Challenges and Advances in Vulvovaginal Disorders

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The presentation by Dr. Hope K. Haefner reviews common and challenging vulvovaginal disorders, highlighting diagnostic and treatment advances. Key topics include candidiasis, lichen disorders, vulvodynia, bacterial vaginosis, and severe conditions like Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).<br /><br />In vulvovaginal candidiasis, diagnostic shifts from traditional microscopy to PCR testing facilitate species identification, guiding targeted therapy. New oral antifungals, notably ibrexafungerp (FDA-approved 2021) and oteseconazole (FDA-approved 2022), offer effective treatment options, including for resistant Candida species. Safety considerations emphasize avoiding use in pregnancy and managing drug interactions.<br /><br />The presentation details management of chronic vulvar itch ("itch-scratch" cycle) using oral and intramuscular steroids, antihistamines, and neuropathic agents (e.g., amitriptyline, gabapentin). For vulvodynia, compounded topical therapies combining analgesics and muscle relaxants provide relief; hormone treatments and systemic agents including antidepressants and anticonvulsants address neuropathic pain.<br /><br />Lichen sclerosus and lichen planus are highlighted for their distinct presentations and treatment needs. Lichen sclerosus treatment centers on potent topical steroids, general skin care, and careful monitoring, with limited surgical roles for adhesions. Erosive lichen planus necessitates topical steroids, intralesional injections, and sometimes systemic immunomodulators to control pain and prevent scarring and vaginal adhesions. Vaginal lubricants and dilators are essential adjuncts.<br /><br />Severe immune-mediated reactions like SJS and TEN require prompt identification and multidisciplinary care. Use of topical steroids on vulvar and vaginal mucosa, along with dilation therapy, aims to preserve function and prevent strictures.<br /><br />Clinical pearls stress thorough assessment, listening to patients, cautious biopsy practices, and evidence-based individualized treatment to improve outcomes in vulvovaginal disorders. Advances in antifungal agents and immunomodulatory therapies offer expanded options for challenging cases encountered in women’s health.

Keywords

vulvovaginal disorders

candidiasis

lichen sclerosus

lichen planus

vulvodynia

bacterial vaginosis

Stevens-Johnson syndrome

toxic epidermal necrolysis

antifungal therapy

immunomodulatory treatment