LAKE BUENA VISTA, FLA. — Empiric treatment with corticosteroids should be avoided in patients who present with vulvar symptoms such as burning, itching, pain, and dyspareunia, according to Dr. Andrew T. Goldstein.
These patients should have a careful examination of the vulva using a colposcope, and if a lesion is present, a 4-mm punch biopsy is warranted.
When the biopsy specimen is sent to the dermatopathologist, it's important to provide clinical correlates and a differential diagnosis or the result is likely to be simply descriptive rather than diagnostic, said Dr. Goldstein, who is in group practice in Washington.
Patients should know the full name of their disorder, whether lichen sclerosus, lichen simplex chronicus, or erosive lichen planus, Dr. Goldstein said at the annual meeting of the International Pelvic Pain Society.
Lichen sclerosus presents with itching, burning, dyspareunia, and skin texture changes often described as “cigarette paper” skin, with crinkling and fissures around the vulva and anus. Hypopigmentation also is characteristic, with scarring and architectural changes including phimosis of the clitoris, resorption of the labia minora, and narrowing of the introitus causing recurrent tearing. It probably is autoimmune, because patients have a high incidence of other autoimmune diseases, especially thyroid disease.
Lichen sclerosus can develop at any age, including childhood, and is more common than generally appreciated, with a prevalence of 1 in 70 women. But “you have to look for it. The vulva is not just something to separate with a speculum when you do a Pap smear. It has been termed the forgotten pelvic organ.”
Punch biopsy performed before initiating treatment may show hyperkeratosis of the epidermis, epidermal atrophy with loss of rete ridges, homogenization of the collagen in the upper dermis, and a lichenoid inflammatory infiltrate in the dermis. Identifying this condition is critical, as patients with lichen sclerosus have a relative risk of 300 for developing squamous cell carcinoma of the vulva, said Dr. Goldstein, also of George Washington University Hospital, Washington.
Treatment of lichen sclerosus is clobetasol 0.05% ointment once daily after soaking. “I believe the Temovate brand is much better than the generic, probably because of the vehicle,” he said. The corticosteroid should be continued until active disease has resolved, not just for the 2 weeks specified in the package insert.
A second vulvar condition, lichen simplex chronicus, is characterized by thick, lichenified skin of the labia majora and interlabial sulcus, accompanied by erosions, fissuring, and tears in the skin that result from the patient's scratching in her sleep, said Dr. Goldstein. This condition represents the end stage of mast-cell and histamine-mediated itch-scratch-itch cycle in predisposed patients that can be initiated by irritants, allergens, or infections.
All irritants must be stopped, including soaps, detergents, and douches, and underwear must be washed by hand in plain hot water. Daily warm-water sitz baths should be followed by the application of a high-potency topical corticosteroid, which must be rubbed into the skin for 3–4 minutes. Breaking the nocturnal itch-scratch cycle can be accomplished by bedtime amitriptyline, 10–50 mg, and the application of a bag of frozen peas to the vulvar area during the night.