Information

APPENDIX 4 Patient Information



Libby Edwards


Handouts can be extraordinarily important for women with chronic vulvovaginal symptoms. Most patients believe that all vulvovaginal symptoms are due to yeast infection, bacterial vaginosis, or sexually transmitted diseases, and they are unfamiliar with other conditions.


This appendix contains handouts on the more common causes of chronic symptoms, as well as information on the use of topical corticosteroids and amitriptyline, and a handout on avoiding vulvar irritants. These are designed to be photocopied for your patients’ use.



Desquamative inflammatory vaginitis (DIV)


DIV is a vaginitis that is irritating but not dangerous in any way. DIV is not an infection or sexually transmitted disease, but it is produced by inflammation of the vagina of unknown cause.


Women with DIV report yellow or green vaginal discharge, with irritation and redness at the opening of the vagina. Most women experience pain with intercourse. An examination shows no abnormalities except for redness of the vagina and yellow-green vaginal discharge, and cultures as well as office testing shows no infection.


First-line therapy is clindamycin (Cleocin) cream in the vagina nightly. Even though DIV is not an infection, this antibiotic cream is usually effective. Clindamycin has a side-effect of decreasing even inflammation that is not infectious (for example, clindamycin has been used for years for acne, another inflammatory skin disease that is not an infection). Sometimes, a corticosteroid (steroid, cortisone) suppository or ointment is used for this as well.


DIV is not usually cured with treatment, but symptoms go away on therapy. Most women either need to use clindamycin once or twice a week to remain comfortable, or wait until symptoms return and retreat nightly. Occasionally, after the inflammation is gone, women still report feelings of irritation, and some of their symptoms are caused by vulvodynia.



Group B streptococcus in the vagina


Group B streptococcus is a bacterium that lives normally in the vagina of many women, along with many other bacteria, including lactobacilli. Group B streptococcus is only medically important in the last stages of pregnancy, since babies can develop streptococcal infections as they pass through a birth canal with group B streptococcus.


Group B streptococcus is a different strep than the bacterium that causes strep throat or “flesh-eating strep.” It is not a sexually transmitted disease, and only causes significant illness in newborns. This is not a health hazard in any other way.


In the past few years, some physicians have observed that group B streptococcus is sometimes associated with symptoms of vulvar and vaginal irritation. Therefore, many physicians who care for women with chronic vulvovaginal irritation, burning, or itching prescribe an antibiotic for women found to have vaginal group B streptococcus on a vaginal culture. Usually, there is no improvement in symptoms, because the strep was coincidental and unrelated. However, an occasional woman experiences clearing of symptoms.


When the antibiotic is discontinued, group B streptococcus usually recurs quickly. So, women who improve substantially with an antibiotic are frequently treated for several weeks or months in order to suppress the streptococcus long enough for the skin to recover. For those women whose symptoms are not relieved with an antibiotic, further treatment is unnecessary and unhelpful.



Lichen planus


Lichen planus is a skin disease that sometimes affects the vulva, vagina, and inside of the mouth.


Lichen planus can appear either as white skin or as superficial sores. The vulvar areas that are white are usually itchy, whereas those areas with sores are usually sore and painful. Often, women have both white skin and sores, with itching and soreness.


The cause of lichen planus is believed to be an overactive immune system (autoimmune disease). The immune system is that part of the body that fights off infections. Lichen planus is one of several skin diseases that occur when the immune system becomes overactive and mistakenly attacks skin.


Lichen planus cannot be cured, but medications improve the skin and provide comfort. Treatments for lichen planus fool the immune system so that it doesn’t attack the skin. Although some medications, especially oral cortisone (prednisone), depress the entire immune system a great deal and allow the skin to heal, this amount of immune suppression is dangerous when used for a long time. Therefore, prednisone is used only briefly – if at all – to help heal skin. Then, we try to control lichen planus with topical corticosteroid (steroid, cortisone) creams or ointments, or other medications that do not suppress the immune system to a dangerous degree.


While there are still open sores, minor infections sometimes occur. For this reason, patients should call their doctor if symptoms suddenly worsen.


When corticosteroid ointments do not improve the skin enough, other treatments can be added. These include topical or oral cyclosporine, topical tacrolimus (Protopic), methotrexate, azathioprine, etanercept, and other medications that partially suppress the immune system. There is no one medication that always clears lichen planus, so different treatments may be tried to find one that is useful.


Untreated or severe lichen planus of the vulva and vagina often produces scarring. When lichen planus occurs in the vagina, the vaginal walls can scar together and close the vagina so that intercourse is no longer possible. Therefore, in addition to using medication in the vagina, women with lichen planus of the vagina should either have regular intercourse or insert a vaginal dilator on a daily basis to prevent scarring.


Often, multiple visits and several different medications are required to control lichen planus. Although the treatment of itchy areas is usually easy, sores and painful skin are more difficult to treat. However, most women become much more comfortable.



Lichen sclerosus


Lichen sclerosus is a skin disease that occurs more often on the vulva than any other area of the body. The cause is unknown. However, many physicians believe that it occurs when the immune system, that part of your body that fights off infection, becomes overactive and attacks the skin.


Lichen sclerosus usually causes itching, and in later stages, easy bruising, tearing, and pain. Skin affected by lichen sclerosus is usually white, and sometimes there is a fine, crinkled texture. When untreated, lichen sclerosus often causes scarring, and the opening of the vagina can narrow. About 1 out of 30 women with untreated vulvar lichen sclerosus develops a skin cancer in the area.


Usually, lichen sclerosus does not affect other areas of skin, but about 1 woman in 10 has a few scattered white spots in other areas. Lichen sclerosus on these other areas almost never itches or causes symptoms in any way.


In the past, lichen sclerosus was treated with testosterone ointment, which was not very useful for most women. Fortunately, more recent research shows that a very-high-potency cortisone (steroid, corticosteroid) ointment usually returns the skin to its original color and texture, although it does not reverse scarring. The usual medications are clobetasol propionate, difluorasone diacetate, betamethasone dipropionate in optimized vehicle, or halobetasol, used once or twice a day. Over-the-counter hydrocortisone is not nearly strong enough to clear lichen sclerosus.


Most women need 3–5 months of daily strong corticosteroid treatment. Women are generally examined every month while using this medicine daily, because sometimes the skin can thin from too much corticosteroid. After the skin has returned to a normal texture, women use the cortisone about three times a week to prevent return of lichen sclerosus.


There is a slight increase of trivial skin infections during the first few weeks until the skin returns to normal. Also, the medication can irritate the skin of some patients. Therefore, brief setbacks are common during the first month or two. Ultimately, women with lichen sclerosus do extremely well.


After the lichen sclerosus is controlled, visits should be made with a health care provider every 6 months. This is to examine for return of lichen sclerosus or for signs of side-effects from the cortisone. Also, the health care provider needs to ensure that scarring is not occurring, and that there are no early signs of cancer. With regular check-ups and use of a topical steroid, these should not become problems.



Lichen simplex chronicus (atopic dermatitis, eczema)

Related posts:

A Systematic Approach to the Dermatoses of Pregnancy of Therapeutics for Vulvovaginal Disease Pemphigoid (Herpes) Gestationis Physiologic Skin Changes of Pregnancy Vaginitis Disorders of Pigmentation

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Apr 29, 2016 | Posted by in Dermatology | Comments Off on Information

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