Vulvar Edema

CHAPTER 25 Vulvar Edema

Edema represents the abnormal presence of fluid deep in the skin and/ or in the subcutaneous tissue. The fluid responsible for edema is either plasma (“angioedema”) or lymph (“lymphedema”). Angioedema occurs as a result of capillary dilation and excess plasma leakage into the surrounding tissue. This generally occurs as part of an acute inflammatory process and, at least in the early stages of the process, it may be transient and episodic. Lymphedema develops when there is interference with the removal of tissue fluid due to absence, destruction, or blockage of lymph flow. When angioedema due to inflammation becomes chronic, lymphatic vessel destruction occurs and there is a gradual developing blend of both angioedema and lymphedema.

The clinical manifestations for these two types of edema are very similar. However at the acute end of the spectrum the edema is softer on palpation (“pitting edema”) and more transient in course. At the chronic end of the spectrum, the edema is firmer, sometimes almost to the point where it will not “pit” with fingertip pressure. Otherwise, the appearance of the two forms of edema is remarkably similar and consists of variably sized, skin-colored to slightly red, poorly marginated, smooth-surfaced, slope-shouldered areas of skin swelling. Edema is generally skin-colored rather than red because the depth and amount of fluid obscure any red color that would otherwise be visible due to the vascular dilation that is an inherent part of the pathophysiology. Edema generally develops in sites where there is loose, distensible skin and thus frequently involves the lips, eyelids, and genitalia. Edema is usually asymptomatic, although when distension of the skin occurs acutely, some pain may be noted. If the edema is the result of an allergic process, some itching may be present.

Acute vulvar edema

Acute angioedema develops over minutes to hours and lasts one to several days. Resolution is accompanied by a complete return to normal-appearing skin. Many instances of acute angioedema are due to allergic reactions (medication reactions, contact allergy, etc.) but others are not (e.g., hereditary angioedema, edema due to use of angiotensin-converting enzyme inhibitors).

Allergic vulvar edema

Angioedema of the vulva regularly occurs as a part of generalized allergic reactions but these patients will not present with the primary complaint of vulvar swelling. Less often, women will develop acute edema localized only to the vulva (Figure 25.1). These patients generally develop their vulvar swelling as a result of an allergic contact reaction. Two such antigens, latex and semen, are of particular importance because they are mediated by immunoglobulin (Ig) E reactions and thus may have the potential to develop anaphylaxis. Patients with reactions to either of these antigens appear to be atopic more frequently than would otherwise be expected.

Latex allergy occurs in about 1% of the general population and up to 4% of health care workers1. This would suggest that there is a large pool of women potentially susceptible to reactions from condoms, diaphragms, and gloved examining fingers. Exact data are lacking regarding the frequency with which vulvar problems arise secondary to latex reactions but the identification of three positive skin test reactions in a group of 92 women investigated for the presence of vulvar contact allergy suggests that this may be a commonly overlooked diagnosis2.

Approximately 80 women have been reported to develop reactions to their male partner’s semen3. But this probably underestimates the real prevalence of this condition based on the finding of two positive skin test reactions among 92 women with suspected vulvar allergic reactions2.

Many patients develop vulvar edema due to lubricants, spermicides, and medications as part of allergic contact dermatitis. These patients experience a type 4, T-cell-mediated reaction rather than a type 1, IgE-mediated reaction. Thus they develop a much greater degree of inflammation than those with classical IgE-mediated allergic reactions and generally present with an eczematous morphology. Such problems are covered in Chapter 18.

Treatment of acute allergic vulvar edema may require the use of systemic antihistamines such as loratidine, hydroxyzine, or diphenhydramine. Prevention of recurrence depends on identifying and removing the cause.

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