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Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions.  You will review the answers and the material covered during your next Continuity Clinic Session.  

Benign Vulvar Dermatoses

Benign Vulvar DermatosesCREOGs Over Coffee
00:00 / 20:36

1. A 7 yo girl reports perineal itching and pain as well as dysuria. Her urine culture is negative. There is low concern for sexual abuse. Genital exam shows a normal hymen and vagina with a symmetrical and well-circumscribed perianal and perineal hypopigmentation in a figure-of-8 pattern on her vulva with punctate hemorrhages. What is the best next step?

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Show Explanation

  • Symptoms are most consistent with pediatric vulvar lichen sclerosus

  • Classic findings include the sharply demarcated white plaques in a figure-of-8 pattern around the labia, perineal body and anus – this spares the vagina and hymen

  • Scratching can lead to small hemorrhages and erosions

  • This is a chronic condition that may have autoimmune etiologies

  • Best treatment is clobetasol (high potency topical corticosteroid). Apply twice daily for 2-12 weeks depending on symptoms, but symptoms can recur.

  • In pediatric patients, the presentation is relatively classic so biopsy is not necessary

2. A 48 yo female has a 1 year history of intense vulvar itching, burning and generalized soreness in addition to yellow discharge. She has been unable to have sexual intercourse due to dyspareunia over the last 6 months. She also has intermittent sores at the bottom of her gumline. What is the most likely diagnosis?

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Show Explanation

  • Lichen planus is an inflammatory autoimmune disorder that affects skin and mucous membranes; this may be T-cell mediated

  • Skin lesions are intensely pruritic with violaceous papules and plaques that often result in erosion and ulceration of the vulvar tissue

  • Vaginal involvement can lead to friable mucosa and yellow discharge

  • Untreated cases can lead to vaginal stenosis and synechiae which cause dyspareunia and postcoital bleeding

  • Wickham striae are fine, white, lacey reticular pattern often seen in the buccal mucosa

  • Other affected areas include wrists, shins, ankles, lower back, scalp and nails

  • Usually a chronic condition – progressive and recurring

  • Treatment can involve lifestyle modifications, vulvar hygiene and topical steroids; refractory case treatment can include cyclosporine, tacrolimus, plaquenil methotrexate, etc.

  • Progression to vulvar cancer is 3-6% per year

3. A 21 yo presents with recurrent yeast infections. For the last 8 months, she has experienced intense vulvar and perineal pruritus. She cannot sleep at night. The labia minora are erythematous and edematous on exam. The labia majora appear pale and leathery with multiple areas of excoriation. What is the most likely diagnosis?

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Show Explanation

  • Lichen simplex chronicus is a chronic eczematous disease that leads to an itch-scratch cycle

  • Usually occurs in mid to late life following an inciting process (environmental or dermatologic).

  • Leads to intractable vulvar pruritus that is often worse at night

  • With longstanding scratching, the skin undergoes “lichenification” with thick, leathery hyperpigmented areas.

  • Yeast and bacterial infections should be ruled out as inciting events

  • Goal is to stop the itch-scratch cycle, remove irritants, treat underlying disease or infection and allow skin to heal

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