N.M
I will ask the patient about the onset, the severity and if the problem has been recurring (HPV). Is it localized to vulval area or generalized body itching. I wil ask her the associated complains such as bleeding, pain, ulcer, cyst, vesicular rash, or mass . I will ask her about any medical illness such as diabetes, HIV positive status, urinary and gastrointestinal conditions such as urinary incontinence/leakage or crohn’s disease). I will as her any history of fever. Any history of acute infectious illness such as herpes, recurrent shingles or abnormal foul smelling vaginal discharge. I will ask her about last menstrual period, if menopausal since when and what is her cervical smear history. I will assess through history if she is exposed to the multiple sexual partners (though unlikely at her age but it should be excluded) and thereby sexually transmited infections. I will ask her if she has any kind of allergies or dermatologic conditions such as eczema, contact dermatitis. She should be asked about history of scabies in family or at work place. I will ask about any lesion at her breast (pagets disease) or under breast skin folds(candida). I will ask her the use of clothing (tight undergarments or silk clothing), any scented soap creams or talcum which may cause the complain. I will ask her about her sexual history and use of latex condoms. I will assess how much her quality of life ( sexual, social and psychological) is affected with this problem. I will ask her about smoking and her socioeconomic conditions. I will perform general and local examination. I will examine if there are scratch marks or rash on the body areas. Any kind of lesions at other body parts such as limbs and abdomen (lichen sclerosis) .I will check if mucous membranes of mouth and throat show any kind of lesions (lichen planus). I will inspect the local vulval and vagivnal area for presence of any rash, lesion or mass. I will perform Perspeculum examination to check the condition of cervix, vagina and any evidence of abnormal vaginal discharge under good light. I will collect the swabs and send for laboratory testing if clinically suspicious for infections such as HPV, candida, trichomonas, threadworm, and herpes. As pruritis can be associated with vulval neoplastic conditions (VIN or other benign and malignant vulval lesions) so excision biopsy should be taken to exclude such conditions. If cervix looks suspicious she should be sent for smear (if due)or colposcopy (if indicated on examination) as VIN can be associated with CIN. It can be assocaiated with multicenteric disease so other suspicious areas if present e.g on vagina, perineum or anus should be biopsied. Nonspecific tests should be performed if indicated such as FBC (leucocytosis for infections) CRP, urinalysis and midstream urinary culture and sensitivity.
The treatment of VIN is controvercial as the natural history of the disease course is unknown and variable. The treatment options can be expectant, medical and surgical and choice of the option depends upon severity/grade of lesion and patient’s choice. Expectant treatment can be successful as VIN is associated with spontaneous regression. However woman should be informed of importance of follow-up. Follow up is very necessary in the cases of VIN because it is associated with higher risk of recurrence, can be multicenteric (vulva, vagina, cervix, perineumand anal canal) disease and carries the risk of progression (6%) to high grade lesion and rarely to carcinoma. Medical treatment includes new topical ointment , imiquimod which is not licensed in UK and is still under evaluation. Topical 5-fluorouracil has not been proven beneficial. Mainstay treatment for VIN is surgical. widelocal excision or laser ablation with Nd-YAG or CO2 can be used. Woman should be provided with psychological support and reassurance. Long term follow up is essential so patient should be counselled well verbally along with written leaflet information.
