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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.
Vulvovaginal Itching
1. A 27-year-old nulligravid woman presents with a 4-day history of worsening vulvar and vaignal itching that has not responded to over-the-counter therapy. She has been seen in your office four times over the past several months for vaignal discharge with itching. She was successfully treated each time with single-dose oral fluconazole. Vaginal pH is 4.3, and microscopy is negative. The best next step in the evaluation of this patient is:
Show Explanation
Symptoms of vaginal candidiasis generally include vulvovaginal itching, burning, or irritation, with thick white vaginal discharge on exam.
Fungal culture is recommended in patients with recurrent vulvovaginal candidiasis, possible non-Candida albicans infections, and women with signs or symptoms or vulvovaginal candidiasis with negative microscopy.
C glabrata and other non-albicans species are present in 10-20% of women with recurrent vulvovaginal candidiasis and may not be susceptible to fluconazole. Treatment options include an oral or topical non-fluconazole antifungals, like clotrimazole or miconazole, or vaginal boric acid.
Vulvar biopsy is indicated if you suspect a vulvar dermatosis or neoplasia. Skin lesions that are hyperpigmented, are raised, have an abnormal vascular pattern, or do not respond to conservative medical management are suspicious and should be biopsied.
2. A 21-year-old woman is referred to you by her primary care physician because of recurrent yeast infections. For the past 8 months, she has suffered from intense vulvar and perianal pruritis, and her symptoms are affecting her ability to sleep at night. She reports that she cannot stop scratching. On examination, you note that the labia minora are erythematous and swollen and that the labia majora appear pale and leathery with multiple areas of excoriations noted. The most likely diagnosis is:
Show Explanation
Lichen simplex chronicus is a chronic eczematous disease that results from a chronic itch-scratch cycle. It typically presents in mid-to-late adult life.
There is typically an inciting process that can be environmental, like tight clothing or feminine products, or dermatologic, like candidiasis or lichen sclerosus.
Symptoms of lichen simplex chronicus include intractable vulvar pruritis that is worst at night and results in unconscious scratching. When symptoms are longstanding, the skin can become lichenified, with thick, leathery, hyperpigemented areas. There may also be excoriations.
Assessment includes ruling out bacterial or fungal infection as an inciting event.
Treatment includes removing irritants, treating he underlying disease or infection, and allowing the vulvar skin to heal.
3. A healthy 7-year-old girl reports perineal itching and pain as well as dysuria. Her urine culture is negative. She lives with her parents, baby brother, and maternal grandmother, and the family has a low level of concern for the possibility of sexual abuse. Genital examination is significant for normal hymen and vagina and a symmetrical and well-circumscribed perianal and perineal hypopigmentation in a figure-of-eight pattern on her vulvar with punctate hemorrhages. The most appropriate initial step is to
Show Explanation
Lichen sclerosus is a chronic skin disorder with possible autoimmune, hormonal, genetic, and cell proliferation etiologies.
Classical findings of pediatric vulvar lichen sclerosus include sharply demarcated white plaques in a figure-of-eight pattern around the labia, perineal body, and anus, with sparing of the vagina and hymen. Frequent scratching can cause small hemorrhages and erosions. Untreated, lichen sclerosus can cause scarring and loss of architecture. Long term, lichen sclerosus is a risk factor for differentiated vulvar intraepithelial neoplasia.
Treatment includes high-potency topical steroids like clobetasol. It should be applied twice daily for 2-12 weeks with frequent reassessment. If symptoms are controlled, the frequency of application may be tapered. Behavioral modifications such as sitz baths and avoiding irritants are also important components of treatment.
A vulvar biopsy is often an important component of evaluation in adults, but may be avoided in pediatric patients unless there is an atypical presentation or a poor response to therapy.