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Managing vulval skin problems

Dermatology GPSI Dr Elizabeth Ogden offers practical advice on managing an often embarrassing problem

Dermatology GPSI Dr Elizabeth Ogden offers practical advice on managing an often embarrassing problem

1 Vulval skin problems are common but rarely present overtly.One community-based study found 20% of the women interviewed had suffered lower genital tract discomfort lasting more than three months and 10% reported having current symptoms. Younger women attending sexual health and family planning clinics are happier to mention vulval symptoms. But older women are more reluctant even though they may be very worried about cancer.

2 Be vigilant for covert signs of a vulval problem. There are the obvious symptoms of vulval itch, pain or splitting of the skin. But dyspareunia, perianal itch, mid cycle bleeding or suspected infertility may all be covert indications of vulval problems.

3 Don't be misled by the ‘I've got thrush again' complaint. It's understandable many women assume their vulval itch must be thrush. But itch without any discharge is much more likely to be a symptom of a vulval skin problem.

4 Vulval skin problems often present late. Many women are ignorant of normal vulval anatomy and changes in colour and architecture can go unnoticed until the condition becomes advanced. Sadly, once architectural change has occurred it cannot be reversed. Even worse, untreated lichen sclerosus (LS) is more likely to undergo malignant transformation to a squamous cell cancer.

5 Taking a smear is an ideal opportunity to examine vulval skin. Look for signs of scratching, colour change, thickened skin, the presence of small haemorrhagic areas and architectural change such as sealing of the labia or clitoris as you would see in lichen sclerosus. It's also a good idea to take a look at the skin around the anus. About 10% of patients with lichen sclerosus will have extragenital lesions resembling cigarette burns with a white thin wrinkled appearance. Often it is easier to see this whiteness in the perianal area. Make sure practice nurses doing smears can recognise genital skin disorders.

6 Patients with eczema and psoriasis often have genital involvement that they are reluctant to mention. Eczema in the vulval area gives darker, thicker, leathery, lichenified skin and is very itchy. Lichen simplex usually gives a one sided severe itch – left side in the right-handed and visa versa. Vulval psoriasis is often misdiagnosed as either a fungal infection or intertrigo. It does not have the scaliness of plaque psoriasis but instead looks red and shiny.

7 Refer to dermatology – not gynaecology.

There are only a handful of specialist vulval clinics so if you have a patient with chronic itch, architectural change or where the vulval skin looks abnormal then refer. Dermatology, rather than gynaecology, is more likely to provide a definitive diagnosis and better management, as the condition should be regarded primarily as a skin problem.

8 Simple measures can make a big difference. Patients should avoid all soaps, gels and scented products, including shampooing hair in the bath. Emollients can alleviate itch. Cotton underwear, and the avoidance of wet wipes and thin gel sanitary pads will also help and rinsing urine traces off the skin can stop irritation. Severe itch will need potent topical steroids to switch off the itch but these do not need to be used for long. A two-week course will usually bring a severe itch under control. Fragrances, nail varnish, topical antibiotics and topical anaesthetics are the commonest allergens involved in contact dermatitis and referral for patch testing may be necessary. Checking for co-existing thyroid disease in cases of LS is also advisable as 20% of patients will also have a thyroid problem. Do not overlook the possibility of underlying psychosexual problems.

9 Early treatment dramatically reduces the risk of cancer. For lichen sclerosus or lichen planus the risk of developing a vulval squamous cell cancer is low if properly treated. Published statistics are 4-5%, and less than 1% where treatment has been given in a dedicated clinic. Data on undiagnosed or untreated cases are difficult to collect but 60% of cases of vulval SCC occur with a background of lichen sclerosus. It is thought that other factors, such as irritation from urine, are involved in the transformation to cancer.

10 Young girls often get vulval itch, but mainly for different reasons. In the prepubertal these are usually poor hygiene, irritants such as bubble bath and tight fitting underwear. Thrush as a cause of vulval itch is rare in younger girls. A more common problem is threadworms, which move into the introitus at night to lay their eggs. It is estimated the incidence of LS in young girls is one in 900 and increasing. Childhood symptoms include a raised red and purple area with a bruise-like appearance, which often erroneously prompts suspicions of sexual abuse.

Dr Elizabeth Ogden is dermatology GPSI in Potters Bar, Hertfordshire, and an associate specialist in dermatology

Competing interests: None declared

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