Essay 289 - vulval disease

SAQ Vulval disease

A   Patient is asked about the severity of her symptoms and the extent to which these are affecting her sexual function. Urinary problems like dysuria, frequency, hesitancy of micturition and pain on defecation are asked. She is asked about vaginal discharge, bleeding and painful ulcers in genital area. She is asked about skin disorder in any other body parts. She is asked about history of diabetes mellitus, thyroid disease, rheumatoid arthritis or autoimmune disorders like pernicious anaemia, which are associated with skin manifestations, family history of skin disorders like psoriasis, eczema is asked. She is asked about the medicines she is taking like hormone replacement therapy, over the counter drugs and any emollients or creams she is using for her problem. She is asked about allergies to different food, chemicals or drugs. Specific enquiries are made about her personal history of whether takes shower or bath, use of soap, bubble bath, use of dark coloured underwear, panty liner, tampons and dark coloured tissue paper, use to biological powder for washing clothes because these can aggravate the skin irritation causing pain and itching.  Obstetric history like parity, mode of birth, previous surgeries are noted as this will help to plan management.

Examination includes pallor, pulse, and exophthalmos for anaemia and thyroid disorder. Skin lesions on scalp, neck, elbows, knees are noted. Local examination of genital area like papules, white thickened vulval skin lesions in form of figure 8 around anogenital area due to scarring is due to lichen sclerosis. Any ulcers, bleeding, swelling, vaginal discharge is noted to asses sexually transmitted disease. Adhesions of labia minora causing narrowing of vaginal orifice, urethral scaring, or clitoral hood scaring is due to lichen sclerosis. Speculum examination includes lesions of vaginal walls and cervix and type of vaginal discharge.

B    Thyroid function tests, serum ferritin, and blood sugar tests done if history is suggestive of the relevant disorder. Urine examination and culture if symptoms are suggestive of UTI.  Endocervical swabs, urethral swab, high vaginal swab to exclude sexually transmitted infection. Skin biopsy is not indicated if diagnosis is made on clinical examination, however it is needed if there is failure to treatment or lesion suggestive of underlying carcinoma.

C    she is thought to have lichen sclerosis so a general advice is given about care of vulval skin is given like avoidance of irritants used for personal hygiene, which increase her symptoms. She is advised to take shower rather than bath, avoid use of perfumed soaps, bubble bath, and biological powder for washing clothes. She can use cream or emollient whichever suites her. She should use light coloured cotton underwear, sleep without underwear, and avoid panty liners or tampons, which irritate her.

For Lichen sclerosis potent corticosteroids like clobetasol propionate for local application is used. It is used daily for one month, on alternate days for next month then twice weekly until it is tapered off slowly. Not more than 30g cream is used for 3 months as excessive use can cause skin thinning. 4-6% of cases are resistant to clobetasol so they are treated with tacrolimis under specialist care. Skin biopsy is needed to exclude malignancy, as lichen sclerosis is associated with 0-9% risk of carcinoma.

Surgery and laser therapy is not generally indicated unless there are symptoms associated with urethral stenosis, vulval adhesions, and lower vaginal stenosis causing dyspareunia. Surgery may be needed for cosmetic purposes.       

A.The woman should be asked in detail about how badly she is affected by these symptoms.A detailed history of use of new soap,shampoo,clothing,emollients  which can cause an allergic reaction to the vulva should be taken.History of use of self medication , over the counter drugs can also aggravate the symptoms or hormonal replacement therapy.Personal history of autoimmune disorders like Thyroid disease,Diabetes mellitus or use of regular vitamin b12 injections suggestive of Pernicious anaemia should be asked as autoimmune disorders have a 40% association with vulval disorders.History of atopy like Asthma,Hay fever ,eczema should taken as these women will have increased incidence of vulval dermatitis.Family history of autoimmnune disorders like Thyroid ,Diabetes,Pernicious anaemia should be taken as there is a 30-40% prevalence of autoimmune disorders in first degree relatives.History of urinay or fecal incontinence  which can cause irritation to the vulva should be asked for.History of last cervical smear should be asked for.History of persistent vaginal discharge should be taken.The woman’s vulva  should be examined in the presence of a chaperone after taking verbal consent in a lithotomy position  .Any areas of skin thinning,erosions ,ulcers  should be documented.All the mucosal areas including the mouth should be examined to look for lichen planus and other areas like scalp,elbows should also be examined for psoriasis.Speculum examination should be done to examine the cervix,vagina and anal region if VIN is suspected.

B.Serum Ferritin should be done to rule out iron deficieny anaemia as there is a association between vulval dermatitis and iron deficiency .Skin patch testing should be done if Vulvla dermatitis is suspected to look for any specific allergans.Thyroid function tests,Blood sugars to screen for diabetes and tests for Pernicious anaemia should be carried out.Vulval biopsy should not be carried out routinely.It should be done only if the clinical examination is inconclusive or there is a suspicion of Vulval intraepithelial neoplasia which is associated with 4% risk of invasive disease.Cervical smear should betaken if the woman is not updated with her smears.Vaginal,endocervical swabs should be taken if history is suggestive of sexually transmitted disease.

C.The woman should be explained about the diagnosis and given written information.She should be counseled about the general care of her vulva and to avoid baths and take showers instead,avoid using undergarments and harsh detergents to wash the vulva.She should be prescribed ultrapotent steroid Clobetasol propionate for local application which should be tapered of slowly over 4 months.Cure rate is 46-84% and there is a relapse rate of 84% in 4 years.If there is no response to clobetasol,then tacrolimus ,an immunosuppressant can be prescribed as a second line treatment.Surgery or CO2 lase treatment offers no benefit in woman with Lichen sclerosus.It can be helpful only in restoring vulval anatomy or function in case of distortion by agglutination or adhesions.Biopsy should be considered in case of failure of treatment as Lichen sclerosus is associated with 2-4% risk of underlying squamous cell carcinoma. 

history from this patient  needs to explore  local plus  other skin site  symptoms , medical,drug and family history.

she is asked  about  severity  of  symptoms aggrevating  and relieving  factors , , a preformed questanair  will be given  so important  things are not missed  and quality  of life assessed .she  is asked about other gynacological  symptoms  like bleeding, discharge  and  prolapse   abnormal cervical cytology,date and result of  last cervical smear, ulcers in  genital area.. whether she has similar  symptoms  on other sites  of skin  .What treatment  she recieved  so far .she is asked about  personal  or family history of autoimmune diseases like diabetes  or thyroid disease ,vitiligo , pernecious anemia   . she is asked about  personal and  family history of  allergies  ,eczema ,asthima ,hey fever.history  regarding symptoms of urinary  or fecal incontinence will be asked.drug history will be asked  use of  antibiotics  for long time , hormone replacement  therapy ,over the counter medicines ,.personal habbits regarding  use of   bubble  baths , soaps .she is asked about smoking ,

she will be examined sysematically  for anemia, signs  of thyroid disease ,skin  all over body specially elbows ,back of neck, for liken planus . nails knees  elbows and scalp for psoriasis .  examinatipon will be carried out in good light  and proper exposure .Local examination  incude inspection for ulcers, thickening or thinning of skin , typical figure of  8 liesion,adhesions , narrowing of interoitus (liken sclerosis)  ,srcach marks ,excoriation ,evidence of soiling with feces or urine. discharge . if possible vagina and cervix examined for discharge   ulcers .

B full blood count is carried out if anemia presend and iron defficiency suspected  serrum ferritin will be carried out.. testing fo thyroid disease ,diabetes , and sexually transmitted diseases carried out if clinically indicated. ,if lichen sclerosis or planus  suspected  she should be investigated for autoimmune diseases  if clinically indicated.skin patch testing carried out  if dermatosis present.Skin biopsy only indicated  if suspicion of VIN or  liesion fails to trearment.cervical smear taken if due.

C)     woman will be coucelled that it is a chronic condition  but   symptoms can be controlled  with simple measures and quality of life improved.she is taught about general hygene ,avoidance of irritants ,like bubble baths and perfume soaps, wearing cotten under garments avoid penty linners , Use of emolliants .ultrapotent  steroids  can be used like clobetasole  which improve symptoms in 50-90% patients .clear advice regarding  use will be given i,e daily for one month then on alternate days for next month  then twice weaky  for three months .4-10% patients are resistant to steroids  in them topical tacrolimus  can be given under supervision of specialist clinic.surgery   is indicated only to restore anatomy  by breaking adhessions  to improve sexual function  or body immage. regular follow up is required . woman is thaught about self examination .If symptoms are controled on high dose steroids or there are frequent recrrences  follow up is in specialist clinic .if she is symptom free  follow up with GP can be carried out  . she will be councelled about 2-4% risk of developping carcinoma in life time .during follow up if changes  suggestive  of VIN  are observed or condition as resistant to  drugs  biopsy will be taken and managed according  to result.

for sexual problem she  needs psychosexyal councelling and referal to specialist will be carried out . use of  lubricants encouraged,

a)Detailed history is taken regarding the most bothersome symptom ,whether itch or pain.Lichen sclerosis or candidal infection is associated with severe itching.Impact on QOl ,effect on sexul lifeis noted.

Associated symptoms of discharge,bleeding ,suggest infection.Presense of any vulvul ulceration with pain may be due to infection or malignancy.

Menstrual hx is taken about LMP.If she is menopausal her symptoms may due to atrophic changes in vulva and vagina.Cervical smear history is taken, as any premalignant changes in Cx may be associated with similar changes in vulva and vagina .

Type of clothing, use of perfumed talcum, soap or detergents  is enquired which may cause allergic dermatititis.Symptoms of urinary or fecal incontinence are asked, which on contact with skin can cause excoriation .

Enquiry is made regarding  autoimmune diseases such as hypothyroidism ,diabetes or pernicious anemia which are associated with lichen sclerosis. Family or personal h/o atopy or eczema is noted .Positive history is found in cases of vulval dermatitis.

Drug history is taken as her symptoms may be caused by over the counter drugs. Type of previous treatment taken  and response are also noted.Hx of smoking is taken,which is a risk factor for VIN.

Examination is done including height weight.BMI is noted.Presense of pallor,is suggestive of anemia.Thyroid enlargement is noted .Presense of any skin lesions on other sites such as mouth ,knees and elbows is noted,which suggests lichen planus.

Vulva should be systematically examined with adequate light.Any symptomatic area is noted.

b) FBC is done for Hb and ferritin, to asses severity of anemia.Correction of iron deficiency anemia is found to relieve vulval symptoms.

Thyroid function tests and blood sugar is done if symptoms are suggestive of thyroid disease or diabetes.In case of Hyper/hypothyroidism autoantibodies are  tested.

Swabs are taken for STI,if signs and symptoms indicate infection.

Biopsy is taken if there is any suspicion of VIN or malignancy, or if her symptoms have not responded to treatment. Patch test  for common allergens is done, if there is clinical suspicion of vulval dermatitis.

C)She should be counseled  about the possible diagnosis and reassured that it is not malignant.Her  symtoms are potentially curable but require prolonged treatment and follow up.

General advice about vulval care hygiene and avoidance of allergens is given.Emollients are given for restoring skin barrier function.

Ultra potent steroids such as clobetasol cream or ointment is applied .Suitable regime is to apply for four months, as once daily in first month,then alternate days for  1month,then twice a week for 1month and once a week for one month .Gradually reduced before stopping.If symptoms recur ,clobetasol may be used every night for 2weeks.This should be explained to her and her GP.Success rate with clobetasol is upto 80%.

If her symptom are not responding to steroids ,second line of treatment may be immune suppressants such as Tacrolimus.

Failure to response may raise suspicion of malignancy and a biopsy should be taken.
Referral to dermatologist may be needed for treatment of resistant dermatitis.

Follow up is required every  1-2yrs ,as about 4% of cases may progress to malignancy.

a) I would ask about the severity of her symptoms and how these impact the quality of her life including sexual function. I would ask about any history of autoimmune conditions such as thyroid disease, pernicious anemia, diabetes mellitus. Atopic conditions such as asthma, eczema, psoriasis should also be asked. Autoimmune and atopic conditions are commonly associated with vulval dermatoses. Ask about any allergies and recent changes in soaps, detergents, sanitary pads as these can cause her symptoms. I would ask about a family history of atopic and autoimmune conditions. I would ask if there are any other areas affected as vulval dermatoses may be a manifestation of other conditions e.g. eczema, psorias. I would ask about urinary or fecal incontinence as these can cause skin irritation. Ask about any vaginal discharge as infections can cause vulval pruritus. Smoking can increase chances of VIN so should be asked. General inspection should be done to look for any psoriatic plaques, nail changes, aphthous ulcers or any extra genital change that may clue in to a diagnosis. Genital inspection should be done to look for specific skin changes eg hypopigmented figure of eight lesion may suggest lichen sclerosis. Illicit any urinary incontinence. Examine thyroid gland to see if enlarged.

b) Appropriate and prompt investigations would lead to a prompt diagnosis and quick implementation of treatment thus reducing morbidity. A FBC with red cell indices should be done. Low Hb, MCV, MCH, MCHC may suggest iron deficiency anemia which is sometimes associated with vulval dermatitis. Serum ferritin should be done to confirm this. A megaloblastic anemia may suggest pernicious anemia. Skin patch testing to detect any allergies should be done. Gastric parietal cell antibodies should be checked. HbA1C should be done to assess glucose control. Formal OGTT may be needed for diagnosis. Swab of any vaginal discharge should be taken. Biopsy should be taken if diagnosis difficult or VIN suspected.

c) She should be managed in a vulval clinic jointly with a consultant gynaecologist and dermatologist. I would explain that Lichen Sclerosis is a skin disorder causing thinning and hypopigmentation of vulval skin. Explain that it is sometimes associated with autoimmune (thyroid disease, DM) and atopic (eczema) conditions. Explain that there is a 3-5% chance of vulval carcinoma. First line treatment would be potent topical steroids eg clobetasol. Second line treatment would be calcineurin inhibitors (eg tacrolimus). I would screen for autoimmune conditions (TFTs, HbA1C etc). If negative it should be repeated yearly. She should have yearly follow up as there is a risk of developing vulval cancer.

A 57 year old woman is referred to the gynaecology clinic with a 6 months history of vulval soreness, itching and pain on penetration during sexual intercourse.

(a) Discuss your clinical assessment [9 marks].

i will ask about the impact of her complaint on the quality of life and sexual functions.asking about most distressing complaint since pain is more prounced than itching in lichen planus while itching is more severe espacially by night in lichen sclerosus.associated symptoms as dysurea with lichen sclerosus due to adhesion formation around the urethra,vaginal discharge with candidiasis,rash with eczema and postcoital bleeding that might indicate associated cervical pathology,haematurea or bleeding per rectum indicate spreading malignancy.asking about the menstrual history regarding LMP since lichen sclerosus presents more in postmenopausal women as well as postmenopausal atrophic changes.history of fecal or urinary incontinence that might cause chronic irritation.history of allergy or exposure to known allergen.history of autoimmune disorders as thyroid disease,diabetes mellitus,vitiligo since 40% of lichen sclerosus cases are associated with autoimmune disorders.history of previous treatment and response to it.history of other lesions in the body since lichen sclerosus is associated with lesions in trunk and limbs in 18% of cases while lichen planus is associated with mucosal lesions in the mouth.cervical smear history since VIN is associated with HPV type 16.asking about risk factors for VIN as immunesupression,obesity and steroids.general examination for BMI,rash,scratch marks,mouth lesions,lesions over trunk and limbs,swellings suggestive of lymph node enlargement.perineal examination,firgure of 8 lesion with thickened white skin that bleed easily and adhesions in labia ,clitoris and fourchette are suggestive of lichen sclerosus.polygonal,violaceous lesions with white striae suggest lichen planus.erythema with sattelite lesions suggest candidiasis,non scaly erythema suggest psoriasis.examination of inguinal and femoral lymp nodes for enlargement,fixation or ulceration suggesting malignancy.examination of vaginal mucosa for atrophic postmenopaosal changes.examination of cervix for gross lesions suggesting malignancy.if malignancy suspected PR examination and bimanual examination to assess spread. 

(b) Justify the investigations that may be offered [5 marks].

a vulval biopsy especially if previous treatment failure or recurrent symptoms to diagnose VIN and exclude invasive disease.screening for diabetes mellitus associated with lichen sclerosus and candidiasis.screening for STI associated with VIN and CIN.serum ferritin since chronic vulval dermatitis is associated with iron deficiency anaemia.skin patch test to diagnose allergic conditions.screening for thyroid antibodies if clinically indicated in cases of lichen sclerosus.if malignancy suspected,CT scan and MRI should be offered to assess spread of disease. 

She is thought to have vulval lichen sclerosus. Discuss your subsequent management [6 marks].

i will explain the diagnosis to the patient and inform her that this is an autoimmune condition,not related to hormonal changes and 40% of patients have or going to have autoimmune disorders as type 1 diabetes,vitiligo or thyroid diseases.i will explain that general vulval hygeine and use of emolients is an essantial part of treatment.medical treatment include clobestasol cream or oeintement used daily for 1 month,then every other day for 1 month,then twice weekly for 1 month then once weekly for 1 month.recurrence is about 84% in 4 years.recurrence can be treated by clobestasol once daily for 2 weeks and if symptome keep recurring long term use for once or twice weekly is considered safe.if treatment with clobestasol fails,offering calcineurin inhibitors shows response in 77% of patients after 10 to 24 weeks but is not recommended for more than 2 years.surgery or co2 laser can be used to dissect adhesions but not for symptom releife.i will explain that there is a risk of malignant progression in 2-4% of cases so follow up is essential however it doesn't have to be hospital based.i will explain symptoms of malignant disease as bleeding,severe symptoms and failure of response to treatment and importance of contacting her GP if she experiences any of these.i will explain and encourage self examination for new or abnormal lesions.i will ask about sexual dysfinction and offer referral to psychosexual specialist if needed.i will provide written information.

A 57 year old woman is referred to the gynaecology clinic with a 6 months history of vulval soreness, itching and pain on penetration during sexual intercourse. (a) Discuss your clinical assessment [9 marks]. (b) Justify the investigations that may be offered [5 marks]. She is thought to have vulval lichen sclerosus. Discuss your subsequent management [6 marks].

a) Ask about associated symptoms such as bleeding or ulceration that would increase suspicion of malignancy. Also ask about vaginal discharge which may be seen in candida, and urinary and faecal incontinence as these may cause irritation & dermatitis. Enquire if she has a history of dermatological conditions or rash elsewhere elsewhere on her body as skin conditions such as psoriasis may involve several sites. Ask about history of thyroid disease and pernicious anaemia, as autoimmune diseases are associated with lichen sclerosus. Also ask about new topical exposures such as new soaps, fragrances or fabrics as these can cause allergy and irritation. Ask about history of smoking, pre-epithelial or cancerous cervical, vaginal or anal disease, as these are associated with higher risk of VIN. Take a history of treatments that she has tried and their efficacy, as well as her intake of other medications, hormone replacement therapy and smoking. Find out the impact of her symptoms on her quality of life, body image, sexual function and passing urine. 

Perform an examination ideally on a couch that allows her to be in a modified lithotomy position with adequate lighting. Using a vulvoscope will allow clearer views. It may be helpful to ask the patient to point to symptomatic areas. Inspect vulval as well as peri-anal skin, especially for features suspicious of malignant disease such as ulceration, and typical for vulval dermatoses such as fusion of labia minora in lichen sclerosus (LS). Examine the vaginal mucosa and cervix for lesions. Palpate for inguinal lymph nodes. Inspect the skin over the rest of the body for rash, as well as the oral mucosa particularly for Wickhan's striae which is associated with lichen planus. 

b) If the diagnosis is apparent after clincal assessment, the woman may be empirically treated without further investigations, unless there is failure to respond. If there is suspicion of malignancy she should be referred to a specialist vulval clinic urgently for examination. I would do a serum ferritin level as iron deficiency is associated with LS. A biopsy would be useful for histological diagnosis, and should be taken at the junction of healthy and unhealthy tissue. Skin patch testing may be done if allergy is suspected, and testing for other autoimmune diseases is justified if she has clinical symptoms, for example testing for thyroid disease if she has symptoms of weight loss, increased appetite and palpitations. A swab may be taken to test for infections such as candida. 

c) First line treatment is with ultra-potent topical steroids such as dermovate. This needs to be applied every night for one month, every other night for another month, twice a week for one month, one a week for another month, then as needed. A 30g tube should last for 3 months. Women should be given clear written instructions for applying steroids. Anti-histamines will help with symptoms of pruritus. The lady should also be given advice on vulval care, such as washing with soap substitutes and regular use of emollients. She should be informed of the 2-4% lifetime risk of developing vulval cancer, and inform the doctor if her symptoms fail to improve or worsen. She should be followed up regularly and referred to a vulval specialist clinic if she does not respond to treatment. Steroid resistant disease may be treated with topical tacrolimus under superivison of specialist clinic. If there is severe architectural distortion resulting in difficult with passing urine or intercourse, surgery to restore anatomy may be carried out. Cervical cytology should be done in accordance with national screening guidelines. 

(a) History should include presence of discharge or bleeding from the vulva. The woman should be asked on relieving and aggravating factors. Her perineal hygiene should be explored, for instance, the types of toiletries that she using. Previous history of similar symptoms should be explored and if she has being treated before, the type of medications should also be asked. The woman should also be asked about the presence of skin porblem elsewhere. Certain vulva disorder like lichen sclerosus (LS) is associated with autoimmune disorders (thyroid disease, diabetes, vitiligo and pernicious anaemia) and therefore, these history should be elicited. Her personal history of atopy should be enquired as it suggests possible diagnosis of dermatitis. Risk factors of vulva intraepithelial neoplasia (VIN) for instance, the state of immunosuppression and being a smoker should be asked. Her risks of sexually transmitted infections (STIs) should also be asked. In addition to that, her drug history should be included during assessment.

Examination should include systemic assessment of the anogenital region. The features of the lesion should be examined as different vulva disorder presents itself differently. In LS, it typically appears as porcelain white lesion in a figure-of-8 distribution and lichen planus (LP) has Whitman striae. If clinically suspicious of malignancy, groin nodes should be palpated. Skin elsewhere should also be examined. If VIN is suspected, speculum examination should be performed as it is associated with human papillomavirus (HPV) infection of the cervix, vagina and anus. Features of autoimmune disease, for instance, thyroid enlargement and vitiligo should be looked for.

(b) Investigations to look for autoimmune diseases should be performed. Full blood count should be performed to look for anaemia and thyroid function test to look for thyroid disorder. Vulva dermatitis is associated with iron deficiency anaemia and thus FBC, serum ferritin and skin patch test should be performed. If cervical smear is already due, then it should be performed during speculum examination. Skin biopsy should be considered if the lesion is suspicious to malignancy

(c) The diagnosis should be explained to patient and written information should be provided. General advice on the care of the perineum should be given to patient. She should be advised to clean her vulva using soap substitute rather than using water only or soap as these can cause dry skin. Following cleaning, it is advisable to dab the vulva dry or to use hair-dryer using cool setting. In addition to that, she should be advised to avoid wearing tight undergarments and pants and to avoid wearing dark-coloured undergarments. Shower is more preferable as compared to bath. 

Ultrapotent steroid in the form of clobetasol propionate 0.05% twice a day has been shown to be effective with up to 96% shown partial or full recovery from symptoms. Up to 30g can be used over three months and once improvements is seen, the dosage can be lowered. Topical use of steroids is associated with local side effects, such as, skin burning, discoloration and thinning. Systemic side effects are rare. In up to 10% of cases are steroid-resistant and thus, calcineurin inhibitor (tacrolimus) can be another option. Use of tacrolimus in LS is unlicensed and due to its safety issue, it should not be used for more than 2 years as there is theoratical risk of malignant transformation. Carbon diaoxide laser coagulation and surgery are not usually used in treating LS. However, it can be used when there is adhesion causing urinary obstruction or narrowing of vaginal introitus. 

Treatment response should be observed. If failed to respond, skin biopsy should be considered to ensure there is no malignancy. The woman should be advised that there is 3-5% risk of malignant transformation and thus should be followed up. 

(a) I will enquire regarding severity of the symptoms and if the symptoms affected her quality of life such as avoidance of intimacy. Enquiry will be made regarding genitourinary symptoms such as dysuria, frequency and haematuria which could indicate urinary tract infection. I will also ask about bowel symtms such as diarrhoea and constipation and rectal bleeding which could signify inflammatory bowel disease or bowel malignancy. Menstrual history such as last menstrual period, time of menopause, menarche, previous menstrual cycle, regularity and duration will be important as her symptoms could be attributed to menopause. I will also ask regarding any use of hormonal replacement therapy. I will also ask about usage of harsh soap and type of underwear fabric as these could cause local irritation at vulva. A background history of Crohn's disease is relevant as it can involve the vulva. In addition, I will need to ask about family history of malignancy such as vulva, uterine, cervical and vaginal cancer, as her symptoms may be suggestive of vulva malignancy. Presence of constitutional symptoms such as loss of weight and loss of appetite will point towards malignancy. Latest cervical smear result will be asked.

(a)    History is taken of current problems regarding severity and effect on sexual functions. Enquiry is made of any vaginal discharge or blood staining that may indicate an infective pathology. Age at menopause, last menstrual period and any previous menstrual complaints are noted. Enquiry is also made of other menopausal symptoms for example hot flushes, sweating etc. History of HRT intake is taken. History of any genital malignancies and its treatment is taken. Past history of any abnormal cervical cytology is taken. Enquiry is made about any fecal or urinary incontinence and use of protection. History of any autoimmune diseases for example thyroid disorders, type 1 diabetes mellitus, vitiligo is taken. Enquiry is made about atopic conditions for example eczema, bronchial asthma, hay fever. History of smoking and intake of immunosuppresants is also taken. Personal and family history of diabetes and sexually transmitted diseases is also taken. Examination is carried out of the vulva for the texture of skin, thinning, fissuring, erythema, ulcers or any other suspicious areas. Vaginal walls are examined for any curdy discharge. Rest of the body, including the mouth, is also examined for lichen planus, psoriasis and eczema.

(b)   Thyroid function tests are done to rule out autoimmune diseases which are common in women who present with these symptoms. Blood sugar will rule out diabetes as a cause of vulvo vaginites. A patch test can be done for common allergens. Any suspicious areas on the vulva will require a biopsy and can be done under LA to assess for VIN and malignancy. Serum ferritin will be done to rule out Fe deficiency anaemia which is common in patients with vulval disorders.

(c)    Management of vulval lichen sclerosis is by topical application of ultra potent steroid- clobetasol propionate. She is advised to use it in the proper way so that a 30gm tube lasts for 3 months. There is symptom relief but recurrence may occur and 4 to 10% of women are steroid resistant. They need to be referred to a specialist clinic for the second line of drugs – topical tacrolimus and pimicrolimus – which are calcineurin inhibitors. CO2 laser may be used to treat sequelae of scarring due to lichen sclerosis for example narrowing of vaginal interoitus. General measures like avoiding soap and detergents and combined use of emollients and soap substitutes provides symptom relief. These women need follow up as 2 to 4% have a risk of developing invasive CA. She should be encouraged to perform self examination so as to detect any suspicious areas and report for follow up. She may need multi disciplinary care including gynaecologist, dermatologist, genitourinary medicine specialist and psychosexual counsellor .

Clinical assessment )

Her symptoms of vulval soreness , itching , superficial dyspareunia could be caused by various conditions like vulval dermatosis, infection, contact dermatitis ,hormone deficiency & systemic skin disorders. Hence I would elicit a history of potential allergens and irritants use like talcum ,skin wipes in vulval region, condoms, tampons, fabric conditioners.  History of urinary frequency  & dysuria , urinary or fecal incontinence , use of  incontinence pads which could cause dermatitis by moisture & friction.

History of previous abnormal cervical cytology , cigarette smoking, immunodeficiency like chronic steroid usage, diabetes as these could be associated with VIN. Previous  treatment history  for vulval symptoms, as inadequate or inappropriate treatment could also contribute to symptoms. Drug history like HRT ,herbal preparations  which could contribute to pruritis also enquired.

Personal or family history of autoimmune disorders like alopecia, thyroid, vitiligo, rheumatoid arthritis .

History of personal or family history of hayfever, asthma, flaky skin ( eczema).

Sexual history of reduced lubrication, reduced desire, psychological assessment and assessment of quality of life done.

Examination done noting BMI , anemia, thyromegaly. Mucosal site like mouth examined for any lesions as lichen planus could be associated with mucosal lesions. Scalp , nails flexures examined for any scaly lesions suggestive of psoriasis.

Vulval examination done in a modified lithotomy position with good lighting  to visualise the anogenital region for any excoriation, redness suggestive of signs of inflammation,  skin atrophy, keratinisation ,splitting,in a  figure of eight distribution suggestive of  lichen sclerosis. Any labial adhesions , introital narrowing  noted as this could also cause dyspareunia. . Examination done to note abnormal vaginal discharge,  the cervix ,vagina & perianal region  examined for any lesions suggestive of VIN( plaque , erosion, warts ,ulcers).  Any granulomas , sinus, or abscess suggestive of  granulomatous lesions like Crohn’s noted.Any regional palpable lymph nodes or  ulcers or lump suggestive of ca vulva   noted.

B)

Full blood count , serum ferritin checked in woman with vulval dermatosis as anemia is commonly associated with vulval dermatosis.

Thyroid function tests  done if there is clinical suspicion of hypothyroidism or autoimmune disorders.  Blood Sugars tested  if diabetes  suspected .  Autoimmmune antibody testing  for pernicious anemia, thyroid disorders ,rheumatoid  done only if clinical symptoms or signs   present.  Lichen sclerosis or planus is a clinical diagnosis  does not require biopsy , but Vulval  biopsy is done if lesions fail to heal, or there is clinical suspicion of VIN or vulval cancer .

Skin patch testing done if vulval dermatosis present.  High vaginal swab, cervical swab, done if there is clinical suspicion of genital infection.

C)

General advice given on the DON’T’s  like avoid  fabric conditioners, coloured panties, toilet papers ,bubble baths, soaps, over the counter preparations . Encourage on use of shower instead of baths , soap substitutes , loose fitting cotton undergarments. Emolients can be given to moisturise the skin & provide symptomatic relief.

She is adviced to use Ultrapotent steroids like clobetesol propionate 0.05% cream used sparingly to the affected areas in a step down fashion ,iniatially once daily , then alternate days , then twice weekly, then once weekly all for one month each  then gradually reduce until she no longer requires it or uses occasionally . I would  advice her  that long term use is safe provided that a  30g of tube should last for a atleast 3 months , otherwise it may cause skin thinning. She is adviced that mild stinging sensation for a few minutes after application may  be present & is  normal  but if prolonged stinging is present she should report the  GP. She should be adviced that regular use before return to “ as & when required use” is associated with a better response & compliance of treatment reinforced. 

If symptoms do not improve with steroids ( clobetesol)  topical tacrolimus  is adviced under the care of a specialist vulval clinic. Use longer tha 2 years not recommended.

She is reassured that generally lichen sclerosis responds well  to treatment with emollients & steroids & the lifetime risk of cancer is approximately 2-4 in 100 & thus  can be followed up with her GP. She is encoured to perform self examination & monitor their skin condition regularly to note any  suspicious areas.

Surgery & co2 laser vaporisation is only recommended for restoration of anatomy & function  when there are labial adhesions causing introital narrowing & dyspareunia or urinary retension.

If sexual problems or  any  negative thoughts of self image present , need additional psychological support.  

a.A detailed history should be asked about symptoms,severity,and how far it affects her QOL.This will be better taken by using patient questionnaire to identify pottential allergens.The history taken should include symptoms from other skin sites, medical drug history and family history. History should be taken about self medication or previous previous inadequate or inappropriate medications.should ask about any urinary or fecal incontinence, use of sanitary products.social history of smoking . past history of abnormal cervical cytology,should be taken .A personal and family h/o autoimmune disorders,like thyroid ,pernicious anaemia by a h/o vitamin b12 injections any hairloss, diabetes.,A personnel and family h/o any atopic conditions like hayfever, asthma,eczema should be taken. h/o sexual function asked

Examination include,a general examination for any skin lesions in other sites including scalp,looking for seborric dermatitis elbows, nails ,knees for psoriasis, oral mucosa for lichen planus lesions , any vitiligo.

systematic examination of anogenital region performed in good light looking for the lesions extent any scarring .if vin is suspected other lower genital tract sites including vagina, cervix and perianal skin examined.

b/ fbc,serum ferritin  to detect anaemia as anaemia can lead to dermatitis

if any clinical suspicion of thyroid disorders like cold intolerence, weight gain ,lethhargy thyroid functions should be checked/ diabetes should be excluded, if any symptioms suggestive of std, screening for std should be done

biopsy should be taken if there is no response to initial treatment or any clinical suspicion of cancer.

if diagnosed as lichen sclerosus or lichen planus other autoimmune disorders should be tested.

skin patch is done in women presenting with dermatitis

c/ first line treatment is general measures like hygiene , avoiding soap products,wearing cotton panties, emolients can help. 

specific treatment is potent steroid like clobetasol. should be used properly.haf to one finger tip to the affected areas, initially once a day for 1 month gradually reducing alternate days next month ,twice a week for 1 month, once a week for 1 month, until needed to use occasionally.30 gm tube should cover 3 months.

some may develop sensitivity . this should be explained

if not responding to steroids second line is tacrolimus.should be under the supervision of specialist clinic . long term use is associated with sec cancer

laser surgery may be needed in those with extensive scarring and dyspareunia.

should give address of support groups

multidisciplinary team involving gynaecologist,dermatologist,genitourinary physician, psychosexual counsellor reduces the risk of inadequate or inappropriate treatment, facilitate communication between specialities,favours appropriate management

a. I would take a detailed history about the severity of symptoms including affect on sexula function.  I would ask abouta ssociated vaginal discharge, bleeding and smear history.  I would ask about a personal and family history of skin conditions, atopy and autoimmune diseases.  I would ask about symtoms of diabetes, thyroid disease and anaemia.  I would take a detailed medication history including treatment already tried.  I would ask about potential allergens including soap poweder, skin products and soap.  I would use a questionnaire to aid history taking.

I would perform systematic examination of the anogenital area, looking for rashes, lesions, ulcers and fissures.  I would exmaine other skin sites, nails and mucosal membranes.  If a suspicious lesion was found then exmaintion of the cervix and vagina should also be performed.

b.  If the history and examination was suggestive of STI then triple swabs should taken.  If there are signs or symptoms of thyroid disease, diabetes or anaemia then TFTs, random glucose and FBC and ferritin should be tested.  If there is clinical suspicion of VIN or cancer then a biopsy should be performed.  If there is evidence of vulval dermatitis then patch testing should be organised.

c.  Written and verbal information should be provided regarding lichen sclerosus, its management and the risk of pregoression to cancer (0-9%), and given information regarding support groups.  Information regarding skin care and hygeine should be given.  She should be advised regarding the use of emollients.  Ultrapotent steroid ointment should be prescribed as a reducing course and the patient and GP should be given clear instructions on how to use it.  She should be advised not to use more than a 30g tube in 3 months as this is associated with skin thinning.  If she does not respond to treatment then a biopsy should be performed due to the risk of cancer.  If this is beingn then she should be referred to a specialise vulval clininc where further management such as tacrolimus may be considered.

If she responds to treatment, follow-up in secondary care is not indiciated.  She should be advised regarding self examination, and to report worsening symptoms and/or new, suspicious lesions.

A) A detailed history should be taken regarding the nature of her pain,any associated vaginal discharge,urinary or fecal incontinence and any aggravating or relieving factor.She should be asked about the impact of pain on her quality of life. She should be asked about any dysuria as labial agglutination following lichen sclerosus can lead to dysuria. She should be asked about any lesions elsewhere in the body as conditions like lichen sclerosus and lichen planus are associated with skin and mucosal lesions.She should be asked about any autoimmune diseases like thyroid disease,diabetis mellitus,alopecia. and vitiligo as these may be associated with lichen sclerosus.Any family history like asthma,eczema and hay fever should be asked.She should be asked about any over the counter medications that she has taken as this may be the cause of allergic dermatitis.Her sexual history should be taken a nd risk of sexually transmitted disease should be assessed.Her last cervical smear history should be taken.A general examination should be done to look for any lesions on the mouth over scalp ,neck, knees ,elbows,nails.Pallor if any should be noted as pernicious anemia may be associated with Lichen planus or sclerosus.Aperineal examination to note any vesicles, ulcers,fissuring over vulva and any change of colour and texture of vulval skin should be done.Hyperpigmented skin may be due to prolonged scratching where as hypopigmented parchment like lesion in figure of eight appearance around the anal region is due lichen sclerosus.Any labial agglutination , vulval atrophy and narrowing of introitus should be noted.A speculum examination to note any discharge and condition of cervix and vagina should be done as vulval intraepithelial neoplasia is often associated with CIN or VAIN.B)Swabs should be taken from vagina and urethra to rule out any sexually transmitted diseases.A full blood count to detect anaemia.Serum T3,T4,TSH to be done as autoimmune thyroid disease may be an association.Plasma glucose levels to rule out diabetis as this may be found in lichen sclerosus.Vulval patch testing may be helpful to diagnose allergic dermatitis.Vulval biopsy usually not needed unless patient fails to respond to standard treatment or there is a suspicion of malignancy.Cervical smear if due should be taken.C)The patient should be given advise about personal hygiene.She should be told to avoid using perfumed soaps,harsh detergents,bubble baths,to wear cotton underwear.She should be told to use emollients as they can cause symptom relief.The definitive treatment for lichen sclerosus is topical application of ultrapotent steroid clobetasol propionate.It is to be used every night for 4 weeks then on alternate nights for four weeks and then twice aweek for 4 weeks.A30 gm tube should last for 3 months.She should be seen 2-3 months after last application if she responds to this therapy.If she is steroid resistant then the second line of treatment is topical application of calcineurine inhibitor tacrolimus.It's maximal effect is seen in 16-24 weeks.Use of tacrolimus is off licence but can be used under specialist supervision.It's use for longer than 2 years is not advisable because of the potency for malignant transformation.Surgery and CO2 laser vaporisation has a role in restoring the functions impaired by agglutinations and adhesions such as dyspareunia that affects sexual function and body image.She should be given written information and emphasis should be given on the risk of the disease progressing to malignancy .She should be informed about the importance of self examination and to report any worsening of symptoms.If her symptoms are in remission a yearly follow up in the GP's clinic is adequate.In case of complicated lichen sclerosus, unresponsive to treatment followup should be in a specialist clinic.

a) History should include menopausal status and any use of hormone replacement therapy (HRT), as atrophy may be the sole cause of these symptoms, and smear history including any treatment for abnormal smears and whether the patient is up to date with screening, as vulval intraepithelial neoplasia (VIN) is strongly associated and frequently concomittent with cervical intraepithelial neoplasia (CIN). History of additional symptoms should be elucidated e.g. discharge, bleeding, any lumps or bumps (these symptoms increase the liklihood that neoplasia may be the cause), the location of the dyspareunia (superficial - likely from the history already received - or deep, which may suggest non-vulval cause), urinary leakage or incontinence (which may result in irritation of the perineum). General history should also be assessed, including any history of autoimmune diseases e.g. hypothyroidism (which are associated with lichen sclerosis), any other skin affected or dermatological conditions already known e.g. eczema, psoriasis, systemic scleroderma. A drug history should be obtained as the patient may already be receiving treatment for a dermatological condition that may be suboptimal. History should be obtained to lifestyle factors that may affect the vulval skin, e.g. hygeine products, dusching, change in detergents etc.

Examination should include the whole body, including scalp and inside of the mouth, for other skin lesions. Examination of the vulva, vagina and cervix is essential. Presence of inguinal and other lymphadenopathy should be assessed. Bimanual examination of the cervix and uterus is indicated if a cervical or vaginal lesion is seen. Sims speculum examination of the vagina may be required is appearances suggest urinary incontinence is the cause to identify any prolapse. Features suggestive of VIN are nodularity, warty lesions, ulceration, bleeding or suppurative lesions. Skin cancers may also be found on the vulva which may be melanocytic lesions with irregular borders or irregular colouration. Presence of white plaques, which may be associated with scarring and fusion of the labia suggests lichen sclerosis. The sole finding may be of vaginal and vulval atrophy.

b) If the patient is not up to date with her screening an opportunistic smear may be taken is there is no overt abnormality of the cervix. If there is any overt abnormality colposcopy and biopsy should be undertaken. Vulval lesions should either be biopsied or excised, depending of the apparent extent of the lesion. Very small lesions may require vulvoscopy to further clarify their appearance and allow biopsy. If lymphadenopathy is present with a significant lesion CT or MRI pelvis should be performed to assess the extent of the disease. If appearances are strongly suggestive of lichen sclerosis then biopsy may be delayed until review after first trial of steroid treatment as if symptoms do not improve then biopsy is indicated. Abnormal discharge with no lesions require transvaginal ultrasound to identify any abnormalities of the upper genital tract, e.g. submucosal fibroids, endometrial or fallopean neoplasia.

c) The diagnosis should be explained as an autoimmune skin disease with a small risk of developing cancer (0-9%). The importance of vaginal toilet should be explained, including the avoidance of excessive washing or using washing products (or indeed water only!). Advise to wash using an emolient e.g. aqueous cream and to moisturise the area. Consideration may be given to the use of topical or vaginal oestragen creams either initially or to improve response to steroids, e.g. orthogynest nightly initially for 2 weeks then 2 x per week. A medium, e.g. betnovate, or high, e.g. dermovate or clobetazol, dose steroid cream should be commenced on a reducing regimen. This may be twice daily for 2 weeks, then daily for 2 weeks, then alternate daily for 1 month, then 2 times weekly for one month, then for use as required when symptoms flare up. The patient should be followed up in gynaecology clinic to assess response and perform a biopsy if not responding and not already performed. Lack of response in proven lichen sclerosis should be referred to a dermatologist or gynaecologist with a special interest. Surgery is rarely required except for progress to VIN or obstructive scarring. If patient responds well to steroids she may be discharged to the GP for yearly follow-up with the GP to look for signs of neoplasia developping or resistance to treatment.

a.)A detailed history to assess the severity of her symptoms, their  impact on her quality of life and sexual functions  is taken. Use of a well planned questionnaire to identify any potential allergens or irritants to the vulval skin is  helpful. History of vaginal discharge and dryness,  bleeding,  dysuria, dyspareunia is noted. She will be asked about skin ulcers or infection anywhere else on the body. History of urinary or faecal incontinence that irritates the vulval skin to cause ulcers will be included.

 A drug history involving past self medication and use of over the counter emollients, creams ,HRT or previous  inadequate treatment for her complaints  is noted .Personal history of smoking that is a risk factor for VIN  and  any  sexually transmitted infections in the past  will be asked.

Past medical history regarding autoimmune conditions like Thyroid disorder, Alopecia areata,Diabetes Mellitus(Type 1) or Pernicious anaemia is verified as there is prevalence with  30-40% of vulval disorders. History of last cervical smear is taken to note atrophic postmenopausal changes or CIN  that has  a recognised association  with Vulval intraepithelial neoplasia.

Enquire regarding personal and family history of atopic conditions like Psoriasis, Eczema and Hay fever since it is present  in about 97% of women  with vulval dermatitis. Menstrual history to note LMP as her postmenopausal  atrophic changes  may be the cause  for her complaints

Examination includes BMI, Pulse,B.P. Presence of  pallor points  anaemia,  thyroid enlargement suggests thyroid disorder.Look for other  mucosal and  skin lesions over scalp,neck,elbows,knees  as in Lichen Planus. Local examination of the anogenital  region is done under adequate light and exposure to note skin ulcers,thinning or splitting as in Lichen Sclerosis where  whole of vulval perianal area is usually involved in a figure of eight distribution.There maybe vaginal narrowing due to midline fusion of labia minora and clitoral hood formation.  speculum examination is done to note cervical or vaginal lesions and type of  vaginal discharge.

b.)Serum ferritin count ,FBC to note anaemia as correction of iron deficiency anaemia relieves vulval symptoms.If clinically indicated Thyroid function tests  for Thyroid disorder  and Blood sugar estimation for Diabetes Mellitus is done.

 Skin patch testing is done in  vulval dermatitis with pruritis  to identify specific allergens like cosmetics,fragrences,clothing or medicaments . Sexually transmitted diseases are ruled out by high vaginal ,endocervical and urethral swabs testing. Urine for microscopy and culture sent. Skin biopsy is done for any clinically suspicious or atypical area to exclude invasive disease.

c.)With the diagnosis of Lichen Sclerosis the woman is advised regarding the general care of the vulval region. She will be counselled about personal hygiene and simple measures like wearing cotton underwear  without panty liners, avoid use of any irritants, perfumed soaps and talc’s, to use showers instead of bath can improve her quality of life.

Use of emollients and ultra potent steroids like clobetasol propionate 0.05% cream relieves the symptoms in 55-95 % of patients. She will be advised specifically regarding timing, amount and frequency of application, to use a 30gm tube over a period of three months as once daily for one month, on alternate days for next month, twice weekly for one month , gradually reducing to once a week for another month.

Approximately 4-10% of women are resistant to this first line treatment and will need immunosuppressant drugs like Tacrolimus under the specialist supervision.Longterm use of these drugs for more than two years is not recommended due to risk of malignant change.

Surgery and CO2 laser treatment has a role in treating scarring due to Lichen Sclerosis and restoring functional impairment as in adhesion formation but not for treatment of symptoms .

Regular follow up under a specialist review is advised if symptom control is not sustained as there is a lifetime risk of developing invasive vulval cancer in about 2-4 % patients. Follow up in a GP clinic if symptom free  with  advise  to do regular self examination to monitor the skin condition and suspicious areas. Information about patient support groups that  provide  self examination techniques  should be given .  Referral to specialist service will be provided  for  psychosexual counselling  in women with psychosexual problems.

Dear Paul,   can you please check my essay as well thanks 

Dear dr Paul,please could you check my answer,thank you.

Details history should be taken including symptoms of menopause especially urogenital and vaginal dryness . Drug history should be taken and any previous or intractable treatment for vulval symptoms . Medical history for chronic diseases such as IDDM or renal disease should be explored . Autoimmune disease such as  vitiligo  ,pernicious anemia and thyroid disease should be asked. Family history of autoimmune disease and vulval or breast cancers should be asked. History of cervical smear and abnormalities should be explored with any history of gynecology cancers such as cervix or vagina. History of irritant materials such as soap, shampoo or underware cloths should be explored . Sexual history for any infections or vaginal discharge should be explored. Urology symptoms such as incontinence or urinary tract infection should be asked. General examination should be done including BP and BMI . External genital examination should be done for ulcers,mass, redness , narrowing and scaring. Vaginal exam should be done and cervix by speculum.

Full blood count ,RFTs should be ordered to identify any chronic disease. Fasting blood sugar should be ordered for DM. Serum  Ferritin level should be checked because it reduces in vulval diseases. Thyroid function tests should be ordered because it can cause vulval diseases from autoimmune disorders . Urinalysis for any infection is useful. Vulval biopsy can be ordered to identify the disese or to exclude premalignant or invasive cancer. Skin patch test can be ordered to identify dermatitis .

Sensitive counseling for vulval lichen sclerosis ( LS ) should be offered because may take long time for treatment . General recommendations should be adviced such as avoid irritant materials and can use some emollents. Topical ultrapotent steroids are useful such as Clobetasol 0.05 % for three mounths and can repeat the treatment in recurrence . topical immunosuppressant drugs can be used in steroid resistance disease. Surgery or Co2 Laser vaporisation  can be used but it is not recommended . Follow up is important for responding or to exclude any Vulval cancers in future.