VULVAR DERMATOSES (old nomenclature: vulvar dystrophies) constitute the most prevalent entity of vulvar diseases.

They comprise four groups:

A. Lichen planus
B. Lichen simplex chronicus (Neurodermatitis)
C. Lichen sclerosus
D. Mixed dystrophy

COMMON CHARACTERISTICS:

Vulvar dermatoses share some common characteristics: They are all benign, idiopathic, pruritic, & affect multiple body sites. Although, they can occur in younger females, they are most commonly found in post-menopausal women. Diagnosis is usually confirmed by vulvar biopsy, & although no cure is available, supportive steroid therapy is often successful in alleviating the symptoms.

A. LICHEN PLANUS

Lichen planus is an uncommon eruption of small papules that can involve the wrists, ankles, groin, genitalia, & oral mucosa. On the vulva the disease often manifests itself as annular erosive lesions with clear margins. The condition often lasts between 6 months to 2 years.

B. LICHEN SIMPLUS CHRONICUS

Persistent unexplained itching and rash characterize lichen simplus chronicus also referred to as neurodermatitis, eczema or hyperplastic dystrophy. The itching is usually intense, and the rash often involves the perineum of both sexes, the side of the neck in women, and the ankles in men. Large patches of thickened, scaly, and occasionally hyperpigmented skin (lichenification) is commonly found. Foci of atypical changes or cancer may lie within these areas. Symptoms often develop or worsen during stress, but once a lesion resolves, recurrence is uncommon.

C. LICHEN SCLEROSUS

Lichen sclerosus is a common disease of the vulva that can occur at any age, but is most common in post-menopausal women. The neck, trunk, and extremities can also be involved. The disease causes a gradual fusion of the labia and prepuce of the clitoris. The thinned-out skin becomes pale and wrinkled like a parchment. Foci of atypical tissue or cancer should always be sought at the time of initial evaluation. These changes are symmetric and recurrence is common. Pernicious anemia, achlorhydria, and autoimmune disorders have occasionally been associated with lichen sclerosus.

D. MIXED DYSTROPHY

Occasionally patients present with mixed vulvar changes of lichen sclerosus and hyperplastic dystrophy: Areas of thinned and thickened skin lie next to each other. Multiple biopsies are important since mixed dystrophies have a slightly higher incidence of atypia.

EVALUATION & TREATMENT:

Colposcopy with toluidine blue guided vulvar biopsies are indicated in all cases of vulvar dermatoses, both to establish the proper diagnosis as well as to rule out vulvar atypia or cancer. Any suspicious vulvar or perineal lesion, of whatever shape or color, should be biopsied.

Any identified irritant (e.g. laundry detergents) should be eliminated. Potent topical corticosteroids are the mainstay of therapy for vulvar dermatoses. Topical testosterone is often used in conjunction with steroids in the treatment of lichen sclerosus. Estrogen creams are often used for the treatment of atrophic vaginitis, which frequently accompanies vulvar dermatoses in the elderly patients. If the itching is very severe and unresponsive to therapy with oral tranquilizers and topical ointments, vulvar nerve block should be considered.