Olushola Akinshemoyin Vaughn, MD, began her enlightening lecture on vulvar dermatoses with a thorough review of vulvar anatomy through a dermatologic perspective, noting it is important to use proper language when addressing vulvar conditions. When approaching a patient with a vaginal dermatosis, she classifies possible causes into these broad categories; inflammatory, infectious, neoplastic, hormonal and nerve/muscle. The most common presentation in her vulvar clinic is dermatitis which can be further divided into endogenous, exogenous and mimicker categories. All patients with vulvar dermatitis complain of itch with burning present if mucosal areas are involved. Vulvar dermatitis typically presents as poorly defined erythema which extends onto the mons pubis and inner thighs with sparing of the vagina. Additionally, patients who present with vulvar dermatitis do not present with vaginal discharge. Dr. Vaughn reports management of vulvar dermatitis relies most on the HPI and exam, with topical corticosteroids as a mainstay of treatment. When prescribing steroids for the vulva, Dr. Vaughn almost always prescribes an ointment steroid.
Coverage: SDPA 21st Annual Fall Dermatology Conference, Oct. 25-29, 2023 in Nashville, Tennessee
Irritant contact dermatitis of the vulva typically presents as a persistent low-grade dermatitis. Ideally, identifying the irritant is the goal, though can be challenging as the list of irritants is quite long including antifungal creams, blood, sweat, urine, feces, condoms, sex and wipes. Dr. Vaughn discourages the use of any wipes in the vulvar region. In addition to avoidance of the irritant, treatment involves use of zinc oxide barrier creams or paste, evaluating the patient for incontinence and hyperhidrosis, avoidance of excessive bathing and soaps and overzealous hygiene. Fifty-four percent of women who present with vulvar dermatoses have irritant contact dermatitis (ICD) or allergic contact dermatitis (ACD) which is often resistant to treatment. When investigating the cause of ACD, Dr. Vaughn utilizes the “toilet paper test” in obtaining a history from the patient which involves asking the patient to list every item that touches their vulva. Ultimately, patch testing may be needed to determine the cause of contact dermatitis in these patients.
Dr. Vaughn reports the two causes of a white vulva include loss of pigment or thickening of the epidermis. She admits that when evaluating these patients, it can be hard not to be distracted by the pigment and there may be some overlap with conditions. She helped clarify characteristics that can differentiate lichen sclerosus (LS) from vitiligo, such as poliosis. Poliosis is the whitening of hair follicles, and this is consistent with a presentation of vitiligo, but not consistent with LS. The standard of care for treatment of LS is topical treatment with clobetasol. It is imperative patients are educated that treatment of LS is lifelong with the need of a topical steroid twice weekly. In her experience, patients who comply with twice weekly application of clobetasol do not develop squamous cell cancer (SCC). The benefit of applying clobetasol twice weekly to the vulva in patients with LS far outweighs the risk of development of SCC. Dr. Vaughn discussed numerous other conditions and had many engaging questions from the audience from this much appreciated topic to the SDPA attendees.
Byline: Sarah B.W. Patton, MSHS, PA-C
Pictured: Olushola Akinshemoyin Vaughn, MD