QUIZ W. ANSWERS

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Dee~

QUIZ W. ANSWERS:

Case history:

A 28-year-old fitness instructor presented with a three-year history of severe vulvar itching. The itching started gradually, and she initially self medicated on multiple occasions with a topical over-the-counter imidazole for yeast and with Vagisil®. When the itching persisted, she saw her family doctor, who treated her with fluconazole and sent her to her gynecologist. The gynecologist diagnosed vaginitis and prescribed oral metronidazole and topical clindamycin. The itching and discomfort worsened, to the point where she was unable to sleep through the night without waking to scratch. She was seen by her local dermatologist who prescribed a low-dose corticosteroid lotion with no improvement.

The patient has a history of asthma and reports that one of her children has eczema. Her gynecologic history is significant for a history of what the patient describes as yeast infections. Her current medications include oral contraceptive pills. Although she has no known medication allergies, she does report an allergy to nickel jewelry. Finally, as a result of her job, she showers two to three times daily.

On examination, the vulva, while structurally intact, is remarkable for whitened and thickened skin involving the inner labia majora extending throughout the perineum. This entire area is filled with numerous small fissures as well as small eroded weeping lesions. The vaginal exam reveals a small amount of clear discharge. Microscopy is normal, without yeast, clue cells, trichomonads or white blood cells. Lactobacilli are present, and the pH is less than 4.0. A vaginal fungal culture is negative.

CORRECT ANSWERS:

THE VULVA

1. What is the most likely diagnosis?

a.

Lichen planus

b.

Lichen simplex chronicus

c.

Lichen sclerosus

d.

None of the above

1.

The correct answer b.Although the differential diagnoses include all of the disorders listed, the most likely diagnosis is lichen simplex chronicus. Vulvar lichen simplex chronicus is a chronic eczematous disease characterized by intense and unrelenting itching and scratching.

In vulvar specialty clinics, lichen simplex chronicus accounts for 10-35% of patients evaluated.

From 65% to 75% of patients will report a history of atopic disease, and as such, lichen simplex chronicus may be a localized variant of atopic dermatitis. All patients report pruritus, and most will report vigorous scratching or rubbing.

They often, as in this case, report sleep disturbances as a result of their discomfort. Clinically, lichen simplex chronicus appears as one or more erythematous, scaling, lichenified plaques. In long-standing disease, the skin appears thickened and leathery, and areas of hyperpigmentation and hypopigmentation may be present. Erosions and ulcers can also develop, most commonly from chronic scratching.

2.

Possible contributing factors from the patient’s history include:

a.

Exposure to topical antimycotics

b.

Exposure to topical antibiotics

c.

Exposure to topical anesthetics

d.

All of the above

2.

The correct answer is d.Lichen simplex chronicus represents an end-stage response to a wide variety of possible initiating processes, including environmental factors (e.g., heat, excessive sweating, and irritation from clothing or topically applied products) and dermatologic diseases (e.g., candidiasis, lichen sclerosus).

Although the precise initiating factor in this case is hard to identify, it appears that she most likely developed dermatitis (or eczema) initially.

Subtypes of dermatitis are numerous and can be classified as either exogenous (irritant or allergic contact dermatitis) or endogenous (atopic or seborrheic dermatitis).

Often, more than one process has led to the symptoms the patient reports. It is not uncommon to see a mixed picture, in which endogenous dermatitis or another epithelial disorder has been worsened by use of ointments or creams to which the patient has adversely reacted.

In this patient, repetitive cleansing may initially have led to a breakdown in the skin’s barrier function. As the skin becomes cracked, secondary infection can result. If the patient is atopic, (Note that's 'atopic' not 'atrophic' which means a genetic tendency towards a condition Dee) the secondary infection will lead to a flare of their condition.

The topical therapies she then used may all have contributed to the perpetuation and worsening of her symptoms. Contact dermatitis is an inflammation of the skin caused by exposure to an external agent that acts either as an irritant or as an allergen.

The former is more common and results from direct injury to the skin, often as a result of exposure to specific irritants such as detergents, soaps and propylene glycol, an additive found in many topical medications.

Discomfort usually begins immediately following exposure. Allergic contact dermatitis, in contrast, is an immunologically mediated inflammatory reaction (type IV delayed hypersensitivity) and affects only individuals previously sensitized. Symptoms usually occur within 24-48 hours following exposure.

Commonly encountered allergens include a variety of topical medications such as antibiotics, antifungals, corticosteroids and the greatest offenders, the topical anesthetics (Vagisil® contains lidocaine hydrochloride).

(Comment: I've personally seen many negative reports on using the Vagisil. Dee)

In this patient, all of the above were used, often repetitively. Furthermore, she has a personal and family history of atopy (genetic) which predisposes her to be more susceptible to irritants as the skin is less able to tolerate environmental insults.

3.

Appropriate additional tests in this patient may include all except:

a.

Biopsy

b.

Patch testing

c.

HIV testing

d.

Vaginal fungal culture

e.

Vaginal bacterial culture

3.

The correct answer is c.Clinical appearance alone cannot consistently be used to distinguish between the numerous pruritic skin disorders than can affect the vulva. Routine bacterial cultures of vaginal flora are of limited value in patients with dermatitis or lichen simplex chronicus.

On the other hand, vaginal fungal cultures are necessary, as yeast can often be a precipitating factor in these conditions. Fungal cultures not only establish the diagnosis of candidiasis, but also allow speciation if yeast is confirmed.

To confidently rule out a yeast infection, two negative vaginal fungal cultures (taken when the patient is symptomatic) should be obtained. Biopsy (which would demonstrate marked hyperkeratosis with widening and deepening of the rete ridges), is rarely necessary unless an underlying disease is suspected.

Biopsy should be considered, however, IF the patient does not respond to treatment.

Patch testing (generally done by a dermatologist) to potential allergens (as well as possible offending topical medications) in cases of suspected allergic contact dermatitis is vital. Such testing, however, should be delayed until the condition has resolved. HIV testing is not indicated in this patient based solely on the diagnosis of lichen simplex chronicus.

4. Initial therapy for lichen simplex chronicus consists of:

a.

Oral corticosteroid

b.

Mid-potency topical corticosteroid

c.

Topical clindamycin

d.

None of the above

..

4.

The correct answer is b.The approach to this patient should include all of the following: removal of the offending agent or practice, correction of barrier function, elimination of scratching and reduction of inflammation.

Barrier function should be restored through the use of Sitz baths, estrogen therapy if indicated, treatment of concomitant infection if present and application of a thin layer of plain petrolatum.

Of note, women on oral contraceptives can often be somewhat atrophic, a condition which further worsens their barrier function.

(Comment: OC's can block our necessary hormones such as the E & T, dee)

Elimination of scratching can be accomplished with the use of medications with antihistamine and sedative properties (e.g., doxepin or hydroxyzine (atarax) for nocturnal symptoms, while cetririzine or a selective serotonin reuptake inhibitor can be used to control day-time itching.

Anti-inflammatory therapy should begin with a mid- to high-potency topical corticosteroid (depending on the presence of underlying disease) applied nightly until symptoms start to abate. Less frequent use (alternate nights, then twice weekly) should continue until the condition resolves.

Ointments, as opposed to creams and lotions, are the preferable form of topical therapy as they tend to be less irritating. A weaker corticosteroid, such as 1% hydrocortisone, can then be continued as needed. In recalcitrant cases, oral or intramuscular corticosteroids may be needed. It should be noted that the success of therapy in lichen simplex chronicus has not been validated in prospective trials.

REFERENCES

Boardman LA, Botte J, Kennedy CM. Recurrent vulvar itching. Obstet Gynecol 2005;105:1451-5. Crone AM, EJC, Wojnarowska F, SM. Aetiological factors in vulvar dermatitis. J Eur Acad Dermatol Venerol 2000;14:181-6. Lynch PJ. Lichen simplex chronicus (atopic/neurodermatitis) of the anogenital region. Dermatol Ther 2004;17:8-19. Margesson LJ. Contact dermatitis of the vulva. Dermatol Ther 2004;17:20-7. Sobel JD. Management of patients with recurrent vulvovaginal candidiasis. Drugs 2003;63:1059-66. Welsh BM, Berzins KN, Cook KA, Fairley CK. Management of common vulval conditions. Med J Aust 2003;178:391-5.