise healthy except for episodes of depression. She has tried multiple agents for her condition including topical steroids, Vagisil, antibiotics, and fluconazole. She used oral steroids but developed knee pain. Tacrolimus has not helped. A biopsy revealed lichen simplex chronicus. Immunofluorescent studies were negative.

Answer: A - Contact dermatitis

Discussion

Contact dermatitis is common. Initially, removal of the offending agent is most important. There are reports in the literature of contact dermatitis to benzocaine, as was the situation in this patient. She was using up to 5 tubes of Vagisil, which contains benzocaine, daily on her vulva. Once the patient stopped using the benzocaine product, her vulva returned to a normal appearance. 

Oral agents for symptom control (tricyclic antidepressants or anticonvulsants) may be needed to help avoid overuse of topical agents. 

Herpes simplex virus (HSV) is a common STD in the United States. In a patient with a normal immune system, such as this woman, the classic appearance is that of an erosion, rather than an ulcer.  The lesions tend to be 1 to 3 mm in size, but they can be up to 1 cm. The area involved on this patient was too large to be herpes because she was not immunocompromised.  

Molluscum contagiosum may have been a consideration in this patient because of the smaller lateral lesions with central indentations, but the overall appearance of her vulva is not consistent with that diagnosis. The lateral lesions  are secondary to extensive scratching.

Cicatricial pemphigoid is a rare condition of the vulva and predominantly a disease of the elderly. In this patient, cicatricial pemphigoid was ruled out on tissue biopsy and immunofluorescent studies.

References

Guerrero A, Venkatesan A. Inflammatory vulvar dermatoses. Clin ObstetGynecol. 2015;58(3):464-75.

Gnann JW, Whitley RJ. Genital herpes. N Engl J Med. 2016;375:666-74.

Centers for Disease Control and Prevention. Genital Herpes  Available at https://www.cdc.gov/std/herpes/ Accessed July 23, 2017

Heslop R, Roberts H, Flower D, Jordan V. Interventions for men and women with their first episode of genital herpes. Cochrane Library 30 August 2016 Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010684.pub2/full Accessed July 23, 2017