[CG] Benign vulval skin conditions

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This guideline is to help with initial assessment and care of women with vulval disorders, with advice on when to refer to the specialist multidisciplinary team.

Commonest presentation is with non-specific symptoms such as pruritus, pain and changes in skin colour and texture.

History

See Appendix 1 for useful questions

This should include the following:

  1. Self medication or previous inadequate or inappropriate treatments which may contribute to symptoms
  2. Cervical cytology, smoking and immune deficiency especially for women with suspected vulval intraepithelial neoplasia (VIN)
  3. Contact with potential allergens or irritants. The most common relevant allergens are cosmetics, medicaments and preservatives. Others include fragrances, rubber, textile dyes, washing powder, fabric conditioners, sanitary towels, panty liners and synthetic underwear. Secondary sensitisation to multiple products is common.
  4. Personal or family history of autoimmune conditions e.g. type 1 diabetes, arthritis, thyroid disease, pernicious anaemia, alopecia, vitiligo
  5. Personal or family history of atopic conditions
  6. History of skin conditions elsewhere on the body – skin and/or mucous membranes
  7. Urinary and/or faecal incontinence. Damage to barrier function or secondary dermatitis exacerbated by moisture, temperature and friction
  8. Impact on sexual function
  9. Drug history to exclude fixed drug eruptions ( e.g. nicorandil )

Examination and Investigations

  1. Perform under a good light, with adequate exposure including peri-anal skin
  2. No necessity for colposcopy or acetic acid, except for examination of VIN
  3. Ask patient to show the affected area first
  4. Consider extra-genital sites: scalp, elbows, knees, nails, oral mucosa
  5. Consider infestations such as scabies, lice, ringworm, pinworm, threadworm
  6. No need to test for auto-immune conditions without a clinical indication
  7. Consider serum ferritin in women with vulval dermatitis. Correction of iron-deficiency anaemia or low serum ferritin can relieve vulval symptoms
  8. STI screen if clinically indicated
  9. Biopsy:
    1. If the woman fails to respond to treatment
    2. There is suspicion of VIN or cancer (20-22% of VIN have invasive cancer on biopsy)
    3. There are atypical or suspicious areas

Benign causes of vulval symptoms include:

Lichen simplex chronicus or Chronic vulval dermatitis: a common inflammatory skin condition, especially in those with sensitive skin, dermatitis or eczema. Severe,intractable pruritis, especially at night. There may be erythema and swelling with discrete areas of thickening and lichenification, especially with scratching. Sometimes linked to stress or low body iron stores.  

Vulval candidiasis: diabetes, obesity and antibiotic use may be contributory. Prolonged topical or oral antifungal therapy may be necessary.

Vulval psoriasis: Involves vulval skin but not vaginal mucosa. The appearance often differs from the typical scale of non-genital sites. It often appears as smooth, non-scaly red or pink discrete lesions.  

Atrophic vulvovaginitis: In premenarchal girls and postmenopausal women. See menopause protocol.

Lichen sclerosus. Skin often pale and affected in a ‘figure-of-eight’ pattern. Inflammation can result in adhesions, fusion and resorption of the labia. See Lichen sclerosus protocol.

Lichen planus: Usually affects mucosal surfaces and commonly seen on oral mucosa. Presents with flat-topped violaceous purpuric plaques and papules with a fine white reticular pattern (Wickham striae) but can be erosive and painful. Erosive LP appears as a well demarcated, glazed erythema around the introitus. Aetiology is unknown, but may be autoimmune. It can affect all ages and not linked to hormonal status. Consider referral to vulval clinic.

Vulval Crohns disease: Vulval involvement by direct extension from involved bowel or metastatic granulomas, rarely preceding or without known bowel disease. Vulva often swollen and oedematous with granulomas, abscesses, ulceration or draining sinuses. Refer to vulval clinic.

Vulvodynia: see vulval pain protocol 

Treatment

General life-style advice is essential in the management of any vulval skin condition. This includes smoking cessation and avoidance of common allergens and irritants (see appendix 2 Vulval skin Care).

The mainstay of treatment for Lichen simplex chronicus is general vulval care and the use of soap substitutes and emollients. Antihistamines or antipruritics may be helpful, especially if sleep is disturbed. Other options include Dermacool or ICL (ichthammol calamine lotion). Moderate or ultrapotent topical steroids may be helpful to break the itch-scratch cycle.

Treatment will depend on the specific diagnosis and should be discussed with a senior clinician.

Women with vulval psoriasis should be followed up in dermatology or vulval clinic.

Clobetasol propionate (eg Dermovate) is the most potent topical steroid available. The ointment preparation is preferred to the cream as it provides better skin contact and is less likely to cause irritation – creams contain propylene glycol, parabens and fragrances. See Appendix 3 for Regime of Steroid Use

Emollients should be prescribed to moisturise, sooth and act as a protective barrier. Women should be advised to leave an interval of at least 30 minutes between emollients and applying other treatments. They can also be stored in the fridge for symptomatic relief. Examples include Dermol 500, Diprobase, Doublebase, Emulsifying ointment, Epaderm, Aqueous cream.

Referral Criteria to Tertiary Vulval Clinic at Stobhill

  • Women who have not responded to standard treatment for their vulval condition
  • Women who are requiring frequent prolonged courses of ultra-potent steroids
  • Women whose disease is steroid resistant
  • Women whose symptoms are poorly controlled
  • Women with rare vulval conditions

Appendix 1: Patient Questionnaire

You have been referred to this clinic with a skin problem. It would be helpful if you could complete this questionnaire before you are seen. This will help to identify any factors that may be causing or aggravating your skin problem. This will be discussed with the doctor, but you may want to add additional notes if you feel it will help you to remember any important information.

 

YES

NO 

SOMETIMES

Do you take a bath?

 

 

 

Do you take a shower?

 

 

 

Do you wash your hair in the bath or shower?

 

 

 

What do you wash over all with?

 

 

 

What do you wash the vulva area with?

 

 

 

Do you use moist skin wipes in the vulval area?

 

 

 

Do you use talcum powder in the vulval area?

 

 

 

Do you use antiseptic in the bath?

 

 

 

What do you use to wash your clothes?

 

 

 

Do you use a fabric softener/conditioner?

 

 

 

What type/material underwear do you usually wear?

 

 

 

Do you wear dark coloured underwear?

 

 

 

What colour toilet paper do you use?

 

 

 

Do you use tampons?

 

 

 

Do you use sanitary towels?

 

 

 

Do you use panty liners?

 

 

 

Do you use incontinence pads?

 

 

 

Do you use condoms?

 

 

 

 

The following questions relate to your own health.

Do you have any of the following conditions?

YES

NO

Diabetes

 

 

Thyroid disease (over- or underactive thyroid gland)

 

 

Alopecia (hair loss)

 

 

Pernicious anaemia (treated by monthly vitamin B injections)

 

 

Vitiligo (patches of white skin)

 

 

Rheumatoid arthritis

 

 

Hayfever /asthma

 

 

Do you have any allergies?

 

 

Do you have any other skin conditions (e.g. eczema, psoriasis, vitiligo, dry skin, sensitive skin, flaky scalp)?

 

 

Are you on any medicines? This includes prescribed/ herbal/ over the                counter/ HRT /contraception. 

 

 

 

If you have already tried treatments for your skin problem, please note them below.

Name of treatment

 

 

 

 

 

 

 

How long did you use it for?

Effects

 

Appendix 2: General care of the vulva

Genital skin has less of a barrier than other skin surfaces and is more liable to irritation. Many products, even so-called ‘low-allergy’ products can irritate skin. Perfumed products should be avoided. The vulval area only needs washed once a day

Washing

The vulval area only needs washed once a day. Use a small amount of soap substitute as washing with water on its own tends to cause dry skin. Use your hand, avoiding flannels/sponges or over cleaning, as this will irritate. Do not use a vaginal wash as this is unnecessary and may cause irritation.

  • Dry the skin very gently with a soft towel (no rubbing) or use a hairdryer on a cool setting
  • Do not use soaps, bubble-baths, deodorants or vaginal/baby wipes in or around the vulval area and avoid antiseptics in the bath
  • Shower rather than bathe
  • When washing your hair, avoid allowing the shampoo from coming in to contact with the vulval area
  • Soap substitutes include Emulsifying Ointment, E45, Hydromol, Dermol

Clothing

  • Wear loose fitting, non-coloured cotton or silk underwear and change daily. Dark textile days may irritate the skin
  • Sleep without underwear
  • Wash underwear using non-biological washing detergent and avoid fabric conditioner

Irritants

  • Use unscented unbleached tampons, sanitary pads and panty liners. Avoid plastic coated pads
  • If passing urine makes your symptoms worse, wash the urine away from the vulval area using warm water whilst on the toilet (e.g. using a jug or plastic water bottle)
  • If you suffer from urinary incontinence, please ask your GP to prescribe a barrier ointment or spray to protect your skin
  • When swimming or exercising, protect the vulval area with a barrier cream such as emulsifying ointment or hydromol
  • Itching can sometimes be prevented or relieved by just holding the area tightly for several minutes.
  • Avoid wearing nail varnish on finger nails if you tend to scratch.
  • Some over-the-counter products may contain possible irritants e.g. baby/nappy creams, herbal creams and thrush treatments.
  • Aim to use ointments rather than creams as they have less preservatives

Sex

  • If sex is uncomfortable, lubricants such as Sylk (contains kiwi extract) may help
  • Oil based products can cause condoms to break
  • Difficulties with sexual intercourse are common. Please discuss with your doctor

Emollients

These soothe the skin and will rehydrate (moisturise) dry areas. They are usually fragrance-free and less likely to irritate. Used daily they can help relieve symptoms and protect the skin. They can be kept in the fridge and dabbed on to cool and soothe the skin as often as you like.  Examples include: Hydromol, Emulsifying Ointment, E45, Dermol, Aveeno, Epaderm

Contacts

The Vulval Pain Society   

Association for Lichen Sclerosus & Vulval Health

Vulval Health Awareness Campaign  

Appendix 3: Use of Clobetasol Proprionate (Dermovate, Clobaderm)

Patient Information on the use of Clobetasol Proprionate 0.05% Ointment

You should apply your ointment sparingly (this means half to one finger tip) to the affected area(s).

These are the areas where you have itch/discomfort or notice changes in the skin. Apply the ointment; Once daily for 1 month

Then Alternate (every 2nd) days for 1 month

Then twice a week for 1 month

Then once a week for 1 month

One 30g tube should last at least 3 months. This amount should not cause you to have adverse effects on the treated skin or elsewhere in the body.

If symptoms return after the above course, you can use the ointment every night for 2 weeks to treat the flare-up and then try to reduce the frequency, as above.

If symptoms keep coming back quickly when you stop using the ointment, you may prefer to use it regularly once or twice a week long term. Long term use is safe as long as one 30g tube lasts at least 3 months. More than this may cause skin thinning.

It is normal to notice stinging for a few minutes after applying the ointment. However, if you notice stinging in the area for more than 1-2 hours after applying it, you may have become sensitive to it. There may be alternative ointments and you should contact your GP or the clinic for advice.

References

UK National guideline on the Management of Vulval Conditions. Clinical Effectiveness Group of the British Association of Sexual Health and HIV. Feb 2014 (accessed online April 2017)

Vulval Pain Society 

British Society for the Study of Vulval Disease 

Last reviewed: 18 September 2017

Next review: 31 August 2022

Author(s): Dr Kay McAllister, Consultant SRH and Dr Simone Vella, Consultant Gynaecologist, on behalf of the Gynaecology subgroup of GONEC

Version: 2

Approved By: Dr Ros Jamieson, Clinical Director Gynaecology