By Claire Ferensowicz, MSN, WHNP-BC
The author reviews diagnostic and management approaches to benign cutaneous conditions affecting the vulva that are commonly encountered in ambulatory women’s health settings. Not all skin is created equal; vulvar skin is markedly more sensitive than skin on other areas of the body. In addition, the association with body image and sexuality can make a benign vulvar lesion or dermatitis anxiety provoking for patients. Nurse practitioners can perform assessments, prescribe treatments, and provide suggestions for improving quality of life for women who have contact dermatitis, atopic dermatitis, intertrigo, lichen sclerosus, or other benign asymptomatic lesions that are uncomfortable and/or worrisome.
Careful examination of the vulva and external genitalia is an important component of the well-woman gynecologic examination. Even though the vulva is the most visible component of the female genitalia, it is sometimes overlooked and, in fact, has been termed the forgotten pelvic organ.1 Basic dermatologic inspection sometimes has lower priority than collecting the cervical cytology sample. Nevertheless, dermatologic complaints are among the most common reasons women see a primary care practitioner. Cutaneous disease is thought to account for 10%-15% of patient consultations with general practitioners.2
Vulvar skin is at particular risk for the development of dermatoses because it contains both keratinized and non-keratinized skin and because the vulva itself is a warm, moist environment often covered and/or exposed to friction. This milieu is ideal for the development of bacterial and yeast infections, contact dermatitis, and other immune-mediated dermatoses. Signs and symptoms (S/S) associated with these conditions (eg, pruritus, erythema, hyperpigmentation) are common and anxiety provoking, and can interfere with body image and sexual function.3-5
The approach to patients with a vulvar complaint is both comprehensive and sensitive. A pruritic patch or new bump in the vulvar area, compared with a similar lesion on an arm or the scalp, may ignite heightened anxiety and stigma. With a keen eye, nurse practitioners providing routine gynecologic care can evaluate and prescribe treatment for women who have contact dermatitis, atopic dermatitis, intertrigo, lichen sclerosus, or other benign lesions that may be worrisome. Many curative interventions are as simple as vulvar care review and empathetic reassurance.
History and physical examination
All patients with vulvar complaints require a focused and detailed history (Table 1).6 NPs should pay special attention to patients’ use of fragranced soaps or scented laundry detergent, hygiene practices, and grooming habits, which are frequently implicated in the etiology of vulvar dermatoses. In addition, NPs need to obtain patients’ personal and family histories of autoimmune conditions, atopy, and other skin disorders. For example, NPs should inquire about a family history of genodermatoses (inherited genetic skin conditions) such as Darier’s disease, metageria, epidermolysis bullosa, and Harlequin ichthyosis.7
When assessing vulvar skin, NPs need to take a multidisciplinary approach—and remember that dermatology and gynecology are not mutually exclusive.8 Physical assessment of the vulva begins with noting the general color, texture, and turgor of the skin. Ample lighting is important when surveying the vulvar area because skin changes can be as subtle as mild scaling or slight hypopigmentation. NPs need to pay special attention to papular lesions, patches, and plaques, as well as areas of inflammation, scaling, and atrophy. From morphologic and histologic standpoints, dermatoses present differently on mucosal versus non-mucosal surfaces. For example, herpetic lesions on cutaneous areas may present as a classic cluster of small bumps, whereas those on mucosal areas may be completely ulcerated and indistinguishable from an erosion or chancre. Furthermore, actions causing friction (eg, sexual activity, exercise) may alter the primary morphology of skin lesions.6
Providing a hand mirror can enhance patients’ participation in the examination by allowing them to direct the clinician to the affected area. At the same time, this process can facilitate patients’ understanding of their own anatomy and targeted areas of diagnosis and treatment.9
One of the most common causes of vulvar pruritus is contact dermatitis. The vulva is inherently vulnerable to irritation because the barrier function of vulvar skin is substantially weaker than that of skin at other anatomic sites.10,11 Along with its compromised barrier function and hypersensitivity, vulvar skin is frequently subjected to caustic practices such as shaving, use of scented panty liners, and overzealous washing.
Contact dermatitis is divided into two categories, irritant contact dermatitis and allergic contact dermatitis12,13; in women with vulvar complaints, the former is more common than the latter.13 In allergic contact dermatitis, the trigger induces an immune response, whereas in irritant contact dermatitis, the trigger itself directly damages the skin. In other words, an irritant substance is one that, if applied in sufficient concentration, induces an inflammatory reaction in everyone. By contrast, an allergic reaction is specific to an individual’s hypersensitivity to a particular substance and thus always involves the immune
The most common contact allergens, which can be identified in individual patients by patch testing, include medications, preservatives, and fragrances.14 Many experts advocate avoidance of all topical vulvar hygiene products to decrease the likelihood of developing contact dermatitis.15 Patch testing, a technique used to ascertain whether a substance that comes in contact with the skin is causing inflammation, is used early in the therapeutic process rather than being reserved for patients who do not respond to treatment.13 Patch testing is performed by placing tiny quantities of allergens in direct contact with the skin and holding the allergens in place with special hypoallergenic adhesive tape. The test is done on an area of skin unaffected by the dermatitis.
After 48 hours, the tape is removed and evaluated by a clinician, who knows that some reactions may be delayed. Patch testing can help confirm whether a substance is causing—or aggravating—a dermatitis. Patch testing is most commonly performed by dermatologists, although NPs with dermatology experience are qualified to do this testing.
In vulvar contact dermatitis, the vulvar skin may appear mildly to severely inflamed, mildly to severely erythematous, and/or mildly to severely edematous, or it may manifest as scaling with thick lichenification from years of chronic rubbing. The area of vulvar involvement may be localized to a small site from deliberate contact or it may be generalized to the perineum and medial thighs.
The best, and only curative, treatment of contact dermatitis is to eliminate exposure to the offending agent. Therefore, comprehensive and specific questioning about hygiene practices and product usage is necessary. NPs review standard vulvar care with patients (Table 2).16,17 Sitz baths in lukewarm water may be soothing; patients are advised to pat themselves dry (as opposed to rubbing themselves hard) with a towel after bathing.
Once the offending agent is identified and removed from the environment, topical corticosteroids may be used to reduce inflammation. These agents are carefully selected with regard to potency and vehicle, keeping in mind that gels and creams can be irritating because of extenders used in the formulations.10 Ointments, the best choice for treating vulvar dermatoses, may be kept in the refrigerator so that the application itself is cooling and palliative. When prescribing topical steroids, NPs must remind patients that although these agents are safe to use for 10-14 days (twice daily, as needed, for redness, flaking, and itching), long-term use may be associated with cutaneous side effects such as atrophy, hypopigmentation, and telangiectasia.14
Therapy is important; otherwise, rubbing and scratching the irritated area can lead to an increase in discomfort and pruritus. Itching provokes scratching, which causes excitation of nerve fibers, which then intensifies the sensation (the itch-scratch cycle).18 If adequate relief is not achieved, another useful intervention to block the cyclical pattern is to recommend a sedating antihistamine at bedtime. Hydroxyzine 10 mg has been shown to be effective in alleviating vulvar itching.10 Patient education and follow-up are essential to optimize treatment and prevent recurrence of vulvar contact dermatitis.
One-third to one-half of women’s vulvar complaints stem from atopic dermatitis (eczema).19,20 Vulvar dermatitis can develop in isolation or as part of dermatitis in other areas of the body. S/S of atopic dermatitis include pruritus, burning, rawness, and stinging.14 S/S may be exacerbated by heat, sweat, stress, or menstruation.19 The diagnosis is clinical, based on a history of chronic vulvar irritation and pruritus. Excessive washing of the vulva by women who fear a lack of cleanliness often aggravates atopic dermatitis instead of relieving it. Patients must be reminded that the vagina is self-cleaning, and that overzealous washing is unnecessary and can lead to painful reactions.
Eczematous skin is especially susceptible to secondary infection and excoriation, which can cause variation in appearance and complicate the clinical picture. Bacteria can take advantage of the compromised barrier function and cause impetigo in the eczema. The trademark of impetiginized skin is honey-colored crust, but secondary infection may also present as pustules or fissures. Impetigo may be treated prophylactically or reactively with topical mupirocin ointment.17
Vulvar atopic dermatitis requires a two-fold treatment modality. A large part of treatment is patient education and behavior modification. Atopic dermatitis is considered endogenous because S/S arise inherently in the skin; they are not due to an exogenous irritant that can be removed from the environment (as is the case with allergic contact dermatitis). Although this condition lacks a cure, it can be ameliorated with proper skin care practices. S/S usually resolve after treatment with low- to medium-potency topical corticosteroid ointments such as triamcinolone acetonide 0.1% twice daily for 14 days, followed by a maintenance dose twice weekly after the flare has resolved.16
Candidal intertrigo is an infection of the skin by Candida albicans that occurs between intertriginous folds of skin—commonly under the breasts, in between the legs, or in the groin area. Intertrigo presents as erythematous, macerated skin that is commonly pruritic and painful.21 The diagnosis of intertrigo is typically a clinical one, although microscopy can confirm it. A KOH preparation on a wet mount of skin scrapings shows hyphae and budding hyphae.21
Management of intertrigo begins by addressing predisposing factors to candidal infections. Predisposing factors include diabetes, obesity, and the wearing of tight clothing, which leads to chafing. A discussion regarding a low sugar and yeast diet is appropriate in these cases.22 Because Candida organisms thrive on simple carbohydrates, patients are encouraged to avoid foods such as white bread, processed food, and sugary snacks. Topical antifungals and low- to mid-potency topical corticosteroids may be used initially to decrease discomfort.22,23 Once the rash has cleared, ketoconazole 1% shampoo (available over the counter) may be used 1-2 times weekly for long-term management. Keeping the intertrigo-prone area as dry as possible can prevent subsequent flares. Use of talcum-based powders on thoroughly dried skin is helpful in warm humid weather.24
Lichen sclerosus is a chronic immune-modulated dermatosis that can cause substantial discomfort and morbidity.25 This idiopathic inflammatory skin disease has a predilection for the genital skin. Although most frequently seen after menopause, lichen sclerosus can present in women of any age group, on any part of the body. In typical cases, lichen sclerosus appears as well-defined white plaques with an atrophic wrinkled surface.26 Longstanding disease can lead to labial shrinking, contributing to a keyhole or figure of eight appearance.15 Ecchymoses, edema, fissures, and erosions may be present on the labia minora, labia majora, and surrounding anogenital skin.27 Although lichen sclerosus can be asymptomatic, in many cases it is characterized by intractable burning pruritus28
The diagnosis of lichen sclerosus is a clinical one, based on the history and physical exam findings. If a biopsy is warranted for confirmation, NPs trained in performing a vulvar punch biopsy may collect a specimen. Referral to a gynecologist or dermatologist is required for refractory cases and/or if NPs are uncertain regarding the area from which the biopsy specimen is to be obtained.29 The biopsy is done at the initial visit, before topical corticosteroid is applied; both clinical and histologic appearances can be modified by corticosteroid usage.15
First-line treatment for lichen sclerosus is a superpotent topical corticosteroid: clobetasol propionate 0.05% ointment twice daily for 3 months.30 When caring for patients with lichen sclerosus, NPs must keep in mind that the speculum examination may be uncomfortable (due to introital narrowing) and that this disease can have an adverse effect on a woman’s body image. Although lichen sclerosus is considered benign, it can be associated with squamous cell carcinoma. Therefore, teaching of self examination is imperative and regular follow-up visits are recommended.31
Not all skin is created equal. Vulvar skin is markedly more sensitive than skin found
on other areas of the body. Concerns are intensified in terms of the vulvar area because of its association with body image and sexuality. Providing anticipatory guidance by supplying patients with a hand mirror and routinely pointing out benign nevi, acrochordons (skin tags), and degree of pigmentation can prevent future stress. Reviewing standard vulvar care is one of the most important parts of a well-woman gynecologic examination. Having a basic understanding of the prevalence of dermatologic conditions in women’s health and an understanding of dermatology terminology can make the diagnosis of a vulvar complaint a routine event.
Claire Ferensowicz is a women’s health nurse practitioner at Pacific Northwest Fertility in Seattle, Washington. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.
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