Psoriasis

Treatment of psoriasis is aimed at symptom relief and minimizing Koebner's phenomenon. After PUVA psoralen (P) and long-wave ultraviolet radiation (UVA) treatment for extensive, generalized disease, psoriatic vulvar plaques may remain due to inadequate phototherapy in this region (18). Thus, vulvar psoriasis may require separate treatment. This disorder often requires more aggressive and prolonged treatment than dermatitis. For cases of limited disease, clinicians can attempt initial treatment...

References

Etiologic factors in diaper dermatitis the role of urine. Pediatr Dermatol 1986 3 102. 2. Buckingham KW, Berg RW. Etiologic factors in diaper dermatitis the role of feces. Pediatr Dermatol 1986 3 107. 3. Berg RW. Etiology and pathophysiology of diaper dermatitis. Adv Dermatol 1988 3 75. 4. Berg RW, Milligan MC, Sarbaugh FC. Association of skin wetness and pH with diaper dermatitis. Pediatr Dermatol 1994 11 18. 5. Andersen PH et al. Faecal enzymes in vivo...

Infectious Diseases Bacterial

Vulvar sites often affected by abscesses or cellulitis include the hair follicle, apocrine glands, Skene's glands, and, most commonly, Bartholin's glands. The infection is usually polymicrobial in nature, with both aerobic and anaerobic (Bacteroides species and other colonic and vaginal bacteria) flora. C. trachomatis and N. gonorrhoeae are encountered frequently. The treatment of Bartholin's glands infections depends on the patient's symptoms. Asymptomatic women less than 40 years of age do...

Contact Dermatitis and Skin Reactivity

Contact dermatitis can be exacerbated in the premenstrual phase. Alexander described a patient whose patch test of fragrance mixture led to positive results only in the premenstrual phase but was negative one week after menstrual bleeding (26). This can be explained by the suppression of the cellular immune response by estrogens mentioned previously (9). Considering the increased skin reactivity to contact allergens during the premenstrual phase, in special cases of premenstrual aggravated...

Contact Urticaria Nonimmunologic Contact Urticaria

The contact urticaria syndrome, or immediate contact reactions, comprises a heterogeneous group of inflammatory reactions that appear, usually within minutes, after contact with the eliciting substance. They include wheal and flare, along with transient erythema, and may lead to eczema. Nonimmunologic contact urticaria (NICU) occurs without previous sensitization and is the most common type of immediate contact reaction. This reaction remains localized it does not spread to become generalized...

Antifungal and Antiviral Agents

Historically, clinicians prescribed oral fluconazole as a treatment, despite little evidence of efficacy, based on a presumptive association with Candida infection (59,60). In one of the few long-term, follow-up studies of this approach, maintenance antifungal therapy resulted in a 71 cure rate among women who had positive Candida cultures at initial diagnosis (3). Injectable interferon- and interferon- have been investigated with mixed results on the basis of the presumptive association of VVS...

Differential Diagnosis

The differential diagnosis can be difficult, which often leads to diagnostic delays. The hallmark characteristics of VVS are the character of the pain (raw, burning pain or sharp, knife-like pain) (6), its localization (confined to the vulvar vestibule), and its elicitation (in response to touch or pressure). Thus, VVS differs from dysesthetic vulvodynia, which involves chronic, often nonlocalized vulvar pain that occurs with or without stimulation. These two vulvar pain syndromes are...

Fungal

Multiple double-blind, randomized studies have proven the efficacy of both oral and topical antifungals for the treatment of candidiasis. Administration route is largely dependant on patient preference. Topical antifungals include butocona-zole, clotrimazole, miconazole, nystatin, terconazole, and tioconazole. Table 1 summarizes topical treatments tested in RCTs. Cure rates are over 80 , with Table 1 RCT-Supported Topical Medications Proven Beneficial for Uncomplicated Vulvovaginal Candidiasis...

Diseases That Cause Vulvar Pain Vulvar Vestibulitis

Vulvar pain was documented as early as 1888, by Dr. Alexander J.C. Skene in his textbook Treatise on the Disease of Women, in which he identified hyperesthesia of the vulva (21). Vulvar vestibulitis syndrome (VVS) was first described by Woodruff and Parmley in 1983 (22). The criteria for the diagnosis were described by Eduard Friedrich in 1987. His three subjective and objective criteria are (23) 1. Severe pain on vestibular touch or attempted vaginal entry 2. Tenderness to pressure localized...

Herpes Gestationis

Herpes gestationis (HG) is a rare pruriginous, blister-forming disorder that occurs, in most cases, in the second or third trimester of pregnancy (37). It can also occur in association with a cystic mole or a chorionic carcinoma (37). Both in pregnancy and in the presence of trophoblastic tumors, the immune system is confronted with foreign antigens of the sex partner, which may potentially play an important role in the pathogenesis of HG. In addition to a certain constellation of human...

Vulvar Dermatitis Irritant Contact Dermatitis

A survey of German family physicians, gynecologists, and dermatologists in 1998 revealed that 24 to 38 of patients with noninfectious genital complaints had a diagnosis of vulvar dermatitis, while the incidence was 20 to 30 in Oxford, U.K., in 2000 (2,18). There are three prototypic clinical responses to irritants acute irritant dermatitis, chronic (cumulative) irritant dermatitis, and sensory irritation. The acute type develops as a result of exposure to a potent irritant and is equivalent to...

Candida albicans

Prepubescent Girls Vulvovaginitis

C. albicans vulvovaginitis is a common infection, which some authors estimate precipitates to 10 million office visits annually (19). In addition, many women Figure 10 Lichen sclerosus classic changes of lichen sclerosus of the vulva and perianal area in a postmenopausal woman, with areas of thin erythematous skin, white parchment paper-like skin in the perianal area, and thickened white skin. (See color insert pp. 4 and 5.) self-diagnose a vulvovaginal yeast infection and treat with...

Resident Vs Transient Microflora

It is generally accepted that resident microorganisms are those that multiply at a specific site, rather than simply survive. Transient organisms, on the other hand, arrive from an outside source, and are unable to compete successfully for a permanent home. While simple to state in principle, this difference is not easy to demonstrate in practice. There is an extensive body of literature concerning the microflora of the skin, but relatively little is known about the quantitative relationships...

Anatomical Structure Of The Vulva

The vulva consists of the mons pubis, the labia majora and minora, the clitoris, and the vestibule of the vagina. The external urethral orifice is situated in the vestibule, as are the ducts of the mucus-secreting paraurethral and Bartholin's glands. The mons pubis and the outer aspects of the labia majora are covered with hairy skin that is similar to that of the scalp and axillae. The labia majora contain numerous sebaceous glands, along with apocrine glands and eccrine sweat Table 1...

Diagnosis

In 1977, Friedrich and Dodson proposed guidelines for characterizing vulvodynia as follows 2. A lack of abnormal physical findings 3. Refraining from sexual intercourse because of symptoms 5. Reluctance of the patient to acknowledge a psychological component to the condition (28). Specific diagnostic criteria proposed by Friedrich in 1987 and still in use today include 1. Vulvar erythema as the sole physical finding, 2. Pain upon vestibular touch or entry, and 3. Tenderness upon localized...

Effect of Occlusion

Semi-occlusive conditions attenuated the erythematous response to all materials (Fig. 5, upper arm, 48 hours). Notably, SLS-induced erythema was reduced almost six-fold (mean scores of 0.6 + 0.1 vs. 3.4 + 0.14, semi- and full-occlusion, respectively). Pretreatment of the upper arm with emollient prevented menses-induced skin irritation, regardless of the degree of occlusion. Taken together, these observations suggest that the vulva (labia majora) is adapted to be less sensitive to...

Lichen Sclerosus

Effective treatment of lichen sclerosus will control symptoms, minimize scarring, and allow for early detection of malignant change. As a result of compelling data from clinical trials, treatment recommendations have changed recently. The current recommended and accepted treatment for all forms of lichen sclerosus is the potent topical corticosteroid ointment, clobetasol propionate (19,20). One RCT comparing clobetasol, testosterone, progesterone, and petroleum jelly showed higher rates of...

Anatomy of the Vulva

Escutcheon Mons Pubis

Aikaterini Deliveliotou and George Creatsas Second Department of Obstetrics & Gynecology, University of Athens Medical School, Aretaieion Hospital, Athens, Greece The vulva, or pudendum, is a collective term for the external female genital organs that are visible in the perineal area. Knowledge of the basic anatomy of the vulva is necessary in order to understand its physiology and appropriately recognize the wide spectrum of vulvar pathology. To achieve these goals the vulvar embryology is...

Diseases That Cause Vulvar Itching Lichen Simplex Chronicus

Lichen simplex chronicus (LSC) of the vulva is a dermatologic condition that causes pruritus. Women may have mild to intense itching, which can occur during the day or night. If the LSC is severe, a woman may commonly scratch Figure 8 Lichen simplex hyperkeratosis and erythema of the left labia majora. (See color insert pp. 4 and 5.) Figure 8 Lichen simplex hyperkeratosis and erythema of the left labia majora. (See color insert pp. 4 and 5.) the vulvar area in her sleep or be awakened by...

Cleanliness And Odorcontrol Products Soaps Body Washes and Bubble Bath

Soaps are water-soluble sodium or potassium salts of fatty acids, produced by saponification or basic hydrolysis of a fat or oil with a strong alkali (Fig. 1A) (1). Evidence exists that several ancient civilizations knew of soap making and Figure 1 (A) Basic hydrolysis a fat or oil with a strong alkali to form soap. (B) Structures of common surfactants. Figure 1 (A) Basic hydrolysis a fat or oil with a strong alkali to form soap. (B) Structures of common surfactants. used the resulting material...

The Masturbation Scare

Masturbation was not an object for prescientific or Galenic medicine, which reigned supreme from the 2nd century AD until the late Middle Ages. For 1500 years until the 17th century of Western history, the precepts guiding medical practices were based on the Galenic conception of the body as a flux of fluid humors black bile, yellow bile, blood, and phlegm. Maintaining good health required the balance of these humors in their correct proportions disease was signaled by either an excess or...

Dermatitis Herpetiformis

Although a report describing a premenstrual exacerbation of dermatitis herpeti-formis was published in 1906 (38), the medical literature contains few reports that refer to the influence of the menstrual cycle on the activity of this disease. Clinically, it is difficult to distinguish the perimenstrual exacerbation of dermatitis herpetiformis from an autoimmune progesterone dermatitis. The diagnosis must be based on histopathology, direct immunofluorescence, and the lack of evidence for an...

Surface Microflora

Researchers inoculated forearm skin of 10 black and 10 white men with Candida albicans and visually scored the severity of dermatitis by the severity of pustules (Table 9) (10,22). They also assessed microflora population after aerobic incubation. Another study evaluated facial skin microflora in black and white women. Both studies found that blacks had more skin microflora than whites, but the results differed with regard to the density of aerobes. Thus, further investigation will be necessary...

Behind The Knee Test

The behind the knee test was developed to assess the frictional effect and mechanical irritant properties of hygiene products that contact specialized skin areas such as the vulva. Test materials are applied daily to the area behind the knee and held in place for six hours by an elastic knee band. Irritation is graded 30 to 60 minutes after test product removal, preferably in the afternoon, and the following morning before the application of the next sample, using the four-point visual scoring...

Evaluation Of Transepidermal Water Loss

TEWL was assessed in 58 women 18 to 35 years of age, with regular menstrual cycles (25 to 35 days) and a menstrual flow of five or less than five days. Exclusion criteria were the use of immunosuppressive drugs, chemotherapy, anti-inflammatories, antihistamines, or steroids an active vulvar vaginal infection high blood pressure cardiovascular disease, and pregnancy. Prior to treatment, the participants completed a medical questionnaire that included an atopic dermatitis self-assessment (Table...

Douches

Douching has a long and ancient history, reaching as far back as 1500 B.C., when an Egyptian papyrus recommended a garlic and wine douche for the treatment of menstrual disorders. In the days of Hippocrates, vaginal rinsing was thought to be the only method of curing vaginal infections. Different ethnic groups have used douching off and on throughout history, but in America, douching had its heyday beginning in the early 1920s and carried on through the 1950s, when women's magazines regularly...

Genital Hygiene Of Infants Vulvar Anatomy and Vaginal Discharge

The vulva of the newborn exhibits the effects of residual maternal estrogen. Immediately after birth, the labia appear swollen, and a white mucoid discharge is present for the first few weeks of infancy. The discharge is normal and can be cleansed by wiping gently from front to back with a damp washcloth, moistened cotton wool, or wipe. As the influence of the residual maternal hormones declines, slight blood spotting may occur because of endometrial bleeding caused by maternal estrogen...

Other Genital Hygiene Practices

Perineal hygiene is part of routine bodily cleansing. In America, showers and baths are the norm, with showers being more common. Handheld showerheads are popular in Western Europe but are less popular in America in a California study, they were used by a one-quarter to one-third of women (52). Sponge baths and the use of handheld showerheads become more prevalent with increasing age, when reduced mobility becomes a factor. The bidet, common in Europe, is used rarely in America (52). Ethnic...

Assessment

As with any diagnosis, taking a careful and focused history and performing a detailed physical examination are essential. Women can present with symptoms, such as vulvar burning, itching, pain with day-to-day activities, coital discomfort, and or discharge bleeding, or any combination of these symptoms as their chief complaint. Patients may also describe a sore, ulcer, or lump. The assessment should seek information about the onset of symptom and duration as well as information regarding...

Allergic Contact Dermatitis

ACD is an immunologically mediated inflammatory cutaneous reaction to an allergen in a sensitized individual. Often, differentiating vulvar allergic versus irritant contact dermatitis can be clinically confusing, as the signs and symptoms often overlap (18) and the physical characteristics of vulvar skin make visual inspection and diagnosis difficult. The acute phase of ACD can produce vesicu-lation and severe pruritus during this phase, ACD can spread beyond the site of contact, such as to the...

Eczematous And Papulosquamous Vulvar Dermatoses Contact Dermatitis Irritant andor Allergic

Contact dermatitis can be either irritant (nonimmunologic) and or allergic (immunologic). Lesions occur on areas of the vulva that contact environmental irritants or antigens. It is essential to restore the normal skin barrier and protect the skin from additional injury. Treatment begins with identification and withdrawal of the offending substance. To prevent recurrence, careful documentation of possible irritants or allergens is necessary. Women with vulvar dermatoses should be patch tested...

Candida Torulopsis glabrata

Torulopsis

C. (Torulopsis) glabrata is a vaginal yeast infection that causes vulvar burning. Typically, women describe constant vulvar burning without an associated increase in vaginal discharge. Usually, these women have seen multiple providers and tried many over-the-counter as well as prescription medications without relief. On vulvar examination, the genitalia can appear normal or there can be generalized erythema. Microscopic evaluation of the vaginal discharge may be normal or numerous budding...

Tissue Structure and Physiology of the Vulva

Estructura Vulva

Feminine Care Clinical Sciences, The Procter & Gamble Company, Cincinnati, Ohio, U.S.A. Department of Dermatology, University of California School of Medicine, San Francisco, California, U.S.A. The vulva is composed of specialized tissue with regional differences in embryonic derivation, structure, and morphology. The vulva comprises the mons pubis, the labia majora and minora, the clitoris, the vulvar vestibule surrounding the urethral orifice and vaginal introitus, and the hymen, a...

Cyclic Vulvovaginitis Candida Vaginitis Pruritus Vulvae

Cyclic vulvovaginitis is marked by pain during certain cycle phases (luteal phase, perimenstrual phase), although the local findings are in most cases nonpatholo-gic. In the final analysis, the genesis is again unclear, although the hypothesis of a hypersensitive reaction to Candida albicans is advanced frequently (32). There have long been indications that the incidence of Candida vaginitis is hormone dependent (2,33). Thus, a Candida infection is observed more frequently in pregnant women...

Contact Dermatitis of the Vulva

Swollen Vaginal Labia

Contact dermatitis of the vulva is an inflammatory condition that can occur at any time during a woman's life in response to primary exposure to an irritant or from an allergic response to an irritant. Contact dermatitis also can occur secondary to another condition, such as a vaginal yeast infection or urinary and or fecal incontinence. Common causes of irritative contact dermatitis of the vulva include laundry detergent, fabric softeners, body soaps, perfumes, hygienic wipes, and douches. In...

Acne Vulgaris and Rosacea

A high percentage of women with acne vulgaris experience a premenstrual exacerbation. The figures in the literature vary between 27 and 70 (16,17). A study of 400 acne patients found a premenstrual exacerbation in 44 of the cases. Women older than 33 years of age appear to be affected more frequently than younger women between 20 and 33 years of age (18). A comparison of acne lesions in the late follicular phase and the luteal phase found that in the premenstrual phase, 63 of the women studied...

Changes in the Vulva and Vagina Throughout Life

Vulva Puberty

Feminine Care Clinical Sciences, The Procter & Gamble Company, Cincinnati, Ohio, U.S.A. Department of Dermatology, University of California School of Medicine, San Francisco, California, U.S.A. Aikaterini Deliveliotou and George Creatsas Second Department of Obstetrics & Gynecology, University of Athens Medical School, Aretaieion Hospital, Athens, Greece The vulva and vagina change over the course of life. The most salient changes are hormonally mediated and are linked to the onset of...

Benign Vulvar Nodules Or Tumors

In most cases, excision of solid lesions is diagnostic as well as therapeutic. Pigmented vulvar lesions include lentigo and nevi. Approximately 2 to 5 of melanomas, but only 0.1 of nevi, are located on the vulva, leading theories that vulvar nevi are at increased risk for malignant transformation (43). As such, detection and careful evaluation of vulvar nevi are critical. The benign lesions of seborrheic keratosis do not require treatment. However, excision can be performed at the patient's...

Characteristics Of Normal Vaginal Discharge

In 1959, investigators examined a group of 113 New York City women, an unknown number of whom showed evidence of cervical or vaginal infection (19). The researchers quantified the discharge by swabbing the entire vagina during the course of an examination and measuring the weight change in the swab. The mean vaginal discharge was 0.76 g for all patients, 1.0 g for women with vaginal infection, and 0.50 g for women who had douched the day before the examination. The mean weight of vaginal...

Perineal Hygiene Among Older Women

Genital hygiene is of particular importance to the health and well being of older women. The consequences of inadequate hygiene vary. Mild skin irritation and fungal or bacterial skin infections become more common in older people who have a diminished capacity to care for themselves. Atrophic vulvovaginitis is prevalent after menopause. Moreover, the risk of pressure ulcers and incontinence dermatitis can be significant when older women suffer impaired mobility and urinary or fecal...

Toilet Habits

Bathroom Habits Female

Maintaining proper toilet habits and perineal hygiene in young girls can be a challenge when parental supervision is first withdrawn. To avoid vulvar contamination with fecal material, young girls should be taught to consistently wipe from front to back after toileting. Common sense dictates that establishing good hygiene habits is desirable and healthful, but research on the contribution of hygiene to premenarchal vulvo-vaginitis has produced mixed results. A case study of 54 patients, drawn...

Effects Of Menses And Venous Blood On The Skin

Some women report vulvar irritation during the menstrual period. To assess whether menses contributes to vulvar irritation, we performed a four-day skin patch test of menses and venous blood on the labia majora and on the upper arm in 20 women volunteers (24). Compositional differences between blood and menses (e.g., proteinase content) (25) and anatomical differences in irritant susceptibility (26,27) could affect the erythema response. In brief, physiologic saline (non-irritant control),...