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Managing common vulvar skin conditions

NOV 2008

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The vulva is subject to a range of skin problems, many of them inadvertently self-inflicted.

You may routinely pamper your face and work hard to keep it moisturized and irritation-free, but what have you done lately for the more sensitive skin of your vulva, the external genital area surrounding your vagina?

Many women have been primed to think no further than "itch equals yeast infection." But with age and the decline in estrogen after menopause, we become more prone to a variety of conditions that irritate vulvar skin. These conditions aren't getting the medical attention they need — and women aren't getting the relief they deserve.

"The differential diagnosis of vulvar problems is as complicated as for headache, chest pain, or diarrhea. There are many, many causes," says Elizabeth G. Stewart, M.D., assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and director of the vulvovaginal service at Harvard Vanguard Medical Associates.

Anatomy of the vulva

The vulva (Latin for womb or covering) consists of several layers that cover and protect the sexual organs and urinary opening. The fleshy outer lips of the vulva — the labia majora — are covered with pubic hair and contain fat that helps cushion the area. Inside the labia majora are the thinner, more pigmented and delicate flaps of skin called the labia minora. The labia minora join at the top to enclose the clitoris. The labia majora, labia minora, and clitoris are made up of erectile tissue, that is, tissue that can become engorged with blood. The area between the labia minora, the vestibule, contains the openings to the urethra and the vagina, as well as the Bartholin's glands, which are located on either side of the vaginal opening and produce lubricant for the vestibule. The flesh between the vaginal opening and the anus (not part of the vulva but often involved in vulvar skin problems) is the perineum. This is where the incision called an episiotomy is sometimes made during childbirth.

Getting a diagnosis

Vulvar skin conditions are highly treatable, but the treatment depends on the specific cause. Few physicians specialize in vulvar problems, and few medical schools provide much training in this field. If your primary care physician can't help, call the gynecology or dermatology department of the nearest teaching hospital and ask for a recommendation. There may be a vulvar clinic nearby — or a gynecologist or dermatologist with a particular interest in such problems or long experience in dealing with them.

Tell your clinician about any other past or present medical conditions (including bladder and bowel issues) and any skin problems elsewhere on your body. For example, psoriasis anywhere on the body raises the risk of a vulvar condition known as lichen sclerosus. (This condition and others are described, below, in "Vulvar conditions and their treatment.") Crohn's disease, a chronic inflammatory intestinal disease, may cause abscesses or draining fistulas in the vulvar area, and vulvar skin problems are often one of its early symptoms. A mouth condition called lichen planus is another cause of vulvovaginal problems. (The term "lichen," as applied to skin disorders, refers fancifully to skin lesions that resemble lichen on rocks.) Long-term treatment with oral steroids, immune suppressants, or antibiotics also raises the risk for vulvar skin infection.

Your clinician will want to know how you care for your vulvar skin, which can help identify possible sources of irritation. Even if you can't pinpoint a change, that doesn't mean your standard routine isn't the culprit. Sometimes vulvar problems are the cumulative effect of long-term practices.

"It's often what you've done day after day, year after year, that causes the problem," says Dr. Stewart. "If you wear abrasive clothing and engage in abrasive activities like bicycling or spinning class and wear tight workout clothes that expose your vulva to sweat or to detergent or soap residue, eventually it might catch up with you."

Report all the symptoms that concern you, including itching, burning, soreness, discharge, bumps, and rashes. It will also help if you can provide a history of your symptoms and recall what seems to make them better or worse. Your clinician will examine the vulva, perhaps using a magnifying glass, and insert a speculum to inspect the vagina. She or he may test the pH (acid-base balance) of the vagina and take samples of secretions to examine under the microscope or culture for yeast. Remember, even if you're seeing an experienced clinician, several visits may be needed to diagnose and improve certain vulvovaginal conditions.

The problem with self-treatment

When vaginal or vulvar itching occurs, women usually assume it's a yeast infection and treat it with an over-the-counter antifungal cream. Often this does the trick, but not always. Of 153 women with recurring complaints who were evaluated for presumed yeast infections at the Vulvar and Vaginal Disease Clinic at Missouri's St. Louis University, only 40 had the common yeast, Candida albicans. In more than two-thirds of the women, the cause of the symptoms was dry skin, a sexually transmitted disease or bacterial infection, a less common strain of yeast that required special medication, or irritation by and allergic reactions to common products such as soaps, creams, and lotions.

If yeast isn't the problem, an antifungal cream isn't the solution. And if your skin is already irritated, you may exacerbate the problem by introducing preservatives (such as alcohol or propylene glycol) and other ingredients contained in many antifungal remedies. That's why it's important to see your gynecologist or dermatologist if a problem persists after you've tried a standard antifungal cream.

Another common response of women faced with a vaginal discharge or itch is to wash the vulvar skin vigorously, on the assumption that this will disinfect the area or remove irritants. But aggressive cleansing can add to the irritation. Until the problem is diagnosed, it's best to follow a gentle skin care routine (see "Gentle vulvar care"). In fact, gentle cleansing applies whether you have a vulvar skin condition or not: Wash the area gently with your fingertips or a soft cloth and pat dry with a soft towel. Don't use a rough washcloth, and don't rub.

Possible vulvar biopsy

Particularly if initial treatment hasn't eased your symptoms, the clinician may need to take a small tissue sample (biopsy) to make a diagnosis. Specialists say that vulvar biopsies are underused. The procedure, which is minor and done under local anesthesia, is extremely valuable, often changing the diagnosis and treatment plan. In May 2008, researchers from the University of Utah reported on the results of 89 vulvar biopsies in women who had been treated for a variety of conditions causing vulvar pain. In 61% of the women, biopsies revealed a previously undiagnosed disease of the skin or mucous membranes of the vulva.

The Utah study provided another important finding: among the 20 biopsies read first by a general pathologist, seven diagnoses were changed after the tissue was re-examined by a dermatopathologist — a pathologist specializing in skin disorders.

"Dermatopathologists have more experience looking at inflammatory skin conditions. If you get a nonspecific diagnosis from a general pathologist, you can ask to have the tissue re-read by a dermatopathologist," says lead author Anneli R. Bowen, M.D., assistant professor of dermatology at the University of Utah.

Selected resources

The V Book, by Elizabeth G. Stewart, M.D., and Paula Spencer (Bantam Books, 2002)

International Society for the Study of Vulvovaginal Disease, www.issvd.org/patienteducation.asp

Vulvar skin conditions and their treatment

Several vulvar skin conditions are familiar from other areas of the body but may be difficult to recognize when they appear on the vulva. These include the following:

Eczema. This inflammatory skin condition disrupts the skin's surface, causing red patches and thin cracks, weeping, and crust formation. On the vulva, crusts are less likely, but eczema may initiate a cycle of vulvar itching and scratching that leads to lichen simplex chronicus — thickened and intensely itchy skin. If eczema affects an area of the vulva called the vestibule, it may cause stinging and burning. Sometimes eczema appears in early childhood and its cause is unknown. More often, it begins with exposure to an irritant or allergen (see "How irritating").

How irritating

Many things can cause an allergic reaction or irritate vulvar skin. Here are some of the leading suspects:

Irritants (on exposure, can cause immediate stinging or burning)

  • Soap, bubble baths and salts, detergent, shampoo, conditioner

  • Adult or baby wipes

  • Panty liners and their adhesives

  • Nylon underwear, chemically treated clothing

  • Vaginal secretions, sweat, and urine

  • Douches, yogurt

  • Spermicides, lubricants

  • Perfume, talcum powder, deodorants

  • HPV medication, tea tree oil, Pinetarsol

  • Alcohol and astringents

Allergens (symptoms may not appear until several days after exposure)

  • Benzocaine

  • Neomycin

  • Chlorhexidine (in K-Y Jelly)

  • Imidazole antifungal

  • Propylene glycol (a preservative used in many products)

  • Fragrances

  • Tea tree oil

  • Latex (in condoms and diaphragms)

Adapted from The V Book, by Elizabeth G. Stewart, M.D., and Paula Spencer (Bantam Books, 2002).

To diagnose vulvar eczema, the clinician will ask about your symptoms; your history of eczema, allergy, and related conditions; your vulvar cleansing habits; and any products the vulva has been exposed to. During the exam, she or he will look for redness, scaling, cracking, and thickening.

All eczema requires gentle skin care. In simple cases, patients use topical corticosteroid ointments twice a day for two to four weeks and then gradually reduce the frequency until the symptoms are gone. Severe cases may require a short course of an ultrapotent steroid ointment such as clobetasol (Temovate, Cormax, others), which can be up to 600 times stronger than standard hydrocortisone creams. If the skin is too thick to absorb ointments, cortisone may be injected directly under the skin.

"Many women and their physicians are fearful of using steroids, but using steroids too sparingly or stopping too soon can cause symptoms to persist or progress. Judicious use of potent steroids in this area is very safe," says Dr. Stewart.

During treatment, you must stop scratching, so your clinician may prescribe an antihistamine (usually taken at night to prevent daytime drowsiness). A cold pack can also help relieve itching.

Psoriasis. This is a common condition in which new skin cells are produced too rapidly, leading to thickened, scaly patches of inflamed and red skin on various parts of the body. On the vulva, skin surfaces are usually too moist for dry scaling, so psoriasis is more likely to appear in the form of pink patches with defined edges. It most commonly affects the labia majora. If the skin cracks open, infection may result.

You may have treated psoriasis outbreaks elsewhere on your body with remedies containing coal tar, vitamin D, or anthralin. Do not apply these products to the vulva, as their harshness can worsen your symptoms. Your clinician may prescribe a topical steroid cream or ointment. If splits in the skin have opened the way for infection, an anti-yeast or antibiotic component may be added.

Gentle vulvar care

Whether you have a vulvar skin problem or are just prone to irritation, gentle care of the area is a must. Wear loose clothing. Choose cotton underwear (and go without when at home). To cleanse the area, use your fingers instead of a washcloth and an unscented, nonalkaline cleanser such as Cetaphil or Basis (plain water is also fine). Soak for five minutes in lukewarm water to remove any residue of sweat or lotions or other products. Pat dry, and apply any prescribed medication or a soothing and protective substance such as Vaseline or olive oil.

Avoid products with multiple ingredients. Even those that sound designed for vulvar care — like A&D Original Ointment, baby lotion, or Vagisil — contain chemicals that could irritate or cause contact dermatitis. In the bathroom, forgo moistened wipes. If you want moisture, use a spray bottle with plain water, and then pat dry.

Lichen planus. This skin condition, believed to result from an overactive immune system, can affect the vulva, the vagina, the inside of the mouth, and other skin surfaces. In most areas of the body, lichen planus causes itchy purple bumps sometimes streaked with white. On vulvar skin, the most common symptoms are soreness, burning, and rawness. The vulva may appear pale or pink, sometimes with a white lacy pattern. If the vulvar skin breaks down, the eroded areas appear moist and red. Lichen planus often affects the vagina as well, causing a sticky yellow discharge and erosions that can make intercourse painful. Eventually, lichen planus can affect underlying as well as surface tissues and produce scarring that alters the vulva's shape, sometimes leading to the virtual disappearance of the labia minora.

Lichen planus is diagnosed by its appearance (although it can be difficult to distinguish from atrophy caused by a lack of estrogen or the excessive use of steroids), and the diagnosis is confirmed with a biopsy. The condition may start as a reaction to certain medications — thiazide diuretics, beta blockers, ACE inhibitors, certain antibiotics, or antimalarial drugs — so be sure to tell your clinician about any drugs you take.

Many therapies for lichen planus have been tried, including powerful immune suppressants, but the most common initial treatment is high-potency topical steroid medication. Unfortunately, lichen planus is persistent and likely to require long-term maintenance treatment.

Lichen sclerosus. Although it can occur elsewhere on the body, this inflammatory skin disorder usually affects the vulvar or anal area in postmenopausal women. By some estimates, one in 30 older women has lichen sclerosus; it's especially common in women with psoriasis. Itching is usually the first symptom, and it may become severe enough to disrupt sleep and other activities. During an examination, the clinician may notice white (sometimes crinkly or shiny) patches. Some may contain tears or red areas from bleeding (often the result of scratching) and these areas may be painful and sting. As the disease progresses, there's a danger that vulvar tissues will scar and shrink.

Lichen sclerosus is diagnosed by its appearance and sometimes by biopsies. No matter how mild the symptoms, it should be treated to prevent progression. Many therapies have been tried. In a bulletin released in May 2008, the American College of Obstetricians and Gynecologists recommended applying an ultrapotent steroid for several weeks, then slowly tapering the dose. In one study, this approach brought complete or partial relief to 96% of women treated; and in 91%, tissues partially or fully returned to normal. After symptoms resolve, some physicians recommend continuing steroid treatment to prevent a recurrence. According to a study from Erasme University Hospital in Brussels, adding a skin protectant such as Vaseline reduces the amount of steroid needed.

Women also need regular examinations after treatment for lichen sclerosus because the condition can make affected skin more likely to develop skin cancer. Early treatment and prompt attention to new lesions or nonhealing sores in the area will reduce the risk further.

In general, women with vulvar skin problems may benefit from estrogen therapy (delivered vaginally via ring, tablet, or cream, or applied directly to the vulva), which can help counter atrophy and inflammation and make the vulvar skin less vulnerable to irritation.