SOAP note AHA Week 7

June 2019 CONTEMPOR ARY OB/GYN 25

TEST YOUR KNOWLEDGE SERIES OF PUZZLERS THAT WILL TEST YOUR KNOWLEDGE OF VULVAR DISEASES

WHAT IS THE MOST LIKELY DIAGNOSIS? A. Lichen sclerosus

flare B. Vulvar candidiasis C. Vulvovaginal

atrophy

WHAT TEST(S), IF ANY, SHOULD YOU CONSIDER? A. Wet preparation (saline and

10% KOH) B. Yeast culture, and if positive,

identification of species C. Vulvar biopsy D. A&B

WHAT PERCENT OF PATIENTS EXPERIENCE AT LEAST ONE EPISODE OF THIS DIAGNOSIS? A. 10% B. 25% C. 50% D. 75%

Pruritus, pain and fissures in a 65-year-old woman What is your diagnosis when you see vulvar fissures? by ROSALYN E. MABEN-FEASTER, MD, MPH, JOHN O. DELANCEY, MD, AND HOPE K. HAEFNER, MD

Dr. Maben-Feaster is assistant professor, Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, Ann Arbor.

Dr. Haefner is professor, Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, Ann Arbor.

Dr. Delancey is Norman F. Miller Professor of Gynecology, Director, Pelvic Floor Research, and Group Director, Fellowship in Female Pelvic Medicine and Reconstructive Surgery, University of Michigan Medical School, Ann Arbor.

HISTORY A 65-year-old woman with a history of well-controlled vulvar lichen

sclerosus presents to your clinic with acutely worsening vulvar pruritus and pain

that feel like paper cuts. She has been using topical triamcinolone 0.1% regularly

without improvement. Examination reveals the findings seen in Figure 1.

FIGURE 1. Appearance of the vulva in this case

FOR THE DIAGNOSIS, TREATMENT PLAN, AND DISCUSSION TURN TO PAGE 26

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June 201926 CONTEMPOR ARYOBGYN.NE T

VULVAR CANDIDIASIS

Discussion Figure 1 demonstrates vulvar fissures, which are linear erosions (loss of epi- thelium) that can be seen in a number of vulvar diseases, including lichen sclerosus, Candida infections, herpes simplex virus infections, lichen sim- plex chronicus (itch-scratch), Crohn’s disease, or tearing from the genito- urinary syndrome of menopause.1,2 Patients with vulvar fissures often describe them as stinging or burning pain that feels similar to a paper cut.1

In this patient’s case, we are drawn away from a lichen sclerosus flare as the diagnosis given the fact that she was previously well-controlled on top- ical corticosteroids. Long-term studies have demonstrated that topical corti- costeroids are safe for lichen sclerosus and decrease the chance of develop- ing cancer if used regularly.3,4 How- ever, we know that these drugs can increase risk of infections, especially Candida.1,3 Thus whenever patients with lichen sclerosus do not respond or are no longer responding to therapy for lichen sclerosus, you should con- sider other causes of their worsening symptoms, such as infection or coex- isting vulvar conditions.1

The first step in evaluation of this patient would be to obtain a sample for a wet preparation with saline and 10% KOH and consider a yeast cul- ture (identify the species if positive).1,5 The advantage to performing direct microscopy is that you can obtain an immediate diagnosis. However, yeast is missed on 50% of wet mounts. So, if the wet prep is negative, or the patient has not responded to prior antifungal treatments, a yeast culture to identify the species and guide your treatment should be considered. Yeast cultures are most helpful in recurrent or resis- tant infections.

Vulvar candidiasis Up to 75% of all women will have at least one episode of vulvovaginal can-

didiasis with 10% to 20% of women be- ing classified as having complicated infections.6 Complicated infections are defined as those that are recurrent, severe, or that occur in patients with diabetes or who are immunocompro- mised.4 Most commonly candidiasis is caused by Candida albicans but other species can also be identified, includ- ing C. glabrata and C. krusei, which can be resistant to first-line therapies.1,5,6 Risk factors for developing this fungal infection include recent antibiotic us- age, incontinence, obesity, diabetes mellitus, and immunosuppression (in- cluding local topical steroid use).1,5

Most commonly, patients present with vulvar pruritus and may have thick white vaginal discharge.4,5 On examination you may also see vulvar

Pruritis, pain and fissures CONTINUED FROM PAGE 25

FIGURE 2. Microscopic image of pseudohyphae

DIAGNOSIS: B. Vulvar candidiasis

TEST TO CONSIDER: D. Wet preparation and yeast culture

PERCENT AFFECTED: D. 75%

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June 201928 CONTEMPOR ARYOBGYN.NE T

VULVAR CANDIDIASIS

fissures, excoriations, and erythema. The diagnosis is confirmed via vagi- nal pH measurement (from the lateral side wall of the vagina) and wet mount. Classic microscopic findings include pseudohyphae (Figure 2). As mentioned above, a yeast cul- ture may be beneficial in cases of recurrent or resistant infec- tions, defined as four or more infections per year, or infec- tions that are unresponsive to treatment.6 We would rec- ommend treating this patient for complicated vulvovaginal candidiasis given her topical cortico- steroid use. Treatment can be topical or oral. Topical treatments to the vulva include miconazole nitrate 2% cream twice daily for up to 7 days or nystat- in ointment 100,000 units/gram two to three times per day for up to 7 to 14 days.6 Intravaginal antifungal treat- ment (numerous azole medications are available) should be given along with the topical treatment to the vulva. Oral treatments include fluconazole, 150 mg for every 72 hours for three doses, before starting a maintenance antifungal regimen.6 For recurrent in- fections, weekly fluconazole can be used for up to 6 months.

For additional information, a yeast app is available in the app store (type in ISSVD). This app was developed by the International Society for the Study of Vulvovaginal Disease with

an unrestricted educational grant from Prestige, Inc., manufacturers of Monistat. The company had no input into the app content, or development of treatment recommendations.

Lichen sclerosus This is a chronic inflammatory con- dition of the skin that is likely auto- immune in nature. Patients typically present with vulvar pruritus, burning or pain with intercourse.4 They may also be asymptomatic. Lichen sclero- sus is characterized by classical skin changes, which include whitening of the skin that can be scattered or dif- fuse with atrophy and a cigarette pa- per/cellophane appearance.1,5 Often the condition manifests in a figure of eight pattern around the vaginal opening and anus.1,5 There may also be thickened areas and fissuring. Vul- var biopsy confirms the diagnosis al- though the clinical appearance can be utilized as well.1

As mentioned previously, treat- ment is with topical corticosteroids. For lichen sclerosus, clobetasol 0.05% oint-

ment is used up to twice daily for 1 month followed by daily for 2 months and then the patient is maintained on topical triamcinolone 0.1% ointment daily. An alternative regimen is to

treat as above, for 3 months with clobetasol 0.05% ointment, then use clobetasol 0.05% ointment three times weekly long term.

Vulvovaginal atrophy A decrease in circulating estrogen that comes with menopause re- sults in thinning of vaginal epithe- lium.1 This increases the likelihood

of erosions and secondary infection.1 Patients often present with complaints of dryness, pruritus, and dyspareunia. Erosions or fissuring from friction may be seen.1 The diagnosis is made based on the clinical appearance of the vagi- nal mucosa and vulvar skin. On wet preparation, you would see parabasal cells (small, round, immature epithe- lial cells), elevated vaginal pH (greater than 4.5) and loss of lactobacilli.1 First- line treatment is the use of lubricants.7 Patients who do not respond to this therapy may benefit from a trial of lo- cal estrogen therapy, ospemifene, or prasterone.7

DISCLOSURES Hope K. Haefner, MD, is on the

advisory board of Prestige, Inc.

Irregular vulvar mass in a postmenopausal woman Do you know how to differentiate precancerous from cancerous vulvar lesions? contemporaryobgyn.net/ IrregularVulvarMass

Vulvar pruritus in postmenopausal woman The patient states she has had a 4-month history of worsening vulvar pruritus. contemporaryobgyn.net/vulvar- tests

Dysuria, painful lesions in 26-year-old woman A 26-year-old G0 comes to the office complaining of dysuria and painful lesions on her vulva. contemporaryobgyn. net/201804quiz

READ MORE

FOR REFERENCES VISIT contemporaryobgyn.net/vulvar-candidiasis

Up to 75% of women will have at least one episode

of vulvovaginal candidiasis.

REFERENCES 1. Edwards L. Genital Dermatology Atlas. Philadelphia, PA: Lippincott Williams and Wilkins; 2004

2. Edwards L. Vulvar fissures: causes and therapy. Dermatol Ther. 2004;17(1):111-116.

3. Dalziel K, Wojnarowska F. Long-term control of vulval lichen sclerosus after treatment with a potent topical steroid cream. J Reprod Med. 1993;38:25-27.

4. Lee A, Bradford J, Fischer G. Long-term management of adult vulval lichen sclerosus. A prospective cohort study of 507 women. JAMA Dermatol. 2015:1061-1067.

5. Wilkinson EJ, Stone IK. Atlas of Vulvar Disease. In: 3rd ed. New York: Wolters Kluwer/Lippincott Williams & Wilkins; 2012:139-142.

6. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep. 2015;64(No. RR-3):1-137.

7. The North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20:888–902. quiz 3–quiz 4.

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