Vulvovaginal disorders: 4 challenging conditions
How to identify and treat candidiasis, contact dermatitis, lichen sclerosus, and vestibulodynia
IN THIS ARTICLE
The symptoms are recited every day in gynecologists’ offices around the world: itching, irritation, burning, rawness, pain, dyspareunia. The challenge is tracing these general symptoms to a specific pathology, a task harder than one might expect, because vulvovaginal conditions often represent a complex mix of several problems. Candida and bacterial invasion frequently complicate genital dermatologic conditions. Atrophy and loss of the epithelial barrier worsen the problem. Over-the-counter (OTC) and prescription remedies can lead to contact dermatitis. Vulvodynia may be the ultimate outcome, possibly from central sensitization after chronic inflammation, which in turn can mislead the clinician into thinking appropriate therapy “doesn’t work.” And it is important to remember that any genital complaint has the potential to dampen a woman’s self-esteem and hamper sexual function.
This article covers the fine points of diagnosis and treatment of 4 common vulvovaginal problems:
- Contact dermatitis
- Lichen sclerosus
Could all 4 problems coexist in 1 patient? They frequently do. As always, a careful history and physical examination with appropriate use of yeast cultures make it possible to manage the complexity.
1. CandidiasisTelephone and self-diagnosis are a waste of time
In vulvovaginal candidiasis (VVC), symptoms can range from none to recurrent. VVC can complicate genital dermatologic conditions and interfere with the treatment of illnesses that call for steroids or antibiotics. Because the symptoms of VVC are nonspecific, diagnosis necessitates consideration of a long list of other potential causes, both infectious and noninfectious.
Candida albicans predominates in 85% to 90% of positive vaginal yeast cultures. Non-albicans species such as C glabrata, parapsilosis, krusei, lusitaniae, and tropicalis are more difficult to treat.
Not all episodes are the same
VVC is uncomplicated when it occurs sporadically or infrequently in a woman in good overall health and involves mild to moderate symptoms; albicans species are likely. VVC is complicated when it is severe or recurrent or occurs in a debilitated, unhealthy, or pregnant woman; non-albicans species often are involved. Proper classification is essential to successful treatment.1
Phone diagnosis is usually inaccurate
Although phone diagnosis is unreliable,2 it is still fairly common, and fewer offices use microscopy and vaginal pH to diagnose vaginal infections because of the tightened (though still simple) requirements of the Clinical Laboratory Improvement Amendment. (Clinicians who do wet mounts and KOH are required to pass a simple test each year to continue the practice.)
Women are poor self-diagnosticians when it comes to Candida infection; only one third of a group purchasing OTC antifungals had accurately identified their condition.3
Clinicians are not exempt from error, either. About 50% of the time, Candida is misdiagnosed,4 largely because of the assumption that the wet mount is more specific than it actually is (it is only 40% specific for Candida).
Ask about sex habits, douching, drugs, and diseases
Accurate diagnosis requires a careful history, focusing on risk factors for Candida: a new sexual partner; oral sex; douching; use of antibiotics, steroids, or exogenous estrogen; and uncontrolled diabetes.
Look for signs of vulvar and vaginal erythema, edema, and excoriation.
Classic “cottage cheese” discharge may not be present, and the amount has no correlation with symptom severity.
Vaginal pH of less than 4.5 excludes bacterial vaginosis, trichomoniasis, atrophic vaginitis, desquamative inflammatory vaginitis, and vaginal lichen planus.
Blastospores or pseudohyphae are diagnostic (on 10% KOH microscopy). If they are absent, a yeast culture is essential and will allow speciation. A vaginal culture is especially important in women with recurrent or refractory symptoms.
Always consider testing for sexually transmitted diseases.
Azole antifungals are usual treatment
For uncomplicated VVC, azole antifungals are best (TABLE 1). For complicated VVC, follow this therapy with maintenance fluconazole (150 mg weekly for 6 months), which clears Candida in 90.8% of cases.5
Non-albicans infection can be treated with boric acid capsules (inserted vaginally at bedtime for 14 days) or terconazole cream (7 days) or suppositories (3 days). A culture to confirm cure is essential, since non-albicans infection can be difficult to eradicate.
Note that boric acid is not approved for pregnancy.
CDC guidelines for treatment of candidiasis
Any of these intravaginal or oral regimens may be used
DOSE (NUMBER OF DAYS)
5 g (3)
Butoconazole-1 sustained-release cream
5 g (1)
5 g (7–14)
1 tablet (7)
2 tablets (3)
1 tablet (1)
5 g (7)
1 suppository (7)
1 suppository (3)
1 tablet (14)
5 g (1)
5 g (7)
5 g (3)
1 suppository (3)
1 tablet (1)
2. Contact DermatitisNine essentials of treatment
Contact dermatitis, the most common form of vulvar dermatitis, is inflammation of the skin caused by an external agent that acts as an irritant or allergen. The skin reaction may escape notice because changes ranging from minor to extreme are often superimposed on complex preexisting conditions such as lichen simplex chronicus, lichen planus, and lichen sclerosus.6
Contact dermatitis occurs readily in the vulvar area because the skin of the vulva reacts more intensely to irritants than other skin, and its barrier function is easily weakened by moisture, friction, urine, and vaginal discharge. The 3 main types of irritant dermatitis are7:
- A potent irritant, which may produce the equivalent of a chemical burn.
- A weaker irritant, which may be applied repeatedly before inflammation manifests.
- Stinging and burning, which can occur without detectable skin change, due to chemical exposure.
Many products can cause dermatitis. Even typically harmless products can cause dermatitis if combined with lack of estrogen or use of pads, panty hose, or girdles.
No typical pattern
Patients complain of varying degrees of itching, burning, and irritation. Depending on the agent involved, onset may be sudden or gradual, and the woman may be aware or oblivious of the cause. New reactions to “old” practices or products are also possible.
Ask about personal hygiene, care during menses and after intercourse, and about soap, cleansers, and any product applied to the genital skin, as well as clothing types and exercise habits. Review prescription and OTC products, including topicals, and note which products or actions improve or aggravate symptoms. A history of allergy and atopy should heighten suspicion.
The physical exam may reveal erythema and edema; scaling is possible. Severe cases manifest as erosion, ulceration, or pigment changes. Secondary infection, if any, may involve pustules, crusting, and fissuring. The dermatitis may be localized, but often extends over the area of product spread to the mons, labiocrural folds, and anus. C albicans often complicates genital dermatologic conditions.
- Stop the offending product and/or practices.
- Restore the skin barrier with sitz baths in plain lukewarm water for 5 to 10 minutes twice daily. Compresses or a handheld shower are alternatives.
- Provide moisture. After hydration, have the patient pat dry and apply a thin film of plain petrolatum.
- Replace local estrogen if necessary.
- Control any concomitant Candida with oral fluconazole 150 mg weekly, avoiding the potential irritation caused by topical antifungals.
- Treat itching and scratching with cool gel packs from the refrigerator, not the freezer (frozen packs can burn). Stop involuntary nighttime scratching with sedation: doxepin or hydroxyzine (10–75 mg at 6 PM).
- Use topical steroids for dermatitis:
- Moderate: Triamcinolone, 0.1% ointment twice daily.
- Severe: A super-potent steroid such as clobetasol, 0.05% ointment, twice daily for 1 to 3 weeks.
- Extreme: Burst and taper prednisone (0.5–1 mg/kg/day decreased over 14–21 days) or a single dose of intramuscular triamcinolone (1 mg/kg).
- Order patch testing to rule out or define allergens.
- Educate the patient about the many potential causes of dermatitis, to prevent recurrence.
COMMON VULVAR IRRITANTS
Lye (in soap)
WEAK CUMULATIVE IRRITANTS
PHYSICALLY ABRASIVE CONTACTANTS
Hot water bottles
Source: Lynette Margesson,MD26
FIGURE 1 A mutilating disease of mysterious origin
Though lichen sclerosus is a disfiguring disease, the intensity of symptoms does not necessarily correlate with clinical appearance. Generally, the first change is (A) whitening of an irregular area on the labia, near the clitoris, on the perineum, and/or other vulvar areas. In some cases (A and B), inflammation can alter the anatomy of the vulva by flattening the labia minora, fusing the hood over the clitoris, effectively burying it beneath the skin, and shrinking the skin around the vaginal opening. Images courtesy Lynette Margesson, MD
3. Lichen SclerosusLifelong follow-up is a must
Although it has long been described in medical journals and textbooks, information on lichen sclerosus was often unreliable until recently, and adequate treatment guidelines were lacking. The cause still has not been fully elucidated, but a wealth of information now allows for considerable expertise in the management of this disease.
Lichen sclerosus is a chronic inflammatory and scarring disease that preferentially affects the anogenital area and is 6 to 10 times more prevalent in women than men.8 Any cutaneous site may also be affected, but the vagina is never involved.
Infection? Autoimmunity? An infectious cause has been proposed but never proven. In some women, an autoimmune component is recognized: Immunoglobulin G antibodies to extracellular matrix protein I have been found in 67% of patients with lichen sclerosus, but whether these antibodies are secondary or pathogenic is unclear.9 A genetic component is suggested by the association with autoimmunity and by the link with human leukocyte antigen DQ7 in women10 and girls.11
Affects 1.7%, or 1 in 60 women.12 In females, lichen sclerosus peaks in 2 populations: prepubertal girls and postmenopausal women.
No remission after age 70. Although remission of the disease has been reported, a recent study concluded that lichen sclerosus never remits after the age of 70; the average length of remission is 4.7 years, although this figure is still in question.13 Only close follow-up can determine if disease is in remission.
Main symptom is itching
Pruritus is the most common symptom, but dysuria and a sore or burning sensation have also been reported. Some women have no symptoms. When erosions, fissures, or introital narrowing are present, dyspareunia may also occur.
Typical lesions are porcelain-white papules and plaques, often with areas of fissuring or ecchymosis on the vulva or extending around the anus in a figure-of-8 pattern.
Both lichen sclerosus and lichen planus may be seen on the same vulva.
Squamous cell carcinoma can arise in anogenital lichen sclerosus; risk is thought to be 5%. Instruct women in regular self-examination because carcinoma can arise between annual or semiannual visits.
INTEGRATING EVIDENCE AND EXPERIENCE
Ultrapotent steroids: Good control, but risk of malignancy persists
Renaud-Vilmer C, Cavalier-Balloy B, Porcher R, Dubertret L. Vulvar lichen sclerosus. Arch Dermatol. 2004;140:709-712.
If we gynecologists have been assuming that lichen sclerosus is one of those nebulous, little-explored diseases out there, we need to think again. Lichen sclerosus is a chronic and mutilating condition, an obstacle to quality of life, a threat to body image, a destroyer of sexual function, and a risk for malignancy.
Cancer developed only in untreated or irregularly treated lesions
In a key study, Renaud-Vilmer and colleagues13