I'm going to give a little bit of time for folks to join here, and then we'll get started very shortly with Dr. Walsh's presentation. And I apologize for the piano practice that is happening in the background. This goes on. Great, I'm watching the people join like a popcorn in the microwave. It seems like the pops are slowing. So I'm going to go ahead and get started. So welcome everyone to the OGS webinar series. I'm Dr. Pamela Fairchild, and I'm going to be moderating today's webinar. So today's webinar is called A Day in Vulva Clinic with Dr. Catherine Walsh. She's going to give a 45 minute presentation, and the last 15 minutes are going to be dedicated to the question and answer session. So Dr. Walsh is an assistant professor of Obstetrics and Gynecology here at the University of Michigan. She is a Michigan native who earned her undergraduate degree at Michigan State. We still like her and still took her back to the University of Michigan. She then did a medical degree at Wayne State, where she also completed her residency at Detroit Medical Center. Her practice encompasses general obstetrics and gynecology, and she has a focus on vulvar diseases. She works here at our Center for Vulvar Diseases with Dr. Hoefner and has great expertise in this area, and I think we're going to learn a lot from her tonight. So before we begin, I'd like to review a couple of housekeeping issues. So this webinar is being recorded and it's live streamed. So we would like you to use the Q&A feature of the Zoom webinar to ask the speakers questions. You can use the chat feature if you have any technical questions, and the Ogg staff that are on the call will be monitoring and can help you if you have issues. All right, so we'll go ahead and let Dr. Walsh get started. Okay, amazing. Thank you so much. Thanks for logging in tonight or in the future. I'm so happy to present this to you today. So again, thank you for the warm introduction. This is a day in vulva clinic. Let's see if I can get this to advance here. I have no disclosures, but I do have a disclaimer. We're talking about the vulva, so there are going to be lots of photos coming through. So please make sure you're in a place where you can see them, but also that you're the only one that's seeing them. So over the course of the webinar, I'm going to briefly review some resources for you, review some tips and tricks for vulvar biopsies, and hopefully learn a few things through patient vignettes. So this is our resources. Certainly you can try to type in that website, but I think it's easier to either type into your search engine vulvar diseases resources for providers, or you can use our QR code here. Now, there is some of the content that's locked and is only for Michigan medicine folks. If there's something that you want access to, you'll have my contact information at the end, and I'm happy to share anything with you that I have. So this is our team, as Dr. Fairchild mentioned, Dr. Hope Hafner opened our Center for Vulvar Diseases Clinic back in the 90s, and we have been growing ever since. My newest partners, Dr. Peyton Schmidt, who is a fellow urogynecologist, Abby Brown, who is our new advanced practice provider, Dr. Saunders, who has been in the clinic about eight years and also trained through Michigan medicine and is a generalist, Dr. Ebony Parker-Brotherstone, who's a family practice physician and a huge asset to our clinic. Who's not pictured here, our incredible medical assistants, our nursing support, one of our nurses has been in the clinic like 20 years, and our sexual health counselors. So our new patients, we get 60 minutes to evaluate them. They all are offered nurse teaching, and they're all offered a separate hour for sexual health. So we take that very seriously, and we really think that's why our clinic has been so successful over the years. So let's dive in. A couple of considerations for vulvar biopsies, sorry, I'm just going to move this real quick. We are most commonly doing four millimeter punch. I don't ever need to do a bigger one, that always gets me enough information if I'm going to get information from a biopsy. But there are often times where I need to do a shave biopsy or what we call like a stitch biopsy and even excisional biopsies. So as we move through the vignettes, my hope is to point out where I do biopsies, which is the biggest question that I get from trainees coming through the clinic, but also which method I've chose to try to get the most information. Other considerations when I'm thinking about doing a biopsy, do I need to do more than one? If I have really thick tissue, am I going to be able to get enough where I'm not just getting like the dead skin on top? If I have something that I'm worried about, like a cancerous lesion or pre-cancerous lesion, trying to get enough tissue that's viable and avoiding the necrotic tissue that the pathologist really can't use. Other thoughts for you, are you interested in doing photographic documentation for your patients? This works very well for us because we're such a large group and we don't always see the same patients. It's nice to have a photo in the chart so that way we can go back and refer and see, oh, okay, this is what this patient looks like six months ago or a year ago, or this is what you looked like before surgery. It also helps us for putting together presentations like these. We do consent our patients because it's a sensitive area that we're photographing and that's uploaded in their chart as well. The other considerations, and this is kind of more of a list of things that I wanted to just kind of include, when I'm thinking about where to do a biopsy, always trying to include a tiny portion of normal appearing tissue. This really helps your pathologist kind of get a background, get an idea of what the patient looks like before they're looking at the lesion. It really helps get a better diagnosis. If you're biopsying a colored lesion, you're worried about an atypical mole, for example, the depth here is important. So sometimes my trainees come through and they're asking, well, how much of the hilt do I need? When I'm biopsying a colored lesion, I want to go all the way down to the hilt to make sure I get that depth. In case you do pick up something unexpected, you have that information already. We see a fair amount of vulvar ulcers in our clinic. If they're large enough, I always do two biopsies. One on the outside edge, again, to get that normal tissue and also get some of the ulcerated tissue, but then also in the deepest area, which usually is the center of the ulcer, to try to get an idea of how deep it goes and if there's any concern for abnormal cells there. So other thoughts, we put together this paper about two years ago on how to perform a biopsy. When I first came to Michigan Medicine, I was like, oh my gosh, I wish I would've learned this way earlier. You guys make it look so easy. And so I was the first to kind of jump on the bandwagon for putting this together. So I do pull it up for my trainees to help kind of give them a resource to go to and a lot of considerations that I'm talking about here. We are almost always using lidocaine with epi or something very similar. The only area that I don't use epi on is if I'm directly biopsying the glands clitoris. Generally I use a 27 to 30 gauge needle. Everybody's office has something different. So whatever you have around is probably sufficient. And for a regular four millimeter punch biopsy, somewhere between one and three cc's is usually adequate. The anesthetic does not distort the tissue. So make sure that your patient is numb. Your crush artifact or you kind of crushing down with your forceps is what distorts the tissue. So being careful and mindful about how you're removing the tissue is going to be the most important part. And so for that, you need a patient who's not feeling anything. My colleagues and my trainees know that I am a total stickler for stickers. I want to make sure that everything is labeled correctly, the right patient, the right biopsy, especially if I'm doing more than one, and then it matches the requisition just to kind of make sure that everything's running as smoothly as possible. For hemostasis, most frequently we're using silver nitrate sticks, but certainly a dissolvable suture is nice, especially in areas where, you know, it's going to be more kind of in contact with urine and that little biopsy site's really going to burn. If you have a bigger area that you need to close. And for kind of more exciting biopsies, I tend to use moncells if they're really bleeding, or if you have a patient who's on some sort of blood thinners. This over here is our kit. So we have several of these made up and they're all laid out for us before clinic, just makes our process so much more smooth and quick, which is what our patients like. So we have a knife handle, a needle driver, small scissors, a couple of hemostats or mosquitoes, adsen forceps, and then some gauze. So everything's laid out for you. In my regular generalist clinic, I have peel packs for everything, and I feel like it takes forever or we're worried we forget something or they're mislabeled. So this is a nice way if you're able to lay out your biopsy sets like this. So let's move into our cases. I have a couple of cases for you to kind of demonstrate some of the most common referrals that we see, and also try to give you some new information that's come up over the last couple of years in our world, and hopefully stimulate some great questions. So case number one, this is a 60 year old female with known lichen sclerosis and difficult to control disease. The patient's photo is going to be on the next slide. So take a moment and think about what's going to be your next step in management. Are you going to increase her steroid regimen, add tacrolimus, biopsy, or refer this patient to dermatology? This is the clinical photo. Patient's mom is up here. I want to draw your attention here perianally. So this patient, I would definitely do a couple more biopsies. So always wanted to think about what my plan is. For this patient, really the palpation of the exam was the most telling. So I think surprisingly, she doesn't have a whole lot of active disease right on the labia here, but perianally and on her perineum, this tissue is really thick. So I chose to do a four millimeter punch biopsy kind of right where this ridge is in the most thick area. And so again, making sure that I get enough depth that I'm actually getting tissue in my sample. And then this was a hemorrhoid with thickening over top. And of course, this is the patient describing really, really itchy, irritating, most bothersome area where she had been scratching and rubbing this as well. So in biopsying this area, I had to be a little bit mindful. This is not a place where a punch would be very suitable. So what we did is kind of injected underneath with our lidocaine with epi to kind of bring the tissue up a little bit. I then made a small ellipse incision overlying this area, removed the whole ellipse, put a stitch at the top, send it off to path and closed with a couple interrupted stitches. So the results are here. We're now calling this HPV independent vulvar intraepithelial neoplasm, but both of my biopsies had comments. So I know my pathology folks well, I know to read these comments. So I did. And basically they said, well, you know, this is probably HPV independent lesion, but it could be these new acronyms. And I was like, oh man. Okay. So we got to go back to the drawing board here. So the possibility here for our first biopsy is differentiated exophytic vulvar intraepithelial lesion, what we're calling DVIL, where our second biopsy may have been FAD, which is vulvar acanthosis with altered differentiation. So great. More acronyms, more things to remember, more things to consider, more things to look up. These lesion names have been around for a couple of years, but I've really kind of come up in the last two or three. We've secretly been doing these things while more pressing things have been going on. So importantly, these acronyms are precursor lesions to either keratinizing or verrucus vulvar squamous cell carcinoma. And so the type of acronym that she didn't have was vulvar aberrant maturation, but I kind of all lumped them together as pre-precamp. And so I pulled two articles here for you, you know, for further kind of consideration if they do come up, you almost always need more information, you almost always need more biopsies and almost always need surgical management for these situations. So I brought this patient back for more biopsies because now we're in the surgical planning area. So again, that initial biopsy, you can see it actually healed quite well and it was here. And then the one over the hemorrhoidal tissue was here. And so in thinking that these are both deep in and need to be excised, this is a sensitive area. We have a lot of important structures and none of this tissue actually looks that great. So how far out do I need to go? So I'm going to use this term loosely as far as like a mapping biopsy. That's really more of like a GYN oncology term, right? But thinking about where are we, how far out does the lesion go? So I did four additional punch biopsies here. These three all came back as HPV independent lesion or DVIN. And this one here higher up on her perineum was LS with kind of thickening. So our plan for this patient is to do a wide local excision and a split thickness skin graft. And we're planning for that in the next couple of weeks. So hopefully we're not finding anything else besides pre-cancer. This patient had six biopsies. There's not much more that I wanted to offer her and she agrees before we move forward with surgery. I do see one question in the Q&A. Okay. So one of our listeners wanted to know how you determine the appropriate depth of your ellipse incision. Perfect. So I think because it's related to this and I have the picture up, it's kind of a balance, right? Because you don't want to go too far in that you're in an exciting situation in clinic and biopsying a hemorrhoid. You want enough that you get the information. So you can always start small and go bigger. You can always take more than one sample and just make sure that they're labeled well. For these pre-cancerous lesions, you really only need the epidermis and a portion of the dermis to get enough information. And sometimes the tissue just kind of shows you the plane. Hopefully that's helpful. For the punches, again, like these are, it's a little thick. So I went, I don't exactly remember, but not all the way down to the hilt, but maybe halfway or three quarters. Again, kind of adjusting each one because of the amount of thick tissue that you see on top. That question, I'm going to wait until the end. Is that okay? Okay. So I wanted to go through a couple of slides and just kind of the highlight to her for lichen sclerosis. I feel like this is the most common dermatoses that you are going to come across and also the most common that we get referrals for and have lots of questions about. There's also a fair amount of new stuff that's come out in the last couple of years for lichen sclerosis. So as you know, this is a common chronic vulvar dermatoses. It's autoimmune. It is genetic. About 7% of patients have some extra vulvar involvement. We know about this by modal distribution, this classic age range from early childhood and then elderly patients, but we really see it in any decade of life. I have a couple more photos here just to kind of show the continuum of disease. So this photo highlights the architectural changes. So this patient has the classic whitening, has phimosis of the prepuce. You can see, maybe this was a healed fissure at some point, but certainly scarring associated with lichen sclerosis, virtually absent labia minora, very classic findings here. Not every patient is this straightforward, but it's nice to have lots of examples. This patient, very zoomed in, this is the glands clitoris here and virtually obliterated and phimosed prepuce. Very classic finding here of scarring and kind of just paleness in general. So treatment, long-term topical corticosteroids remains first-line therapy. Our patients, we emphasize vulvar care measures, comfort, we address their sexual health. As I mentioned, we're really fortunate and we can offer our patients sexual health right within our clinic. We definitely use topical estrogen as needed, age-related or otherwise. Testosterone is no longer recommended for the treatment of lichen sclerosis. And laser therapy, which has been a very hot topic in the last couple of years, is not recommended or approved for lichen sclerosis. So with initial diagnosis or upon initial consultation in our clinic, we start folks on super potent steroids and an ointment. The ointments are petroleum-based, they're very comfortable, they don't have any alcohol in them, they shouldn't burn when they're applied and usually very well tolerated. Our go-to is either clovetazole or halavetazole, 0.05%. I make the call based on insurance. Most of our patients have clovetazole covered. We start with an initial treatment of three months. For the first month, they can choose to use once or twice a day and then once every 24 hours for the following two months. And then we'll talk about what to do next. I do want to emphasize, a lot of folks feel like more is better. So an important teaching point for patients is to kind of tell them how this medication comes in a tube, like a tube of toothpaste, and that they really only need a fingertip unit or a small amount of medication, especially this thick ointment. It spreads really far. And more can cause steroid overuse, it can cause damage that we can't fix. So really making sure that patients know where to apply it and how much is really, really integral to getting the right treatment going. So once your patient is feeling better, they complete that three-month course, then maintenance therapy. Maintenance therapy, maintenance therapy, maintenance therapy. The biggest thing that we see is patients come in and they're just not doing great and it's because they're not using steroids. So we have success with kind of two different regimens, either two to three times a week with clobetazole or your super potent steroid, or daily triamcinolone use. And this is the 0.01% most of the time. I'm very much a habit person. I think, you know, if people can get in the habit of using a medication every night, they brush their teeth, they put on their medication, they go to bed, you're going to get better patient adherence, you're going to get better success. Our Australian colleagues came out with this paper about a year ago, quality of life involve our lichen sclerosis patients. It's this very nice study. They looked at their lichen sclerosis cohort. They had them fill out this quality of life index. And then they did a chart review where they looked at how their patients were using steroids and importantly, what was their cancer rate or pre-cancer rate? And what they found is that patients who are on a long-term regimen just really did well. They scored higher on the quality of life index and they had less cancer and pre-cancer. For many patients, that's what their goals are, right? And so we can definitely meet those. So what if they can't use topical steroids? Well, the first thing that we try is that maybe there's a reason why, maybe they have an irritation or an allergy to the product. So we use a fair amount of compounded topical corticosteroids. So still within that first line, they just need a different base or a different vehicle. So we send patients to a specialty compounding pharmacy. The pharmacy sends them trial of bases, which is like little tubs of medication. The patients try it first on usually their wrist and then they try the base alone. And then they call the pharmacy and the pharmacy makes up the medication in that base. We have a lot of patients who do really, really well with this. Most pharmacies like this will ship anywhere in your state. So once you find a good one, if you have a local referral, you can send them there. Other options. Well, calcineurin inhibitors are second line. I find that they're tolerated very well on other skin or other parts of the body, but on the vulva, it really causes burning. I have very few patients who can tolerate this. So it's really reserved for a special cohort of folks. Surgery is very rare. Now this is surgery not related to pre-cancer or cancer. This would be patients who have stricturing that is limiting their function, a stricture that's over the external urethral meatus, and occasionally strictures over, that have like completely obliterated the glands and they develop these cysts underneath. But we are not taking our lichen sclerosis patients, like our run-of-the-mill folks to the operating room. Patients with really difficult to control disease. We have them meet with our dermatology folks, and oftentimes they're started on systemic medications. Patients who do not respond to therapy need further evaluation, because they probably have something else going on. So this is a condition that, as you probably know, can lead to skin cancer, right? So the literature varies a little bit, but somewhere between 2% to 5% risk of developing squamous cell carcinoma of the vulva. So these patients need to have exams. It's up to you and your patients. Some patients should be seen every six months or every 12 months. Certainly if you have someone that you're watching a little bit more closely, we see some folks every three to four months. There's no role at this point for vulvoscopy, unless they have a history of DEVEN or HPV, independent lesions, or they have a comorbid condition, which would be HPV dependent lesions. So we have several patients who have both, and they do need to come in for a vulvoscopy. Any new or suspicious lesions or thickened areas need to be biopsied. Okay, so I hinted at it a little bit. This is case number two. I'm going to pause here for a second and just check. So Erica Wasenda was wondering for your lichen sclerosis patients, do you also have them use vaginal estrogen externally? Yeah, so usually what I recommend, I find that most lichen sclerosis patients do better with creams. It's a little bit messy, and I want that for the patient. So apply in the usual manner with the applicator, and then whatever's left over, I have them use externally. I have some patients who use like a tablet, but it doesn't get quite that same effect externally. I find that very few lichen sclerosis patients, especially those of a certain age, can tolerate the ring. So I would say the estrus cream is usually my go-to. Okay, so moving on to case number two. A 45-year-old patient resents with complaints of vulvar pruritus. It awakens her at night. A yeast culture was negative. She's been intermittently treated without success with topical corticosteroids for over a year. The following is her exam. So start thinking about what could this be? Are you worried this is cancer? Is this just a really bad yeast infection that the culture didn't pick up? Is this a herpes outbreak? Is this lichen simplex chronicus? Okay, so this is a very zoomed-in photo. This is a patient's legs coming out here, labia majora here. I want you to focus in on these little areas here and the overall hair distribution. So this is lichen simplex chronicus. And again, this is something that we see very, very frequently in our clinic. So Dr. Hafner is not only an amazing gynecologist, but she's also trained in GYN pathology. So she always does these amazing path slides. I like this one because you don't have to be a pathologist to kind of understand what this is looking like below the surface. You see this really, really thick layers. You see these irregular ready pegs and lymphocytic infiltration down here. So lichen simplex chronicus, the goal is once you've figured out the diagnosis to stop the itch-scratch-itch cycle. You need to rule out any infectious causes, including yeast, which can be coexisting, remove irritants, and really focus on vulvar care measures. Lichen simplex chronicus can be either primary or secondary. This is so important. And I would say, maybe my partners would say it varies month to month, but probably somewhere between 50 and 80% of our consults are a secondary lichen simplex chronicus. So let me talk about that for a second. I have some silly ways of thinking about this and teaching patients and just to kind of help us think about how this works. So I think about primary lichen simplex chronicus as kind of the way that the brain talks to the vulva. And so instead of maybe putting out a pain signal, it's putting out an itch signal. And so these patients have this kind of aberrant signaling process. There's nothing wrong. There's no anatomy issues. There's no lesions that you really see. You're going to see those changes that you saw on the slide where there are erosions because they've been scratching so much. Maybe even the hair is disrupted because of the scratching or rubbing, but there's nothing inherently causing that. Opposed to secondary, which of course implies that there's something else going on. So a lot of the times it's lichen sclerosis or psoriasis that's been untreated or undertreated. And then they have the secondary lichen simplex chronicus that really needs addressed. If you just give them topical steroids, they're not going to get better. So you have to treat their whole body to get this one cured or feeling better. Of course, either primary or secondary can recur and this can be very difficult to treat. So we have this really, really great regimen. We have handouts and we have it computerized and we use it almost every time we're in clinic. And it has several like stepwise approaches and a little bit of customization. So we all have our own preferences, but I'll walk through kind of what I do and why. And this is from a Journal Watch article from a couple of years ago. So these patients, again, they need systemic treatment. So the options are either oral prednisone for 15 days or an intramuscular injection. I find that after counseling, most patients want to do the shot. I like it because they don't have to fumble with 15 days of pills. I'm giving them other stuff. It's a lot to keep track of. They may already be coming with medications. And I like the concept of starting treatment before they even leave my office. This is weight-based. One make per keg, and it's pretty easy to keep in your office and our nurses administer. Patients also benefit from oral antibiotics, not because they have an infection, but because they have a lot of inflammation. So we tend to use Cephidroxil. If they have an allergy, we use clindamycin. Antifungals, some of us give one kind of reflexively. We're giving antibiotics, we're gonna give the antifungal. And some of us wait and see what a yeast culture shows and then decide to treat based off of that. Oral medications for pruritus. So I think there's kind of two camps here. I tend to use hydroxazine when I think I'm treating secondary lichen simplex chronicus. I think this is gonna be temporary. They just need to get relief over the next couple of weeks to months. This is probably not gonna be a long-term medication for them. Where I reserve amitriptyline and gabapentin and citalopram for patients who really have more primary lichen simplex chronicus or they have really difficult to treat disease. Maybe they've tried something similar and then they're coming to us for consult. We have written out regimens for these patients to follow. We even can fax them to the pharmacy so they're on track too. We have a process in place for how to keep track of these patients who end up on these medications and do quite well. Then we treat locally. So these patients still benefit from topical corticosteroids. Again, that same three-month principle with your ultrapotent steroid and then generally going down to trimecinolone or going longer to clovidazole like two or three times a week. Emphasizing the vulvar comfort measures and helping the patient understand how they can feel better while they're waiting for their tissue to heal. So what if this was yeast? What if it wasn't lichen simplex chronicus? Well, these are kind of the high points of considerations for yeast. And I want to talk about some of the new stuff that's on the market. So only topical azole therapies applied for seven days are recommended for use in pregnant patients. When treating with topical medications or when I counsel patients, consider recommending a seven-day treatment over these shorter intervals. I just saw a patient this week who had tried one of the one days and had this really bothersome contact dermatitis because those medications are so potent. And so we may have eradicated her yeast infection, but now she's dealing with kind of consequences from these medications. Topical medications may weaken latex condoms. So making sure that your patients are aware of that if that applies. For yeast, partner treatment is rarely indicated. Now, our clinic, we do a lot of yeast cultures. The species identification is so helpful for us. It helps us really treat these really difficult to treat patients, but we rarely need to do sensitivity testing. I have a little icon here. If you go into the app store and you look up yeast treatment, don't just type in yeast because you've got a lot of interesting stuff for baking. They also be interesting, but not useful here. There is an app through the ISSVD that can be very helpful and we refer to a lot. So I did also want to draw your attention that the CDC updated their SDI treatment guidelines in 2021. If you do use that app, their app is not up to date yet. So you do need to go back to their website. So let's talk briefly about Ibrexifungur. This is a new yeast medication on the market. It is an oral tablet with high bioavailability. It is a triterpenoid derivative that blocks the synthesis of the fungal cell wall. It's fungicidal, which is very exciting. And it's marketed as a one-day treatment, 300 milligrams in the morning and then at nighttime. Patients who were in the clinical trials and who are now using this medication, if they're having adverse reactions, it's really all GI related. So Ibrexifungur has demonstrated in vitro activity to Candida labrata. It has good activity at the normal vaginal pH. It has a nice safety profile. It doesn't have the QTC prolongation effect and a long half-life. It's now FDA approved. It's not recommended in pregnancy and it does interact with CYP3A inhibitors. This is a new medication. It's very expensive. Lots of patients are going to need prior auths or it just may not be accessible. Usually medications like this have something on their website that patients can use. This is a little table that I made up kind of comparing Ibrexifungur to our old friend, fluconazole. Of course, they have different mechanisms of action. They have different activity against Candida. So again, the Ibrexifungur is fungicidal, whereas fluconazole is fungostatic. They both are advertised for one-day dosing, but also, of course, we know fluconazole can be used in varying regimens. Neither one is recommended in pregnancy. So Ibrexifungur is really the new kid on the block. In the trials, it really doesn't match up with fluconazole, but the fluconazole trials are much older. They're in a different group. We didn't have the same type of yeast resistance and the same issues that we're having now. So what we really need is a head-to-head trial for these two medications to kind of see where Ibrexifungur is gonna fit into our treatment regimen. There may be use for Ibrexifungur in patients who have Candida glabrata, who have quick recurrence, and that patient who's really frustrated comes to your office, wants to try something new, and they can afford it. There is another medication that's coming out. It's in the early clinical trials, and it seems to be very exciting. So make sure that you keep on the up and up about yeast. Okay, so we're gonna move on to case number three. I'm gonna pause for like 30 seconds and see if anything comes through the chat that was related to that case. I think we're okay on time. Perfect. Okay. Okay, so case number three. This is a 35-year-old female who presents with bilateral bartholin gland cysts. The left is bigger than the right. It's most bothersome with arousal, and it's really causing detrimental dyspronia. On initial presentation, the glands are palpated and felt to be about two by two centimeters. The patient reports a distant history of surgery. It's a little unclear what she's had. And so what would you be thinking about? What would you want to offer this patient and why? And this is a nice one where we have some good collaboration with you guys, with our FBMRS folks. So we offered her surgery. Otherwise, she wouldn't have made it into my discussion here in the webinar. For this patient, because of her exam, she didn't have those very classic active cysts, something that I felt like I could operate on or do something with in clinic. I felt like I needed more information. Again, she had this distant surgical history. I wasn't sure from her description. It sounded like she'd already had a MRSA utilization, but it was about eight to 10 years ago, and she was still having really bothersome symptoms. And then importantly, she reports that the cysts, I'm sorry, the glands were getting bigger with arousal and really not something that I could duplicate in the office. And so I had this patient undergo an MRI to get a little bit more information, and you can see these bartholones here. So these are some images from this patient's surgery. We ended up offering her bilateral bartholone gland excision for kind of the reasons I stated. So we, to back up for a moment, we rarely do incision and drainage. The reason why is because they tend to close over and recur very quickly. I haven't placed a word catheter in years and years and years. I find that they don't work very well for patients and they're very uncomfortable. Our preference is to do an office marsupialization. It's a really nice office procedure. Patients tolerate it very well under local. They get immediate relief. They heal very well. So if I have a patient who's coming in with kind of a really active bartholone, that's going to be my go-to. Excisions are really high risk surgeries. These are going to be reserved for really recalcitrant cases, cases where they've had multiple INDs and a marsupialization, and it keeps it coming back and it's very bothersome, and in a patient who's been counseled appropriately to know what the risks are. Risks being not only immediate bleeding, but bleeding that can happen postoperatively and hematomas at home, nerve damage, changes in sexual function and lubrication, a chance that you may not get everything and it still can recur. A lot of folks avoid these surgeries for that reason. This patient, we were fortunate to be able to operate as partners, which doesn't always happen at an academic institution, so it's really a pleasure that we're able to do that here and kind of put our heads together in this quite complex and difficult case. You can see the image here of the excised right side, and her pathology ended up being like this nodular hyperplasia, and I think that just really reflects the scarring and kind of longevity of her. In this case, it's from a couple months ago. I have seen the patient several times postoperatively. She's doing very well, has healed, and important for her return to the sexual function that was a priority for her. Okay, we're going to move into the last case, and this has ended up being one of my favorite patients who has taught me so much, and one of the most kind of random ways that we started learning about her. So your patient stops you in the hallway for advice. This patient is a 23-year-old female with prior biopsy-proven lichen sclerosis and uncontrollable vulvar pain. She's currently under the care of a neurology physician in an outside institution for recalcitrant pain. She's on narcotics. She's maxed out on gabapentin. She's on an SNRI. Nothing is working. She can't even put on her topical corticosteroids because of the burning. These are her photos, and these are of all the selfies. So this patient had put them through the portal and just saying, like, you've got to get me in. You've got to help me. So what are you thinking is going on? What's your next step in management? Are you going to biopsy? Are you going to compound your corticosteroids? Because I said that's probably what you need to do next, right? Probably this is an allergy. Review her home remedies, vulvar care measures, refer her to the anesthesia pain service. So starting with a good history and physical, review the home remedies and vulvar care measures. So I've been holding back a little bit. This patient tells me seven years of symptoms, frequent visits to the urgent care and emergency room for pain, meaning that she's seeing all different types of providers and physicians with varying knowledge in vulvar conditions. In our system alone, she had had eight visits in five months. She had exhaustive STI screening. She was told four months ago to stop her topical steroids. And again, this patient just can't function. So these are more of all the selfies. And I want to draw your attention to this area right here, right on her labia minora. So what are you thinking is going on? Is this ligand sclerosis? Again, this patient came to me with a biopsy proven paper, contact dermatitis also, um, is this Bichette's? Is this herpes that was missed on screening? Is this pemphigus? This is contact dermatitis. This is benzocaine. And so again, these little erosions here, um, are excruciatingly painful. So contact dermatitis, um, the, the hardest part is to identify and then have the patient stop the offending agent. Again, ultra potent topical steroids are going to be your treatment short term when you're managing the contact dermatitis long-term for this patient with the underlying ligand sclerosis, bland emollients for comfort, sleep aids. Now for this patient, that wasn't appropriate, but certainly in others that may be, and a very severe, as my colleague patient was, uh, systemic steroids. This is not an exhaustive list, but this isn't a list of common irritants and allergens. I did highlight the urine and feces. As you know, um, patients with really advanced incontinence, they're wearing adult briefs. Maybe they are having trouble with it, you know, getting dry, um, getting everything changed. We see a fair amount of contact, um, dermatitis from, from these. Um, so certainly something to consider. So I saw this patient, um, one month later, the patient had been able to stop the benzocaine, but after seven years, um, she was really struggling with this. And I really enjoyed this patient because she was just so candid with me and really able to share what she was feeling. I gave her a second dose of systemic steroids, an additional month of a potent topical steroids. By the time I had seen her, she was already off the narcotics and starting to feel a little bit better. And she was ready to accept sexual health and general counseling to start talking about the last seven years. This is the before and after. So again, that's like one of those initial of all the selfies. Um, and this is my office photo. You can see that these are still healing here. This is the patient two months later. So she is now several months out, um, has not gone back to any narcotics. She's weaning off her gabapentin. She actually really liked that SNRI. And I think it's, it's kind of helping her in many facets. And we ended up increasing it. Um, she's on daily triamcinolone. She's in counseling. Um, and this patient is now wanting to be like a patient advocate, um, knows that I'm presenting her and very happy about that, um, identifies as a young black woman and really wants, um, some solidarity and learning about folks that are just like her. So that's the end of my webinar for you. Um, I've left ample time for questions and I think we'll start with what's in the chat. Yeah. Um, so we have 15 minutes and everyone should be submitting questions to the Q and A. We do have a few that have already come through. One is in regard to immicrolod for VIN1. Why not use immicrolod and for a few months and then determine if excision is needed later? So these, um, this is a great question. Um, these are high grade lesions and because they, you know, she's had multiple biopsies and it has had the HPV independent, um, this patient is really high risk for us finding some kind of microinvasive cancer. Um, I would say that, uh, immicrolod should be reserved for low grade as you're kind of implying VIN1. Um, we do use immicrolod off label for patients who are unsafe to go to the, um, operative room. They're, um, have such massive disease, um, that we're trying to like debulk them a little bit, but that's really, really rare cases. Um, and you have to be sure that you are not putting immicrolod on an active cancer. Great. And the next question, I think probably you already answered this with your prior answer, which is why not use laser in that first case? Why did you choose a wide local? Um, sure. So again, because of the, um, differentiated VIN or the HPV independent disease, laser's really not recommended for that. Um, the old literature states that maybe 50% of these patients had invasive disease. Um, we're finding now that we're just learning more about this area. And so it's probably a little bit less than that, but it's really not recommended to laser HPV independent disease. The classic zoom. I'm still muted, but talking error, I apologize. Um, and I'm working here. Um, one of our participants said that they always biopsy and confirm like in simplex chronicus before starting an extensive regimen. What do you think about that? So that's interesting. Um, historically we had always biopsied our lichen sclerosis patients that always biopsied our LSC patients. It was really great for data and for projects, but, um, we're kind of moving towards treating them clinically, like, uh, excuse me, diagnosing them clinically first and then treating. And then if they're not getting better, um, to go back in, um, biopsy, I think it's really kind of dependent on what you're comfortable with. I would never say no to a biopsy if someone was thinking about it. Um, but oftentimes these patients just do so well. Um, and you know, this is a kind of a special niche, right? We're doing dermatology of a special part of the body. We're seeing hundreds of these patients. And so our clinical kind of expertise is just a little bit different. Um, and so it may be very appropriate to say, gosh, I'm just not sure I want to biopsy this before I do the treatment regimen. Great. And then another question we have, this is, this is interesting because I know that we've had some data that's come out of Michigan about this povidone iodine prep, the new recommendation from AAGL about chlorhexidine. And, um, I would just give a spoiler alert that we have some data that's going to be published soon that actually states that, um, iodine is superior to chlorhexidine and we don't use it at the university of Michigan unless there's an allergy. But the question is, have you seen issues with people that have gotten chlorhexidine for a procedure and then developing, um, both our vaginitis issues? So I can think of a few where it's been on like the list of possibilities that that was related. Um, certainly I've heard of, um, folks getting chlorhexidine that's not diluted and having kind of immediate reactions postoperatively. Um, so I think that there's probably more short, short term, like allergic or irritant kind of concerns that could be treated, not necessarily causing longterm effects. Great. And Dr. Khan has an excellent question that this happens to us all the time as gynecologists, which is patient comes in, they've got the chronic itching and burning and their biopsy comes back and shows chronic inflammation. Um, so what do you do with that information? Oh, it's so frustrating, right? So, um, you know, oftentimes you get these nonspecific inflammation, spongiotic dermatitis, um, they really probably need steroids, right? So they probably need topical steroids, go back to your clinical findings, seeing if you can kind of fit them in a box of, um, morphology, um, and what your differential is. Um, you can certainly try to treat, and then if they're not responding, going back for further biopsies, um, or refer out. But I would start in a case like that chronic inflammation, topical steroids. Great. And this is another good one, very pertinent to the crossover between vulvar disease and urogynecology, which is when you have a patient that has a vulvar dermatosis, and then they have a posterior repair or something that, that might interrupt that area. When can they resume those steroids? Yeah. So I am, if they're using estrogen products, um, like right up until surgery and like, depending on what your hospital protocol is, their topical steroids or intravaginal steroids, um, maybe a week before and have them resume, um, like three to four weeks after I've had a couple of patients who've undergone, um, who've had like in plantas and undergone hysterectomy. And we worry about, you know, it is, are we going to obliterate more of the vagina than we were planning to? Um, and so bringing them in earlier for your like cuff check or for your post-op check for, uh, uh, AP repair, uh, making sure that the vaginal walls aren't agglutinating, um, and resuming probably within the first couple of weeks. And the next question is vestibulitis. How do you diagnose and how do you treat? Um, Ooh, we need another webinar. So, um, that's a really challenging diagnosis of exclusion. Um, there are lots of resources on our website, um, to talk about vulvodynia, vestibulitis, um, and kind of at all of the subsets of that. Um, you have to have a patient who has no anatomical or architectural findings. They have negative yeast culture and they have, um, positive future testing, um, pain on exam. And then I'm, I generally use the vulvodynia guideline or the update, um, to follow their treatment algorithm. Um, this is just a reminder from Charles Butrick, who's saying that he sees a lot of folks that have untreated LS and a lot of irritation and burning, and then they end up with pelvic floor dysfunction due to pelvic floor, muscle spasms, and just a reminder for everyone to treat all the pain generators, which I think is a good reminder. Oh yeah, definitely. And then, um, inter-trigo lesions of the groin and folds. And how do you treat those? Um, so if that's something that's difficult to treat, I would consider culturing, um, even sometimes biopsying I've been duped before thinking that it's inter-trigo and it's actually tinea or, um, psoriasis. And so, um, again, if you're trying something that you thought would work and it didn't, um, kind of go back to the drawing board. Um, I like nystatin powder, um, for patients who have kind of recurrent inter-trigo issues. It just does a really nice job. Yeah. I saw two of those in clinic today. And it's an issue that comes up all the time in urovine. Yeah. Do you like the nystatin powder too? I love the nystatin powder. I think it's great because it has that drying effect and it treats whatever underlying yeast is going on. Um, this is a good question too, is it, do you always do your wide local excisions? When, when are you going to plan to refer that person to gynecology oncology? So we have a unique situation here at Michigan medicine, um, where we do a lot of the excisions and a lot of the vulvar disease. Um, I recently gave a talk and kind of pulled the audience. I, and it was an audience of really generalist OBGYNs. What are they doing for these patients who have pre-invasive disease? It was about 50 50. Um, some patients, uh, live in an area where their oncologists are so busy that they won't see a patient without a cancer diagnosis. And so as a generalist, you're kind of doing everything up until that, um, others are more open to referral. So I think it really varies by institution. Um, and then any place for direct steroid lesion injections? Yes. Um, we do, um, ILKs frequently. I do them the most for hidradenitis, which we didn't get to talk about. Um, and we do see quite a bit of, um, I do for maybe like a little patch or plaque of lichen sclerosis. That's been difficult to treat. And the patient isn't a candidate or doesn't want to do topical steroids. Um, they're a diabetic for example. Um, and so yes, absolutely. Next question is a, is a little case series here, a case for us, which is a 35 year old who has vulvar changes, itching, and dyspareunia looks like lichen sclerosis, but then on biopsy, it says benign acanthosis. What would our next step be? I would still treat her with topical steroids. Um, I think trust your clinical judgment. Um, sometimes the biopsies don't catch what we are seeing. Um, and if you're still having kind of itching and irritation, then kind of go back to the drawing board. Great. And then general hiatus stenosis associated with lichen, how do you treat that dilators or surgery? Yes. So we see quite a fair amount of lichen planus. Um, I see also lichen sclerosis that has a narrowing, um, definitely starting them on medication, making sure they're applying it to the right place. Um, we offer lots of dilators, um, and dilator teaching importantly. Um, we also have our own process for surgery for lichen planus. Um, we have a video on our website and we're in the midst of doing a review of our cases and have had very good success over the years. And then last question looks like it's going to be, how do you assess to confirm yeast infection or rule out yeast infection? So, um, let me think about what the question is. So I think across kind of, um, the nation wet mounts have kind of fallen by the wayside. A lot of it is you have to have the rights, um, CLIA documentation and all these protocols. And so it's being very difficult and expensive. Um, so if you aren't doing yeast cultures or have something worked out with your lab, um, that's where I would go to next. Um, because even if you're someone who looks at wet mounts all day long, you're still going to miss some. And certainly the non-Albicans yeast. Um, and so the yeast cultures can be just very, very helpful. Um, even the pH papers are hard to come by in certain offices. So that's what I would kind of go for next. Uh, and then thinking about that, um, yeast, um, yeah. Well, one more thing, PCR testing for yeast question mark. Um, we haven't started doing it. We culture out. Um, I I'm not sure we'd have to look at like the cost effectiveness and everything, but maybe that's what's coming. Yeah. I don't, I don't have, think we have that order in our system. Interesting. Um, great. Well, I think this has been a great talk, Katie, and I would encourage the participants to check out the vulvar diseases website, um, which has a lot of great resources that I use as my vulvar crutch, almost a daily basis when this stuff comes up, um, on behalf of odds, I'd like to thank Dr. Welch and for everyone for joining us today, um, for the full list of upcoming webinars, please visit the odds website. You can sign up, you'll get notifications. Um, and you can see some other great webinars. Thanks for joining tonight. Thank you so much.

vulvar conditions

lichen sclerosis

topical corticosteroids

long-term maintenance therapy

lichen simplex chronicus

systemic steroids

vulvar care measures

Bartholin gland cysts

contact dermatitis