Good evening, welcome to the Ogg's Bureau of Gynecology webinar series. I'm Dr. Joy Wheat, I'm the moderator for today's webinar. Today's webinar is titled Common Vulvar Dermatoses Evaluation and Management. Our speaker today, Dr. Katie Schwartzman, currently serves as the Vice Chair of Education in the Department of Gynecological Surgery and Obstetrics at the Uniformed Services University School of Medicine in Bethesda, Maryland. She attended Albert Einstein College of Medicine through the Navy Health Professions Scholarship Program and she completed residency training at Beth Israel Deaconess Medical Center in Boston and was then stationed at the National Naval Medical Center, which is now Walter Reed National Military Medical Center, where she served her military commitment. She is the founder and director of the Vulvar Dermatology Clinic at Walter Reed, and Dr. Schwartzman's clinical and research interests include medical student and resident education, as well as general obstetrics and vulvar dermatology. So I'd like to welcome Dr. Katie Schwartzman. Thank you so much for being here with us this evening. Thanks so much for having me. Before I turn it over to you for our lecture, I just want to give out some last minute reminders for the attendees. So just as a reminder, the presentation will run about 45 minutes. We'll try to save about the last 15 minutes of the webinar for questions and answers. And then just a few other housekeeping items that I'd like to remind you before we begin. The webinar is being recorded and it is live streamed. A recording of the webinar will be made available in the AUG's eLearning portal. If you have a question, please use the Q&A feature of Zoom webinar to ask any of the speakers questions, and then we will answer them all at the end of the presentation. You can use the chat feature if you have any technical issues. There is an AUG staff member standing by who will be monitoring the chat and can help with any assistance. But mainly for your questions, please try to put them in the Q&A function. All right, with that, I'm going to turn it over to Dr. Schwartzman, and she is going to give us this awesome lecture, and I'll be back at the end. Thank you. Well, thank you so much, Joy, and thank you to AUG for giving me this opportunity to speak with you guys today. Like Joy said, my name is Katie Schwartzman, and I am a general OBGYN by training, but about 10 years ago, I developed an interest in vulvar dermatoses and kind of have focused my clinical practice on that. It's been a lot of on-the-job training, you know, I didn't learn too much in residency. There's also a lot of overlap with dermatology, which I know we don't necessarily get that in OBGYN training. So I'm going to take you on this journey with me and share with you what I've learned. And also, you know, if there's an area of study that really interests you guys, it's definitely possible to develop a niche, and, you know, oftentimes it becomes pretty popular. So I have nothing to disclose. I do work for the Department of Defense at the Uniformed Services University, so these are my views and opinions and not those of the government or Uniformed Services University. These are my learning objectives, so by the conclusion of the lecture, learners should be able to accurately describe vulvar physical exam findings, discuss indications and techniques for performing a vulvar biopsy, counsel patients on the goals of therapy, and formulate an initial plan of management. I kept these learning objectives overall general because while some of you guys, I think, have had a lot of exposure in vulvar disease, maybe you had a vulvar clinic in your residency, maybe some of you haven't. So I'm going to give the general overview and then focus on the vulvar dermatoses. So I'm going to start with this picture. When I started my vulvar clinic, this was one of the very first patients that I saw. Looking at this picture, I think that it's obvious to see that this is abnormal. There's a lot of scarring, the labia minora are absent. You can't see this patient's clitoris, but what else do you see in this picture? I think if you look at the fullness of her labia and the hair pattern, even though it's shaved and stubble, like if it was grown in, it would likely be full. So this patient is really young. This patient was 25 years old. It wasn't what I was really expecting to see when I started my clinic. But also, what you can't see from this picture is the frustration on this patient's face because she's itching all the time and the sadness she feels because she's young, she's newly married, and she can't have sex with her partner. And also, the shame she feels because she thinks she's disfigured, she doesn't want to be naked in front of her new husband. So these are, you know, when I started the clinic, I thought I would see a lot of like vaginitis and just want to have patients follow up with me to close the loop to make sure they were getting better. But actually, I ended up seeing a lot of vulvar dermatoses. But before we talk about abnormal, I think we should review normal. So you guys are very well familiar with vulvar anatomy, the borders of the vulva. Anteriorly is the mons, posteriorly the perineum, and laterally the genitofural or labiofural folds. One thing to remember is that the most variable part of the vulva is really the labia minora. So the labia minora can be small, can be large. This sometimes complicates exams, because if a patient comes in with itching, you don't know if they've had a change in their vulvar architecture, or maybe they just have small labia to begin with. And then the labia minora come together anteriorly to form the frenulum of the clitoris, and superiorly to form the preface or the hood of the clitoris. And then the borders of the vestibule are anteriorly the frenulum, medially is going to be the hymen, and then laterally is Hart's line. Now, what's the significance of Hart's line? So, you know, you can see in this picture that Hart's line is really the border of the mucus membrane. So at this point is when mucus is the protective aspect, and is in contrast to the vulva that starts kind of on the medial aspect of the labia minora and all the way to Hart's line, which is partially keratinized. So it does have sebaceous glands and can form a protective barrier. So that's often called the modified mucus membrane or partially keratinized. And then finally, the hair-bearing part is dry, keratinized hair-bearing skin, which has similar protective properties to other skin on your body. So I thought this was a really interesting study. They did a study comparing the biophysical variables, permeability and irritant susceptibilities in the forearm versus the vulvar skin, just to drive home that the vulva can be super sensitive and very different than other parts, than skin and other parts of the body. So they found that the vulva had an elevated hydration and decreased water barrier, which meant that it lost water more quickly than at the forearm, had a higher friction coefficient and was susceptible to more chafing and maceration. It has increased penetration of certain medications, which is great when we're using medications to treat inflammatory conditions when we're using our steroids. But also, it has increased intensity of irritation reaction. So irritants that you put on the skin can have a greater reaction on the vulva. And as urogynecologists, I think you guys are well aware that too much moisture can cause maceration, especially in your patients with incontinence, and then too little moisture. So if you're not getting enough moisture or you've lost the moisture, it actually disrupts the barrier by dehydrating the cells and pulling them apart. So I know you guys all know how to take a great history, but I just want to highlight a few things that are really important to ask when taking a vulvar history. So I always ask, when did the symptoms start? I am trying to differentiate, is this an acute process? Is this a chronic process? Am I thinking more like vulvar dermatoses, or am I thinking more infectious? But I try to pinpoint exactly when the symptoms started, because I ask the patient, what happened at that time? Were they experiencing a stressor? Did they have a yeast infection that was treated? But maybe the itch never went away. So I always say like, oh, what happened three months ago? Just to get those important details. And then, as I learned over the years, that patients don't always know their anatomy, and they refer to everything as the vagina or down there. And so I really try to ask them to differentiate between vulvar symptoms and vaginal symptoms. Is this external itching, or do you feel like this is internal? Because that really also makes a big, big difference. And then, what treatments have they tried? What have other people given them? What have they gone and bought over the counter? Because we all know patients delay coming to us when they have vulvovaginal symptoms because they're embarrassed. So the first thing they do is they'll go to the pharmacy and see, what can I try? Maybe this will help. So I always get a list of treatments they tried. And recently, I had a patient tell me that she was taught to use something called Dettol to clean her genital area. And when I looked it up, it's not sold in the States, but it's comparable to something like Lysol. So really important to ask about hygienic practices. I really focus on, do they use baby wipes? Do they wear pads? What kind of soap do they use? How do they clean the area? I encourage them just to use their hand and a mild soap. No loofahs, no washcloths. Really minimize any irritation to the area. And then, I ask about the other things on this list. But these are really the main points that I want you guys to take away. So here's an example of a patient who used baby wipes. Now, if you look at the ingredients, you think, oh, we use them on babies. They should be fine. So they should just have water and maybe something else that keeps them wet. But no, they have a lot of other ingredients. And that can be really irritating. So you can see the pattern. The patient was wiping herself. And here, too, it's often towards the bottom. This was a patient who had this irritant dermatitis. And then, on top of that, developed a bacterial infection. So she was on a lot of medications. And then, after discontinuing the baby wipes and treating her for her infections, this was her resolved appearance. I know it still doesn't look normal because this patient has lichen sclerosis. But you just see how much more sensitive things can be in patients with underlying vulgar disorders. Here's another example. Like I mentioned, the patient will first go to the pharmacy. And look, here it is. Instant, long-lasting relief from her intense itching. This is exactly what she needs. It's the number one cream. But really, if you look at the ingredients in Bagesil, there are two analgesics. They're just there to numb it. And then, they have all of the... Then, they have... And then, they have all of these other inactive ingredients that are just waiting to cause irritation for the patient. I can't get my thing down. Okay. I'm just having an issue with my... Sorry. So, as far as physical exam, I encourage everybody to develop a systematic approach. I always examine patients from the outside in, meaning from the labial curl folds or the genital curl folds in. I first will sit in just before I do any exam. Look to see what the anatomy looks like. So, in this patient, overall, her architecture is preserved. You see some pallor. So, there is a little bit of whitening and lightening along the labia. And then, the little spot is a healing biopsy. But it's really important to make sure we look in the inner labial fold because you can see this is where she has that start of some scarring. And we can counsel the patient, like, make sure that you use the appropriate management in there. So, after I look in the inner labial folds, I examine the labia minora very carefully. I ensure to retract the clitoral hood because that's really important to make sure the clitoral hood retracts. And then, examine the perineum and perianally because we know some of these vulvar dermatoses present in a figure of eight pattern that can affect those areas and sometimes just those areas, actually. So, physical exam, we want to document carefully the overall appearance and the architecture of the vulva, commenting on the morphology of the lesions. So, what do they look like, what color, consistency, any loss of architecture that you see. Like I mentioned before, can we retract the clitoral hood or not? And then, the perineal body and the anus. And then, for patients that I'm seeing for the first time, I always do a vaginal exam just to make sure that, you know, there's no additional infections or atrophy or mucosal changes that can be affecting their symptoms. And it's also important to know that all of the vulvar dermatoses, the most common vulvar dermatoses that I'm going to discuss today, have an extragenital component, but the extragenital component looks very different on the skin than it does on the vulva. So, the first picture is a picture of lichen planus on the wrist, which looks very different than on the vulva. This is lichen sclerosis, lichen simplex chronicus, and this is psoriasis. So, I'm not going to really talk about psoriasis too much today, but I will point out that in this picture, you can see the like classic scale, but on the vulva, we often, because of the moisture, don't see the classic scale of psoriasis. So, Bornstein et al. developed a guide to clinical and colposcopic terminology of the vulva, including the anus, where they describe the things that we should comment on during the exam. They know what the normal findings are. So, if you see like micro papillomatosis, sebaceous glands, or some vestibular redness, along with abnormal findings to describe the lesions. And on my next slide, I'm not going to talk too much about each one of these, but I have a picture of this, like when I see clinic, and it's nice to refer to because these are really dermatologic terms. So, I've learned over time to use these to describe my exam findings, and then we can all speak the same language between specialties. So, common ones would be, you know, a macule, and then a coalesce macule, greater than a centimeter is a patch or a papule. And then if it's raised and greater than a centimeter, it's a plaque. Lichenification is when the skin is thickened and rough. And then erosions with the loss of the epidermis, fissures we see, and excoriations when patients scratch. Okay, so I want to share some things that are normal, but may look abnormal or concerning. So, see in this picture, this is vulvar papillomatosis, kind of like grape-like vesicle projections, maybe confused with genital warts or HPV. You know, if you're concerned, it's never wrong to take a biopsy, but once you see it once, you'll start to recognize it over and over again as something normal. It's the same color as... It's the same color and consistency as the mucosa. And then over here is a picture blown up of alabia minora, the inside of alabia minora. And you can appreciate this coalescence of kind of enlarged or hypertrophy sebaceous glands. Also very normal. Also very normal, but patients, you know, they'll be in the shower. And like I mentioned before, they don't really examine themselves. All of a sudden they may feel something abnormal. It doesn't bother them, but they feel something. And then they look and they're like, oh my God, look at what's going on. And then, you know, they're coming in concerned. So this, you can reassure them that this is normal. Again, in the picture on the left, we see a multiple epidermal inclusion cyst and some comedones, you know, looks concerning, but again, normal. The middle picture is a large epidermal inclusion cyst. You know, there's not really good treatment for those or prevention, and oftentimes I reassure the patient, but if it's really bothering them or in a spot that may be interfering with sex or, you know, they're just really uncomfortable and sometimes they can get irritated and flare, I will incise and drain it. Sometimes it just comes, you know, the whole cyst comes completely out. And then the picture all the way on the right is angiokeratomata, so very common in postmenopausal women, just brittle blood vessels that break and then thrombose. So overall normal, and you can reassure the patient. I do want to mention that pigmentation can influence the appearance of skin lesions. So in patients with skin of color, things may look a little bit different. Erythema may be a little bit more difficult to detect and may have a more violacious rather than red appearance. When the skin is dry, it may look white with an ashy color. And then post-inflammatory hypo and hypopigmentation may be exaggerated because of the higher levels of melanin. And it may be more challenging to distinguish diseases of hypopigmentation, and I'll give you an example of that in this next slide. So this patient has multiple things going on. So if you look down here near her perineum, she has hypopigmentation, this most likely is vitiligo. And then if you look anteriorly above her clitoris, you can notice maybe like a cigarette paper like an indication of appearance and obvious scarring. And this appears like in sclerosis, as we'll talk about later, both are autoimmune disorders. So it's not unusual that she has both of these things going on. And then potentially from the inflammatory aspect or from itching, she's caused some hyper, post-inflammatory hypopigmentation. I always worry also about like melanoma. So in this patient, I would take two biopsies, one here and then one in the hyperpigmented area. And lastly, the diagnosis of vulvar disease can be complicated because same in urogynecology, patients delay seeking care. The presentation of vulvar dermatosis differs from what appears on regular skin. So we talked about how you can lose the scale in psoriasis or something that's dry may look more moist. And then multiple conditions can present similarly. So the differential can be broad. And then lastly, distinguishing primary pruritus from secondary pruritus is difficult because, if they have like in sclerosis and then they start itching and itching and itching, they can develop like in simplex chronicus on top of that. And then oftentimes you're going on your clinical picture. So this is when your biopsy can become helpful. I had biopsied a lot more patients when I first started the clinic than I biopsy now because I learned over time, oh yeah, this is like in sclerosis, this is like in simplex chronicus. But at the beginning, I definitely biopsied a lot more patients. And, but the indications I think remain true regardless. So if you're ever concerned about cancer, definitely biopsy. If the diagnosis isn't readily apparent on visual inspection, you should biopsy. And then if you've tried something, but it's not working, that's, you know, take a biopsy. So as far as biopsy techniques, I kind of just limited to two techniques on the vulva, punch biopsy, which I think most of you guys are familiar with, and that's preferred for tumors, pigmented lesions, indurated ulcers or a deeper process. It samples the epidermis, the dermis, and even gets down to some fat. And occasionally it does require a suture. I often use a four millimeter that seems to be like I can usually get away without a suture with a four millimeter and still get a good sample. And the other is a shave biopsy. So shaves are great for superficial disease. So when I'm looking for like in sclerosis or like in plantus, all I need is just that little bit of the superficial kind of epidermis. And I will show you, so I use a suture technique and I'll show you in a video in a minute, but I thought this was a really nice depiction of how far your biopsies go. And this was an article about inflammatory skin disorders. And you can see that for a shave biopsy, it's just that eczema disorders, lichenoid disorders, psoriasis does just fine. Okay, let's see if I can play. So this is an example of how I do a shave biopsy because sometimes it's hard to use like a razor. So I just like take a very superficial bite with a small needle. Sorry, that's me videoing. So if anybody's getting nauseous, I'm sorry. And then you take the suture and you can nicely kind of pull up on the area. And then I just take iris scissors and you can see how tough that skin is. And you can just take a really small biopsy that's really all they need and you don't get a lot of bleeding or anything. And so once you have your biopsy and your initial diagnosis, just general principles of treatment that I review with each patient. So if they're using anything that's causing irritation, obviously remove whatever irritants. I go over all of our hygiene with them. And then I tell them the goals of our therapy are threefold. We wanna control your symptoms. So whether it's itching, pain, we gotta control the symptoms. If you have a chronically progressive disease, we need to try to slow the disease progression. And then whenever you have an inflammatory condition, often it has a risk of cancer. And so treatment helps to decrease this cancer risk. I always recommend ointments over creams. Ointments just have a low risk of sensitization because there's very few products in them. And then they can use as much Vaseline or petrolatum-based product as they want to help with prevent water loss. So just as another kind of take-home point, you see this is the ointment and it basically has clobetazole in an ointment base with propylene glycol and maybe like a couple of things. While this is the cream, and it again has a whole list of potential irritants. All right, now I'm gonna talk about the vulvar dermatoses. I created this slide to kind of show you all of them at once. So to be able to compare and contrast because I think it's really helpful and then we'll review each one individually. But you can see lichen sclerosis is definitely a scarring disorder. Often presentation is hypopigmentation or whitening of the skin and only affects the vulvar epithelium. There's like a few case reports of vaginal lichen sclerosis but I think it's a rule of thumb. It's mostly isolated to the vulva. Lichen simplex chronicus has more of like a dry looking and skin with redness. And oftentimes it really affects a lot of the labia majora and this kind of like perineal area I find. And then lichen planus can be an erosive and red appearing, more difficult to treat than the other two and located close to the vestibule. Okay, so as far as lichen sclerosis, patients report like an intolerable varitis like they're itching all the time. I have seen it in asymptomatic patients which is why the vulvar exam is so, so important. I think oftentimes, if a patient comes in for an annual exam, we're like, oh, awesome. Grab the speculum, let's do the pap and move on. But the vulvar exam is really important because patients don't examine their own genitalia. They're not familiar with it. And I think we need to like normalize that and encourage patients to do that more. And I mentioned, you know, this patient was 25 years old and actually her biggest concern, yes, she had itching but it was really dyspareunia. So in this younger population, oftentimes they may come in, you know, they can live with the itching but it's the pain with the intercourse that is really, really affecting their quality of life. On exam, you see white papules or plaques. It could be patchy or it can be generalized, you know hypopigmented with a cigarette paper appearance or this like cellophane-like sheen. Classically, it can have a figure of eight pattern. Doesn't involve the vagina. About 10 to 20% have extra genital lesions. So definitely ask about a history of skin disorders. They can have excoriations, purpura, and then scarring leading to loss of vulvar architecture. And when you counsel patients, they are not gonna get resolution of any scarring or, you know, the architecture is not going to return to normal. So it's really important to set those expectations. The etiology is not a hundred percent known but most likely autoimmune as it is associated with other autoimmune disorders. Most commonly thyroid, alopecia areata, vitiligo like we saw in our other patient and pernicious anemia. And it carries about a 5% risk of squamous cell carcinoma. So here's just some examples of patients with lichen sclerosis. And you can see this, you know, affecting the labia minora and this classic figure of eight pattern. You know, it's hard to say like, were her labia minora always like this or is this an effect of the disease? I always tell patients like, I'm seeing you for the first time. And, you know, this is gonna be our initial data point and let's, you know, try to not have any more progression of the disease. Here's another patient and also kind of a figure of eight pattern, but you can see that the disease is not confluent, it's in patches. So they have the whitening around the clitoris with some echemosis and then down here by the perineal body. And then you can kind of see like a faint hypopigmentation also, you know, along the perineum here. So here's a patient, again, you can see the whitening of lichen sclerosis along with this echemosis, which is very common because the skin becomes very, very fragile. And then, you know, we have to ensure to really look at the posterior foreshad, the perineum for any additional changes. And this patient is post-menopausal. She's older, I think she's in her late seventies. And so you see this combination, like there's no pigmentation here. So this may be some atrophy or it could be lichen sclerosis, sometimes this is hard to discern. So, you know, biopsy is really important. And then, you know, talking about skin of color and kind of doing that initial exam where you don't, where you just kind of sit and look at the labia majora, when you initially look at this patient, you're like, oh, everything looks fine. But then when you start to, when you part the labia majora and you do her exam, you quickly see, oh, she's got loss of pigment here. The labia minora are either very small or absent. And this area down here definitely looks different. Now this was lichen sclerosis, but, you know, they took a biopsy because it could also be genital warts, but it was lichen sclerosis. And then here's some other examples. So you see in this, you see fissuring on the side here with complete, you know, loss of the labia minora again, some post-inflammatory hyperpigmentation. And then over here, I think I probably biopsy this patient every time she comes to see me. I say almost every time. Her exam thankfully hasn't changed. So now I feel better, but I have biopsied her a lot just because of, you know, it's not classic. And I'm always, you know, I'm worried I'm going to miss something or is this patient going to develop cancer? But this patient also has lichen sclerosis. And so you can see kind of the different presentation. I would think this patient is more consistent on her left side with maybe lichen planus, but she definitely has this whitening. And then over here are kind of the end result of really progressive lichen sclerosis. So what do we do for these patients? I, you know, there's no guidance. So there's actually a lot of it is based on consent. A lot of the literature is based on consensus statements, but I do, because it's an autoimmune disorder, I do check a TSH on patients who haven't previously had a TSH checked. And then I really educate the patient regarding the chronic nature of the disease, you know, setting the expectation again that the scarring is irreversible and review our goals of therapy and really, really review all of our hygiene. You know, it becomes complicated because, you know, a lot of these patients are also have incontinence and so they wear pads and that can be super irritating. So trying to come up with solutions for that as well. And then remembering there's a 5% risk of cancer. So treatment. The nice thing is all three diseases that I'm gonna talk about today are treated similarly. Clobetazole is like my best friend. I use it all the time. So I usually start recommending, this is daily, but I tell them to put it on at night, every night, eight to 12 weeks, then every other night for four weeks. And I tell them keep going every other night until you come see me in follow-up. And I usually like to see them at about three months. But if they're not able to follow up and they're feeling better, I do say like you can eventually taper to twice a week, but do not stop the medication. As I said, there's no like evidence-based approach, but the literature supports continued use of steroids and also does show that continued use of steroids for maintenance therapy, so that twice a week does decrease the patient's cancer risk of developing squamous cell carcinoma. The other thing I see is patients who have this steroid hesitancy, they're nervous to use the steroid. Their primary care physician gave it to them, but they're like, okay, just use it for two weeks and you have to stop. Or they go pick it up at the pharmacy and the pharmacist is like, oh, you know, this is really strong, you shouldn't be using it for so long. So really like reassure them about the safety of the steroids and your goals of therapy. And the other thing I do is I have the patient use a mirror or I take a picture and then we review the picture together so I can tell them exactly where to apply the steroid and how much to apply. If you could get a little like tube with an ointment in it, you can show them, oh yeah, if you just get like a little rice-sized amount or a pea-sized amount and they don't need a lot. The goal is really sparingly, but enough to cover the area and it should be all the way rubbed in. I recently went to a lecture and they recommended actually having patients soak in a tub for, you know, 15 minutes before and then rubbed the medication in for 30 to 60 seconds after to really get it well applied. Clobetazole works really well in most patients. there are a few that are really resistant. So you can consider intralesional steroids, calcineurin inhibitors like tacrolimus. And then as I mentioned, regular follow-up, I initially see them every three months, then six to 12 months. Moving on to lichen simplex chronicus. So lichen simplex chronicus is that itch that scratches, and when it itches and they scratch it, it feels really good. So they have this cycle. It's unclear what started their cycle. So maybe they had a yeast infection and they started itching and it felt good, but the yeast infection is resolved, but they have now developed this chronic itch, or maybe they have lichen sclerosis and now have developed this relentless lichenified layer over that. So it's like that relentless varitis, worse with heat and stress and menstruation. So during the period, they may say like, oh, it's much worse. Marked lichenification, you can have pigmentation changes just from scratching or even like hair loss from scratching. And it could be unilateral or bilateral and can have excretions and crust. So here you see in this patient, her vulvar architecture is pretty well preserved. So she doesn't really have a lot of loss of architecture, but you notice that red, um, dry appearing lichenified skin, um, mostly on the labia majora. So oftentimes that's, that's where I see it. And here again, um, the patient, um, you know, here on the left, this is an example, uh, you can see of unilateral, um, lichen simplex chronicus, you know, you have to look carefully, but when you look carefully, you see that she's been scratching, you see these excoriations. Um, the other thing, when I see excoriations, um, I sometimes do a herpes test because it's hard for me to tell, like, is this scratching, is this, um, uh, herpes virus. So like, don't hesitate to do that, that either. And I have found, um, patients who have herpes here. Um, here you see it again, unilaterally, it's probably been a really prolonged disease process now that she has, um, lost pigmentation in that side. And then here's an example in a patient, um, both of these patients are patients skin of color. So you can, you can appreciate the changes, but here you can see, like, it's, it's pretty subtle and, you know, patients are often frustrated. They'll say, like, people don't see anything wrong. Um, but I'm, I'm really itching. No, you know, I've been to several doctors, but if you look carefully, you know, it's, it becomes fairly obvious. Um, and then this is a patient that I saw, um, and it made me nervous, right? Like young patient, obviously still menstruating. Um, I was like, Oh, you know, she's not in the age group for cancer, but there are some concerning findings. So I took some biopsies and it came back like in simplex chronicus treated her with, um, labate is all. And she's like, Oh my gosh, it's so much better. The skin is almost back to normal. Um, you know, this, you can also see she's got preservation of her architecture. So probably not like in sclerosis. And then, um, you know, here's a picture of the patient, like a far away and then close up where you can really see, um, you know, how deep like these excoriations that they've, they've scratched into their, um, skin. So as far as treatment, um, Um, the, you know, general principles is really reduce the triggers, like anything that is making the, um, itching worse, try to restore the normal barrier, um, and break that itch scratch cycle. Again, same thing, clabetasol, same regimen nightly, eight to 12 weeks. And then every other night, um, you know, if it's really severe, you can do oral steroids. Um, but oftentimes clabetasol does the trick. If they get a super infection, you would treat that either bacterial or yeast. And then if patients are scratching at night, you can, um, think about using hydroxine, um, or like an, a sedating antihistamine. And finally, like in plantus, um, I think these patients are the most challenging. Um, they have pain, pruritus, dyspareunia is, is also at the top of the list. Like in plantus can be erosive and can, um, in, uh, involve the vagina. Um, so I've seen patients with really erosive, uh, like in plantus where the vagina has basically fused closed. Um, and the classic finding is these like erythematous plaques with a reticular pattern, again, probably autoimmune, um, and can affect other areas, skin, scalp, nails, as well as mucous membranes. Um, uh, I'll show you in the next slide. So here again are some, um, examples of, uh, like in plantus, you can see it's red, this, um, kind of, uh, lacy, um, reticulate stray pattern. And then, uh, you know, classic kind of test question. I remember we were always asked is the, um, binding in the mouth, um, weakens striae. So actually I get a lot of referrals from dermatology in patients who have like in plantus in their, um, oral cavity, uh, to do a vulvovaginal exam to see if they have any, um, genital findings of, of like in plantus and the treatment. So, um, again, it's the super potent steroid with clavatozole, um, the vaginal disease can be treated with, if you take, um, a hydrocortisone, uh, 25 milligrams and pository, that's usually used rectally and tell patients to insert it vaginally, um, that sometimes helps. Um, and if they require like systemic therapy, I, um, you know, that includes things like methotrexate or, um, like plaquenil, I, um, you know, collaborate with my germ partners. I don't feel so comfortable, um, treating, treating that. So, um, we're coming to the end and I hope that you've learned just one thing at least. Um, so in summary, have a systematic approach to your physical exam. Um, make sure you describe your findings in detail so we can all speak the same language and the patient can be seen from one provider to the next. Biopsy as indicated, and don't be afraid to have a low threshold. Remember, um, the goals of management, control symptoms, low disease progression, decrease cancer risk, and set good expectations for the patient. And then clavatozole is your best friend can be used for lifetime maintenance. And then finally, um, I want to bring you back to that first patient I saw. Um, you know, I just wanted to do an overview of the disorders, but, um, you know, the, um, we really need to treat the whole patient. It's not just treating, you know, their underlying skin disorder. A lot of these patients, um, have a lot of emotional and psychological challenges that go along with this. It can affect their relationships and sexual health. Um, the patient patients may feel really isolated. Like they're the only one with this, um, really try to, um, uh, help them with any steroid hesitancy they have because that's going to help them the most, um, provide resources and anything you have for support groups. These are really good, um, resources for patients. The ISFBD.org and the University of Michigan has, has a great program and great, great resources, um, online. And lastly, I just want to thank Dr. Joy Wee for moderating Dr. Christine Beccaro for inviting me and Wee Zhao for, um, keeping me on track and making sure that I turn in all the, uh, things that she asked for. So that's all I have. And I'm happy to take any questions. Thank you, Dr. Schwarzman so much for that great lecture. We really appreciate taking the time to come and speak with us this evening. Um, I do have a few questions and we'll try to answer what we can. And obviously, um, you know, people can come and go as they need to, because they've started piling in here at the last minute. Um, in your routine practice, do you document in the chart with photographs of a patient's lesions? Why or why not? And how do you discuss this with patients since it's such a sensitive area? Yeah, so that's a great question. Um, so our current, um, I, we are getting a new computer system. So I'll answer it like this. We're getting a new computer system. And I plan to document in the chart with pictures. Our prior computer system was too clunky. And, um, it was very, very difficult. But I do take pictures and I always, um, I keep kind of like a de-identified library, but I, I can tell, um, who it is. And so for comparison, um, I'm really like an army of one plus like, you know, some of the residents or fellows that work with me sometimes. So I'm seeing a lot of these patients, but if you are able to take pictures and keep them in a record, I think that is awesome. And then what's your opinion on mometasone for use after clobetazole? Um, I think if clobetazole is working for the patient, I don't necessarily change, um, to a different steroid. Occasionally if like the clobetazole starts to be irritating, um, I will try a different steroid and that one's that's fine. Um, but unless there's an issue with the clobetazole, I tend to just continue it. Um, how do you handle it when you have an active infection such as recurrent candidiasis and they require chronic topical steroid use? Yeah. So that's tricky. Um, it just depends on the disease. Like if they have, um, you know, like in spirosis and they need the steroid use, I will treat, um, the yeast infection, uh, orally. And then I, I always give a prolonged course. I think in my patients, like one dose of Diflucan does not do the trick. So I'll do, you know, three to five days, you know, every 72 hours. And some patients require, you know, going on a weekly, um, treatment, a weekly Diflucan. Uh, just a question about the biopsies about, um, how you do your biopsies without a punch biopsy and why you choose that technique sometimes. Oh, um, I choose that technique to do the, um, shave that way because sometimes the punch goes deep and the patients will bleed, but with the shave, it just seems to have, um, a little bit of less blood loss and you don't really need, um, that much tissue. But if I always say like, do what you're most comfortable with. Like if you're comfortable with a punch, then, then definitely do do a punch biopsy, just showing different, um, you know, options, but obviously, you know, if you're comfortable with a punch biopsy, then, then you'll just get more tissue. So that's fine. Does, uh, squamous cell carcinoma risk with lichen sclerosis increase with time or 5% regardless of the duration of the disease? Probably, uh, with time, probably with time. I think we answered what you do for patients who are irritated with clobetazole ointment, maybe switching to a different, um, steroid. Yeah. Oh, wait. The other thing you can do if patients are irritated is you can have them mix the clobetazole with Vaseline too. Um, and then for intralesional therapy for LS, how many injections do you usually perform and what steroid do you prefer to use? So try a kind of log triamcinolone. Um, what was the first question? How many, how many, um, it just depends on the area of the lesion. Again, I don't do it very often, maybe for like ones that are a little thicker or like, we just can't, you know, seem to, to get through. Um, so just, you know, as much as you need to, to cover the area, but again, like not, not very common, it's not that common. Um, there was a question on the fact that there's been some studies on energy-based devices, such as CO2 laser for LS, and they just want to know what your thoughts are on that. Yeah. So, um, I mean, I would love to find a cure or anything, uh, to help these patients. I mean, like I would, um, and I hope the laser is promising and the next best thing. I just think there's not enough data at this point to use it as a first-line therapy. I know that there are, um, several, uh, trials going on now in using laser and, um, clobetazole together. And so hopefully they'll, you know, they'll be there, they'll be promising, you know, other therapies that have been tried are like, um, platelet-rich plasma that hasn't really, you know, been shown, um, to help in, in, you know, everything needs kind of like a larger, larger study at this point. Um, thanks for the great talk. Can you please comment on vulvar epidermal hyperplasma and hyperkeratosis? Um, maybe, um, I think like hyperkeratosis is more like, like in simplex chronicus. Um, actually, um, there's a really good article by, um, Colleen Stockdale and she breaks down like the, like what you see on histology and then what it's consistent with. Um, and that really helps. Um, I can pull it up, but I have some funny slides in between, so I won't, but, um, uh, it really helps to kind of, um, gear your diagnosis. So like, if path says like, oh, I see acanthosis or hyperkeratosis, that's most consistent with like in simplex chronicus or like in sclerosis. So I can, I can share that, um, resource and I should have put my email on here, um, because I'm happy if anybody wants to email me any questions. Um, I don't know how to share that at this point, so I apologize for that, but I would love to like, if anybody has any questions, I'm happy to start a conversation or, you know, answer anything because I'll probably learn from you. Um, I know we're kind of running out of time. You have, there's a lot of questions for you. Um, we've gotten probably to the majority. It's up to you, Dr. Schwartz. And if, if you wanted to share your email, like in the chat, that's something that, oh, yeah, that's good. Yeah. I can share it. Oh, but the chat, let me see if I can go to everyone. Oh, but the chat only goes to hosts and, oh, maybe not. I can, let me, let me do it. I can, I can switch it so that everyone gets her email. Okay. Thanks. Um, just, I don't know if you're up for a couple more questions. We're past nine o'clock, so I don't want to keep you any longer than we promised we would. Um, just a question about, is there a role for vaginal estrogen in these patients? Yes. Thank you for asking. Um, yes. So I think that in, um, post menopausal patients, um, you can always treat, uh, you know, oftentimes they do have confounding, um, uh, atrophic vaginitis or, you know, the gender urinary, um, syndrome of, of menopause. So, um, you can combine both, um, topical estrogen and, um, steroid use. Uh, the nice thing is like when you get to maintenance therapy, you're often using the steroid twice a week, and then you're using the topical estrogen twice a week. So, you know, they're able to kind of make a schedule. That's my email. Yeah. In the chat. Um, another question on, you know, what do you do with a pathology diagnosis that just shows chronic inflammation and kind of going along with that? Do you recommend biopsying LS like on a regular annual basis, or if not, what do you look for when you decide to biopsy and how often? Yeah. So, um, I stick to the indication. So I think if there's been a change, um, if the treatment isn't working or if I see like an isolated concerning lesion, I biopsy, but if the exam is pretty much stable or symmetric or it looks like LS, I don't biopsy. I've actually gotten away from, um, I don't biopsy every single LS patient. I'm like, this is LS. And, um, also back to the question about pathology. So, um, you know, I just went to this, um, international society of, um, vulvovaginal diseases. And, um, if the clinical, um, exam is consistent with like in sclerosis, but the pathology does not confirm that I would go ahead and still treat for like in sclerosis. Um, you know, it may be that the biopsy just didn't pick it up. Um, but you know, you may, the, I would go with clinical exam over, over biopsy, if that makes sense. Yeah, absolutely. Um, I just want to thank you again for all the time you've taken today, both for your great lecture and answering all these questions, um, and for being gracious enough to share your email with us. So if people have questions that they didn't get to answer, didn't get answered, we got to them, the majority of them, but I want to be respectful of your time because we're already over. Um, so thank you for sharing that for people who want to reach out and ask questions, um, for all the attendings, just a couple of things before we go. Um, I just wanted to make sure that you know, that we have a couple of webinars coming up in August, uh, August 17th, please register for how physiatry and urogyne are interconnected. And then on the 23rd of August, uh, it's the urethra, what we know and how much we don't know. Um, and just again, on behalf of AUGS, I want to thank Dr. Schwartzman for, um, joining us today and for all of you for joining us as well. Thank you guys so much. And thank you for your attention. Thank you both. Good night.

Dr. Katie Schwartzman

vulvar dermatology

evaluation

management

common vulvar dermatoses

therapy goals

physical exam

biopsy techniques

lichen sclerosis

lichen simplex chronicus