Benign Disorders of the Vulva

Urogenital atrophy due to hypoestrogenism predisposes postmenopausal women to common skin disorders of the vulva. Vulvar pruritus is the primary symptom. Evaluation involves direct examination and, often, biopsy.

Vulvitis

Various agents (eg, deodorants and soaps used to mask the odor associated with urinary incontinence) can cause superficial irritation and dermatitis, with pruritus, edema, and burning. Treatment involves removal of the cause of irritation and topical use of a corticosteroid cream.

Candidal vulvovaginitis is especially common among elderly women who are diabetic or obese. The most common symptoms are vulvovaginal pruritus and discharge. Candidal vulvovaginitis is diagnosed by physical examination and the use of a wet preparation, in which a cotton-tipped applicator is used to obtain a sample of the discharge from the posterior vaginal fornix. Microscopic examination of the sample reveals the presence of yeast pseudohyphae or spores. Treatment involves use of topical antifungal drugs and, to relieve symptoms, local corticosteroids.

Vulvar Non-Neoplastic Epithelial Disorders

(Vulvar Dystrophies)

Lichen sclerosus, a dermatosis of unknown etiology, is characterized by epithelial thinning, edema and fibrosis of the dermis, and labial shrinkage. It typically involves the vulvar vestibule and especially the labia minora, where the affected skin resembles thin, white parchment paper. Vulvar pruritus is the most common symptom. Diagnosis is made by biopsy. A high-potency topical corticosteroid, such as clobetasol propionate cream 0.05%, is applied twice daily for 2 to 3 weeks and then nightly until symptoms and findings subside. The dosage can be tapered to 1 to 3 times weekly depending on response.

Squamous hyperplasia may occur anywhere on the vulva and may be localized to a small area. Squamous hyperplasia produces vulvar pruritus; the skin appears thickened and raised. When squamous hyperplasia affects more than one site, the involved areas are typically asymmetric. The diagnosis is usually one of exclusion. However, biopsy may be necessary to establish the diagnosis. A topical medium-strength corticosteroid, such as triamcinolone acetonide cream 0.1%, is applied twice daily and decreased to once daily until symptoms resolve (usually 2 to 3 weeks). Eliminating local irritants (eg, detergents, dyes, perfumes) and practicing good perineal hygiene (eg, wiping front to back after bowel movements and voiding), with emphasis on keeping the area dry, often cures squamous hyperplasia.

Other dermatoses (eg, lichen simplex chronicus, lichen planus, psoriasis, chronic eczematous dermatitis) can often be diagnosed on clinical grounds alone. However, if the patient has seen other physicians or has been treated previously, biopsy is usually indicated.