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Genital Dermatology    

Genital Dermatology    . Michael S. Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences Univ of California SF School of Medicine policarm@obgyn.ucsf.edu. Genital Skin Rashes. Infectious Candidiasis Tinea Cruris Tinea Versicolor Erythrasma. Non-infectious Psoriasis

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Genital Dermatology    

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  1. Genital Dermatology     Michael S. Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences Univ of California SF School of Medicine policarm@obgyn.ucsf.edu

  2. Genital Skin Rashes Infectious Candidiasis TineaCruris TineaVersicolor Erythrasma • Non-infectious • Psoriasis • Seborrheic dermatitis • Intertrigo • Atopic dermatitis (eczema)

  3. Vulvar Candidiasis • Vulva will be very itchy; often excoriated • Presentation • Erythema + satellite lesions • Occasionally: thrush, LSC thickening if chronic • Diagnosis: skin scraping KOH, candidal culture • Treatment • Topical antifungal therapy daily for 7-14 days, or fluconazole 150 mg PO repeat in 3 days • Plus: TAC 0.1% or 0.5% ointment QD-BID

  4. Vulvar Candidiasis

  5. Tinea Cruris: “Jock Itch” • Asymmetric lesions on proximal inner thighs • Plaque rarely involves scrotum; not penile shaft • Well demarcated red plaques with accentuation of scale peripherally; no satellite lesions • Fungal folliculitis: papules, nodules or pustules within area of plaque • Treatment • Mild: topical azoles BID x10-14d, terbinafine • Severe: fluconazole 150 mg QW for 2-4 weeks • If inflammatory, add TAC 0.1% on 1st 3 days

  6. Tinea Cruris: Rash and Pustules

  7. Psoriasis • Background • Fast mitotic rate in skin triggers inflammatory response • 30% have family history • New onset often preceded by strept infection (eg, throat) • Drugs may unmask in older patients: b-blockers, lithium, NSAIDS, terbinifine, gemfibrozil • Other triggers: stress, alcohol, cold • Findings • Red or pink irregular patches with elevated silver scales • Commonly involves elbows, knees, scalp, nails • May involve mons, vulva, crural folds

  8. Psoriasis

  9. Psoriasis: Treatment • Decrease mitotic rate • Tar (LCD 5% in TAC 0.1% ointment) • Topical retinoids (Tazarac) • Decrease inflammation • Steroid ointment (e.g., TAC) • Calciprotriene (Dovonex); vitamin D derivative • Clobetasol- Dovonex combination • Tar preparations, topical steroids • Don’t use oral prednisone, as withdrawal may cause pustular psoriasis

  10. Intertrigo • Occlusion, rubbing of skin chafing, inflammation • If moist, often superinfection with candida or tinea • May lichenify to LSC • Findings • Dull red, shiny skin fold; if moist, white surface • Follows clothing lines; under breasts, pannus • No satellites; border not sharp • Treatment • Keep skin clean and dry; use cornstarch • Reduce friction with bland emollient • Treat secondary infection with topical imidazole

  11. Vulvar “Eczema” • Atopic dermatitis • “Endogenous eczema” • Contact dermatitis: “Exogenous eczema” • Irritant contact dermatitis (ICD) • Allergic contact dermatitis ACD) • Lichen Simplex Chronicus • “End stage” eczema

  12. Contact Dermatitis • Irritant contact dermatitis (ICD) • Elicited in most people with a high enough dose • Rapid onsetvulvar itching (hours-days) • Allergic contact dermatitis (ACD) • Delayed hypersensitivity • 10-14 days after first exposure; 1-7 days after repeat exposure • Atopy, ICD, ACD can all present with • Itching, burning, swelling, redness • Small vesicles or bullae more likely with ACD

  13. Contact Dermatitis • Common contact irritants • Urine, feces, excessive sweating • Saliva (receptive oral sex) • Repetitive scratching, overwashing • Detergents, fabric softeners • Topical corticosteroids • Toilet paper dyes and perfumes • Hygiene pads (and liners), sprays, douches • Lubricants, including condoms

  14. Contact Dermatitis Symmetric Raised, bright red, intense itching Extension to areas of irritant contact

  15. Contact Dermatitis • Common contact allergens • Poison oak, poison ivy • Topical antibiotics, esp neomycin, bacitracin • Spermicides • Latex (condoms, diaphragms) • Vehicles of topical meds: propylene glycol • Lidocaine, benzocaine • Fragrances

  16. Contact Dermatitis: Treatment • Exclude contact with possible irritants • Restore skin barrier with sitz baths, compresses • After hydration, apply a bland emollient • White petrolatum, mineral oil, olive oil • Short term mild-moderate potency steroids • TAC 0.1% BID x10-14 days (or clobetasol 0.05%) • Fluconazole 150 mg PO weekly • Cold packs: gel packs, peas in a “zip-lock” bag • Doxypin or hydroxyzine (10-75 mg PO) at 6 pm • If recurrent, refer for patch testing

  17. Why Not Steroid-Antifungal Combination Drugs? Which products should be avoided? Lotrisone Clotrimazole and Betamethasone 0.5% Mycolog II Nystatin and Triamconoloneacetonide) Why avoid them? Inflammation usually clears up before fungal infection Steroid overshoot  skin atrophy Local immunosuppression (from steroid) may blunt antifungal effect

  18. Genital Skin Itching Infections • Candidiasis • Tineacruris Dermatitis • Psoriasis • Seborrheic dermatitis • Eczema Dermatoses • Lichen sclerosus • Lichen simplex chronicus (LSC) • LS + LSC Neoplasms • Paget’s Disease (women) • Vulvar Intraepithelial neoplasia (VIN) • Penile Intraepithelial neoplasia (PIN)

  19. ISSVD 1987: Vulvar Dermatoses ISSVD: International Society for the Study of Vulvar Disease

  20. 2006 ISSVD Classification of Vulvar Dermatoses • No consensus agreement on a system based upon clinical morphology, path physiology, or etiology • Include only non-Neoplastic, non-infectious entities • Agreed upon a microscopic morphology based system • Rationale of ISSVD Committee • Clinical diagnosis  no classification needed • Unclear clinical diagnosis  seek biopsy diagnosis • Unclear biopsy diagnosis  seek clinic pathologic correlation

  21. 2006 ISSVD Classification of Vulvar Dermatoses

  22. Lichen Sclerosus: Natural History • Most common vulvar dermatosis • Prevalence: 1.7% in a general GYN practice • Cause: autoimmune condition • Bimodal age distribution: older women and children, but may be present at any age • Chronic, progressive, lifelong condition

  23. Lichen Sclerosus: Natural History • Most common in Caucasian women • Can affect non-vulvar areas • Part (or all) of lesion can progress to VIN, differentiated type • Predisposition to vulvar squamous cell carcinoma • 1-5% lifetime risk (vs. < 0.01% without LS) • LS in 30-40% women with vulvar squamous cancers

  24. Lichen Sclerosus: Findings Symptoms Most commoly, itching Often irritation, burning, dyspareunia, tearing 58% of newly-diagnosed patients are asymptomatic Signs Thin white “parchment paper” epithelium Fissures, ulcers, bruises, or submucosal hemorrhage Changes in vulvar architecture: loss of labia minora, fusion of labia, phimosis of clitoral hood Depigmentation (white) or hyperpigmentation in “keyhole” distribution: vulva and anus Introital stenosis

  25. “Early” Lichen Sclerosus Hyperpigmentation due to scarring Loss of labia minora

  26. Lichen Sclerosus Thin white epithelium Fissures

  27. “Late” Lichen Sclerosus Agglutination of clitoral hood Loss of labia minora Introital narrowing Parchment paper epithelium

  28. 68 year old woman with urinary obstruction Labial agglutination over urethral meatus

  29. Lichen Sclerosus: Treatment Biopsy mandatory for diagnosis Preferred treatment Clobetasol 0.05% ointment QD x4 weeks, then QOD x4 weeks, then twice-weekly for 4 weeks Taper to med potency steroid (or clobetasol) 2-4 times per month for life Explain “titration” regimen to patient, including management of flares and recurrent symptoms 30 gm tube of ultrapotent steroid lasts 3-6 mo Monitor every 3 months twice, then annually

  30. Lichen Sclerosus: Treatment Second line therapy Pimecrolimus, tacrolimus Retinoids, potassium para-aminobenzoate Testosterone (and estrogen or progesterone) ointment or cream no longer recommended Explain chronicity and need for life-long treatment Adjunctive therapy: anti-pruritic therapy Antihistamines, especially at bedtime Doxypin, at bedtime or topically If not effective: amitriptyline, desipramine PO Perineoplasty may help dyspareunia, fissuring

  31. Lichen Simplex Chronicus = Squamous Cell Hyperplasia Cause: an irritant initiates a “scratch-itch” cycle LSC classified as Primary (idiopathic) Secondary (superimposed upon lichen sclerosus, candidavulvitis; vulvar contact dermatitis) Presentation: always itching; burning, pain, and tenderness Thickened leathery red (white if moisture) raised lesion In absence of atypia, no malignant potential If atypia present , classified as VIN

  32. Lichen Simplex Chronicus

  33. L. Simplex Chronicus: Treatment • Removal of irritants or allergens • Treatment • Triamcinolone acetonide (TAC) 0.1% ointment BID x4-6 weeks, then QD • Other moderate strength steroid ointments • Intralesional TAC once every 3-6 months • Anti-pruritics • Hydroxyzine (Atarax) 25-75 mg QHS • Doxepin 25-75 mg PO QHS • Doxepin (Zonalon) 5% cream; start QD, work up

  34. Lichen Sclerosus + LSC • “Mixed dystrophy” deleted in 1987 ISSVD System • 15% all vulvar dermatoses • LS is irritant; scratching  LSC • Consider: LS with plaque, VIN, squamous cell cancer of vulva • Treatment • Clobetasol x12 weeks, then steroid maintenance • Stop the itch!!

  35. Epidermoid Cysts • Usually multiple, but can be single • Contain sebaceous material; liquid or dried • Usually have yellow or cream color • May have “BB shot” or “dried bean” texture • No treatment, unless infected

  36. Epidermoid Cyst Scrotum STD Atlas, 1997

  37. Vestibular Cysts

  38. Hidradenoma • Peculiar to Caucasian women • Sweat gland origin • Grows in interlabial sulcus • 0.5-2 cm diameter; solid • Initially non tender, but can develop an umbilicated center that later ulcerates • Benign tumor, although path closely mimics adenocarcinoma • Treatment: shells out easily with excision

  39. Genital Skin: Large Tumors Bartholin duct cyst Bartholin duct cancer Vulvar carcinoma (squamous, basal cell) Hydrocoele (cyst) of Canal of Nuck Vulvar hematoma Vulvar edema Benign solid tumors Lipoma, leiomyoma, fibroma

  40. Bartholin Duct (BD) and Gland (BG) Bartholin duct and gland at 5, 7 o’clock cephalad (deep) to hymeneal ring Makes serous secretion to “lubricate” introitus If BD is transected or blocked, fluid accumulates Non-infected: BD cyst Infected: BD abcess or BG cellulitis All surgical treatments are designed to drain fluid and create a new duct

  41. Bartholin Gland: Infectious Conditions Bartholin gland cellulitis Painful red induration of lateral perineum at 5 or 7 o’clock, but no palpable abscess Most commonly due to skin streptococcus Treatment: oral cephalosporin, moist heat Will either resolve or point as abcess Admit immunecompromised women (especially diabetics) for IV antibiotics and close observation May develop necrotizing fasciitis

  42. Bartholin Duct: Infectious Conditions Bartholin duct abscess Usually due to Staph, but may contain anaerobes Fluctulent painful abscess; if uncertain, needle aspiration will confirm pus Treatment: I&D, then insert Word catheter for 6 weeks Antibiotics usually not needed, unless Cellulitis (cephalosporin) Anaerobic smell with drainage (metronidazole)

  43. BD Abscess: I&D • Retract abscess laterally to select incision site… inside the hymeneal ring if possible • Inject 3 cc. lidocaine • 1 cm incision with #15 blade perpendicular to abscess • Lyseloculations with clamp • Irrigate cavity with saline • Insert Word catheter; inflate until snug fit in abscess cavity • Tuck nipple into vagina

  44. Word Catheter: Correct Position

  45. Bartholin Duct: Non Infectious Bartholin duct cyst Nontender cystic mass Treat only if symptomatic or recurrent Tx: marsupialize or insert Word catheter x 6 weeks Bartholin duct carcinoma Most common in women over 40 Can be adenoca, transitional cell, or squamous cell Firm non-tender mass in region of Bartholin gland Suspect if recurrent BD cyst or abcess with firm base after drainage

  46. Management of Vulvar Hematoma Almost all are due to straddle injuries Initial management Pressure Ice packs Watchful waiting Complex management Use if extreme pain or failure of conservative mgt Incise inside hymeneal ring, evacuate clots Pack with strip gauze, sitzbaths

  47. Genital Skin: White Lesions VIN/ PIN Depigmentation disorders Vitiligo Partial albinism Leukoderma • Lichen sclerosus • Lichen simplex chronicus • LS+LSC • Tinea versicolor • Intertrigo

  48. Vulvar Intraepithelial Neoplasia (VIN):Prior to 2004 Grading of VIN-1 through VIN-3, based upon degree of epithelial involvement The mnemonic of the 4 P’s Papule formation: raised lesion (erosion also possible, but much less common) Pruritic: itching is prominent “Patriotic”: red, white, or blue (hyperpigmented) Parakeratosis on microscopy

  49. ISSVD 2004: Squamous VIN Since VIN 1 is not a cancer precursor, abandon use of the term Instead, use “condyloma” or “flat wart” Combine VIN-2 and VIN-3 into single “VIN” diagnosis Two distinct variants of VIN VIN, usual type Warty type Basaloid type Mixed warty-basaloid VIN, differentiated (simplex) type

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