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Vulvar dermatologic conditionsBELIEVE MIDWIFERY SERVICES, LLC
VULVAR DERMATOLOGIC CONDITIONS
EFFECTIVE DATE: May, 2009
Certified Nurse Midwives and other clinicians who provide primary gynecologic care are likely to see women with
lichen sclerosus and lichen simplex chronicus, and, while lichen planus is less common, early recognition is
BLOOD BORNE PATHOGEN
I (Involves exposure to blood, body fluids, or tissues) FUNCTION: Care of Clients
1. Assessment supplies and equipment2. Vaginal exam supplies3. Laboratory supplies POINTS OF EMPHASIS:
Providing care to women with vulvar conditions is often challenging and time consuming. These conditions can be
difficult to evaluate, do not always respond to treatment, and may improve gradually. Often more than one visit is needed, and women should be told this in the beginning to avoid unrealistic Lichen Sclerosus is a benign, inflammatory, immune-mediated skin disease that usually affects the genital area. Often unrecognized and underdiagnosed, its prevalence has been difficult to determine but is estimated at 1 in 300 to 1 in 1000. One study showed that lichen sclerosus affected 1 in 30 elderly women in a nursing home. It can affect women of all ages but is most common in perimenopausal and postmenopausal women. PROCEDURE:
1. A detailed history of the symptoms should be obtained, including time of onset, chronologic course, specific location, and exacerbating and alleviating factors. The most important question may be asking the woman what she is most concerned about.
a. A full medical, surgical, gynecologic, obstetric, and dermatologic history should be reviewed, including medications, allergies, and systems review.
b. Chief concerns and associated symptoms should be explored c. Vulvar and menstrual hygiene practices, with particular attention to potential vulvar irritants, and a sexual history, including the woman's specific concerns, are also important.
2. Women have often seen other providers and used several prescription and over-the-counter medications and products; it is useful to find out what was used and if the treatment helped. Obtain past records if possible, particularly test results and biopsy reports.
3. It is important to take time to examine the entire vulvar, from above the clitoris to below the anus. Make sure all parts are present, including the labia minora and clitoris. Changes in anatomy easily can be missed without deliberate examination. The clitoral hood should be mobile and easily retracted to visualize the clitoral glans. Examine the labia majora, labia minora, interlabial sulcus, the perineum, and perianal folds for color and texture and for fissuring, excoriation, erosions, ulcerations, and lesions.
4. A speculum examination (if tolerated by the client) should be performed to examine the vaginal mucosa and cervix for erythema, erosions, ulcerations, synechaie, and discharge and to obtain cultures and a wet BELIEVE MIDWIFERY SERVICES
preparation sample when indicated. A bimanual or digital vaginal examination should be done if tolerated to evaluate the length of vaginal canal.
5. Vaginal discharge should be evaluated. This includes checking the pH and microscopic assessment of squamous cells, the presence or absence of lactobacilli, white blood cells, and bacteria, which provides information regarding infection, inflammation, and hormonal status. A potassium hydroxide slide may be done to examine for yeast, but a yeast culture is necessary, at least at the initial eavalution, because yeast is seen on wet preparations only 20% to 50% of the time, and non-albicans strains of yeast such as Candida glabrata are difficult to identify without a phase contrast microscope. The vaginal walls and discharge should be cultured for yeast, and any areas of vulvar erythema, fissuring, or excoriation should be swabbed as well. Make sure the laboratory can perform a specific yeast culture that identifies Candida species - a routine genital culture does not provide this necessary information and is inadequate. 6. It is important to keep in mind that women with vulvar conditions may have more than one condition, and reevaluation is often necessary.
7. A biopsy is required for the diagnosis of many vulvar dermatologic conditions, including lichen sclerosus and lichen planus. While history may be suggestive, the clinical appearance of these conditions is not always diagnostic. In addition, lichen sclerosus and lichen planus are life-long conditions, requiring long- term treatment and follow-up, and a biopsy prior to obligating women to this is important.
a. A biopsy also is indicated for any lesions, nodules, erosions, or ulcerations suspicious for vulvar intraepithelial neoplasia (VIN, which is precancer) or vulvar cancer. A biopsy should not be done if the skin appears normal. Use of a topical corticosteroid prior to a biopsy can interfere with results; women should refrain from using these 2 to 3 weeks before a biopsy is performed.
b. The site for the biopsy should be the area of the vulva that appears most characteristic of the condition; a novice may need assistance from a more experienced clinician to determine this. Avoid the clitoris if possible. Only one biopsy is needed unless there is a concern for VIN or cancer. Local anesthesia should be provided with topical lidocaine prilocaine cream (EMLA 2.5%) applied for 10 to 15 minutes, followed by instillation of 1% lidocaine with 1:100,000 epinephrine.
c. After a biopsy, women may experience discomfort for 1 to 2 days and may use acetaminophen, ibuprofen, and/or ice. Petroleum jelly can be applied topically, but other topical medications should be avoided until the site has healed.
d. Specialized dermatopathologists with experience reading skin biopsies are very helpful when interpreting biopsies. A negative diagnosis does not necessarily mean absence of disease. If the biopsy is negative or inconclusive, and the woman has persistent symptoms or clinical signs of vulvar disease, a referral to a vulvar gynecology or dermatology specialist is recommended.
Management Guidelines for All Vulvar Conditions 8. Women with recurrent or chronic vulvovaginal conditions often have symptoms not only from the condition itself but also from resulting scratching and rubbing; cleansing routines and products; exposure to urine, menses, and stool; and medications and products used to alleviate symptoms. The vulva is more permeable than exposed skin and is particularly vulnerable to irritants. Women who are estrogen deficient (post-partum, menopause, and medication induced) may be even more vulnerable. The first step is treating all vulvar conditions is to eliminate all sources of irritation.
9. Women should be instructed to avoid scratching and rubbing. Comfort measures include cool gel packs, sitz baths, refrigerated petroleum jelly, and cold yogurt on a pad. Petroleum jelly is nonirritating and very soothing; it can be used anytime an ointment is desired and liberal use is encouraged especially in postmenopausal women. Applying after showering, bathing, or soaks can soothe irritated vulvar skin. Giving women written information on vulvar care and hygiene and avoidance of irritants is helpful.
Use of Corticosteroid Ointments 10. Topical corticosteroid medications frequently are used for vulvar dermatologic conditions to treat symptoms, decrease inflammation, and prevent disease progression and scarring. Ointments, which do not contain alcohol or preservatives, are less irritating than creams and are recommended for the sensitive vulvar tissue. The modified mucous membranes of the vulva are relatively steroid resistant, so potent corticosteroids often are required and are safe when used as instructed.
11. It is very important to instruct the woman exactly how to use the prescribed steroid ointment. Especially with super-potent topical steroid ointments, women must use a scant amount to avoid side effects that can occur from overuse, such as tissue thinning, striae, and rebound steroid dermatitis. Instruct the woman to BELIEVE MIDWIFERY SERVICES
use the amount a toothpick picks up, usually much less than expected, and demonstrate this to them. Show the client exactly where to apply it using a mirror during the examination if she is comfortable with this, or a diagram of the vulva. Prescribe only a 15-g tube of ointment without a refill to prevent overuse.
12. While it is important to warn against overuse, it is often equally necessary to encourage women to continue to use their topical medications as prescribed. They may be suspicious of steroids in general, and written information provided with the medication warns against long-term use. The importance of following the prescribed treatment to prevent disease recurrence and progression and the safety of the medication when used as prescribed must be reinforced over many visits.
US Brand Name
Class I: Super high potency Clobetasol propionate 0.05% ointment Halobetasol propionate 0.05% ointment Class II: High potency Triamcinolone acetonide 0.5% ointment Kenalog Aristocort Class III: Midpotency Mometasone furoate 0.1% ointment Class V: Low to midpotency Prednicarbate 0.05% ointment Class VII: Very low potency Hydrocortison 2.5% ointment Use of Sedating Medications 13. Women with vulvar itching may scratch or rub and are not always aware of it, often at night. This can worsen the skin condition. For significant nighttime itching, consider use of a sedating agent. Benadryl can be used, or Hydroxyzine, a prescription antihistamine that has sedative effects, is helpful with typical dose of 10 to 30 mg orally about two hours before bedtime; instruct the woman to start with 10mg and increase up to 30mg if needed. If these are not effective, oral doxepin (10mg about 2 hours before bedtime) may be tried for severe cases; it is much more potent than hydroxyzine.
Sexual Function 14. It is important to inquire in a way that allows women to express concerns as comfortably as possible and to provide support based on individual needs. For some women, sexual function is not important; for others it is a significant concern. For premenopausal women, contraceptive choices and pregnancy may need to be considered. Post-menopausal women with vulvar conditions often need vaginal estrogen (if not contraindicated) in order to have comfortable intercourse. 15. A vaginal dilator may be needed by some women to maintain vaginal patency. Offering resources and/or a referral to a sex therapist may also be helpful in some cases. The American Association of Sex Educators, Counselors and Therapists offers referrals here: 16. These conditions are not well known, so it is important to discuss them thoroughly with the client and provide accurate written information that women can refer to after the visit. It is very important that clients understand they do not have a sexually transmitted disease or cancer; both are often hidden concerns.
17. Information about vulvar care and hygiene should be provided and reinforced at every visit.
Follow-up and Referral 18. A follow-up visit is usually scheduled 1 to 3 months after the initial evaluation. Subsequent visits are based on the woman's condition, response to treatment, and individual needs. Women should also be seen as needed for persistent or recurrent symptoms. Women with vulvar conditions do not always improve after initial diagnosis and treatment, and reevaluation may be necessary.
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19. Referral to a vulvar specialist (gynecologist or dermatologist) is recommended when the evaluation, testing, and/or biopsy are inconclusive; for women who do not respond to treatment; for women with persistent, recurrent, or advanced disease; or when the needs of the woman are beyond what the clinician is able to provide. The International Society for the Study of Vulvovaginal Disease (ISSVDdes referrals to vulvar specialists through its web site. If this is not possible, collaborative management with, or referral to, a gynecologist or dermatologist who has experience with vulvar disease is suggested.
Lichen Sclerosus ATTACHMENTS: (Required – if referencing forms, charts, etc. throughout the policy)
Preferably within the last five years Originated: (date policy started)
Penny Lane MSN, CNM
Available online at www.sciencedirect.com Molecular Phylogenetics and Evolution 47 (2008) 637–649 The human progesterone receptor shows evidence of adaptive evolution associated with its ability to act as a transcription factor Caoyi Chen a,1, Juan C. Opazo a,2, Oﬀer Erez b, Monica Uddin a, Joaquin Santolaya-Forgas b,c,Morris Goodman a,d, Lawrence I. Grossman a, Roberto Romero a,b,*, Derek E. Wildman a,b,e,*