Vulvar Disease Pearls

Normal vulvar anatomy

The first pearl for managing vulvar disease is recognizing normal vulvar anatomy. The vulva is defined as the structures between the thighs bounded laterally by the genitocrural fold, anteriorly by the mons pubis, and posteriorly by the posterior commissure. The main anatomic structures include the mons pubis, labia majora, labia minora, clitoris, vestibule, urethral meatus, and the hymen with its surrounding vestibular glands including Bartholin's glands. The innermost aspect of the vulva is

Normal vulvar anatomic variations

The second pearl is recognizing vulvar anatomic variations. These normal variations can be misinterpreted as abnormality.

The most frequent is sebaceous hyperplasia, which is found in 75% to 95% of women in the reproductive age group. These are small, yellow sebaceous glands found along the inner aspects of the labia minora and up around the edges of the clitoris. They can be prominent and can coalesce into cobbled, yellow plaques. They are completely harmless.

Vulvar papillomatosis, another

Recognizing candidiasis

Common conditions affecting the vulva are missed because of atypical presentations and misinformation. The most common misdiagnosis is candidiasis, so the next pearl is to recognize candidiasis.

Vaginitis is one of the most common complaints in clinical medicine and vulvovaginal candidiasis is one of the most common causes. The result is that most women and their caregivers mistakenly assume that any itchy, burning, vulvar irritation whether it is caused by a dermatosis, bacterial vaginosis, or

Herpes simplex virus

Herpes simplex virus (HSV) is the most common sexually transmitted disease in the world and the most common cause of vulvar ulcers. This genital infection is familiar to all caregivers but is far too often overlooked because of atypical presentations. Genital herpes is caused by HSV-2 in 80% of cases but the frequency of genital HSV-1 is now rising [16]. HSV infections affect 20% of the sexually active population in the United States with an estimate of 500,000 new cases of genital HSV

Vulvar contact dermatitis

The next pearl is to recognize contact dermatitis on the vulva. Vulvar contact dermatitis is frequent and complicates all vulvar conditions. It can be difficult to diagnosis because the clinical presentation may vary from minor to extreme and often may be superimposed on pre-existing conditions, such as lichen simplex chronicus; lichen sclerosus; herpes simplex; or even a tumor, like squamous cell carcinoma.

Vulvar contact dermatitis can be irritant, allergic, acute, subacute, or chronic. The

White vulvar conditions

All white vulvar conditions in the vulvar are not lichen sclerosus. Lichen sclerosus is the commonest chronic vulvar condition and the most familiar. White vulvar areas can be seen with lichen planus, less likely lichen simplex chronicus, rarely mucous membrane pemphigoid, and even in vulvar intraepithelial neoplasia.

Lichen sclerosus has a prevalence of between 1 in 300 and 1 in 1000. It most commonly affects women 30 to 40 years of age and presents as an itchy, white, scarred vulvar condition.

Concomitant vulvar conditions

Dermatologists are the experts in skin diseases and excel in recognizing the concomitant cutaneous problems often present in the vulvar area. It is not unusual to see any of these conditions with secondary candidiasis, contact dermatitis, HSV, atrophy, and even cancer. Any of these conditions can be found separately or together to complicate other problems. Always look for more than one problem (Fig. 14).

Pearls for vulvar therapy

Vulvar patients take time. It is important to explore their expectations and be supportive. Sometimes the chief complaint is not the chief worry. They may be complaining of itching or burning and be very worried about sexually transmitted disease, infidelity, or cancer. Be sure that the clinical picture fits their chief complaint. Avoid telephone diagnoses. Because the area is unfamiliar and is fraught with embarrassment and taboo it is important that patients understand their condition, the

Long-term supervision

Effective vulvar care requires long-term supervision. Supervision not only ensures improvement and monitors for complications but also improves compliance. Many of these conditions are chronic with no cure. In the case of treated lichen sclerosus, up to 96% are symptom improved and about 70% symptom free, but without treatment 85% of them relapse in 4 years. The cancer risk is about 4%. The difficulty with lichen sclerosus and even lichen planus is that these conditions can so often be

Summary

Dermatologists are vital for vulvar care. They are the best trained in pattern recognition of disorders of the skin and so are the most effective physicians for recognizing vulvar conditions. With an understanding of the normal vulvar anatomy and normal anatomic variations, and capable of recognizing and diagnosing contact dermatitis of the vulva and the chronic white conditions (lichen sclerosus, lichen planus, and lichen simplex chronicus), dermatologists are uniquely positioned to diagnose