Interview, Examination Equally Valuable in Vulvar Diagnosis

CORONADO, CALIF. — Patience, persistence, and asking patients the right questions are key to diagnosing vulvar disease, Dr. Erika Klemperer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Does it itch? Is it the type of itch you want to scratch? Does scratching make it feel better or worse? The answers to these questions, along with a thorough examination and possibly a biopsy, may bring clarity to what otherwise might be a challenging clinical evaluation.

“The vulvar anatomy is just skin, but it's unique,” said Dr. Klemperer, a dermatologist in private practice in Santa Barbara, Calif.

Conditions that may be obvious elsewhere on the skin can look different in the vulvar region, either because of moisture, pigmentation, skin fragility, or complications of yeast, bacteria, or contact or irritant dermatitis. That's why, after Dr. Klemperer has taken the time to put patients at ease, she asks them specific questions about their symptoms.

Pruritus that makes a patient want to scratch points to the possibility of lichen simplex chronicus or lichen sclerosis. If scratching feels good, the diagnosis leans toward lichen simplex chronicus. If scratching makes things worse, think lichen sclerosis, she said.

When patients complain of pain, Dr. Klemperer asks more questions. Erosive disorders should enter the differential diagnosis if patients complain of a raw sensation. Burning pain opens up the possibility of vulvar pain syndromes.

Finally, it pays to ask patients what they have used, on order of another physician or on their own, to treat their symptoms, because treatments may be driving the primary or secondary diagnosis. It took five visits for one patient with necrotic ulcers to admit she had been scrubbing her vulva with Lysol disinfectant thinking if she got clean enough, her symptoms would resolve.

As this case illustrates, the psychologic component of vulvar disease cannot be overstated. By the time some women see a dermatologist, they may have long endured profound symptoms, often becoming desperate in their attempts to self-treat their symptoms or seek help from other clinicians. Their self-esteem and sexuality may be affected, and they may fear a diagnosis of a sexually transmitted disease or cancer.

“These women are often miserable. [They] need extra time. They need a really supportive environment,” she said.

A complete examination of the genital region under magnification and with proper lighting may reveal obvious or very subtle signs to guide the diagnosis. Manipulating the skin folds is important, since they may obscure fissures and erosions, the fernlike patches of lichen planus, or scarring.

But typical signs of skin disease may not be present in the vulvar region, Dr. Klemperer cautioned.

A thorough mucocutaneous examination will often reveal better clues, such as the classic skin changes of psoriasis that demystified the diffuse erythema on one patient's vulva.

Unusual morphology and often nonspecific clinical vulvovaginal findings mean that biopsy is important to an accurate diagnosis, she explained.

Vulvar skin's unique physiology also makes it more permeable, more susceptible to irritant activity, and more sensitive to stimuli, such as itch and pain. It has a unique microbial ecology and increased blood flow—important considerations when weighing therapeutic options, she said.

Know What's Normal to Catch What's Abnormal

Normal anatomic variants of the vulva include:

▸ Vulvar erythema. There is a “huge variation” in the pinkness of the vulva by ethnicity, skin type, and simple differences between individuals. “Redness can be normal. The important thing is change,” Dr. Klemperer explained.

▸ Vestibular papillae. These 1- to 2-mm, soft, filiform papules are sometimes misdiagnosed as condylomata.

▸ Labial papillae. Generally seen on the tips of the labia minora, these may have a cobblestone appearance. They are normal.

▸ Fordyce's spots. These often occur on the medial aspect of the labia minora. Like the yellowish, globular papules seen in the mouth, they are common sebaceous glands.

▸ Labia minora variations. The labia minora can appear as “little vestigial remnants or large, redundant skin.” They may be asymmetric.

▸ Syringomata. Commonly seen on the labia majora, these 2- to 5-mm, skin-colored or hyperpigmented papules are often seen in clusters. They are frequently misdiagnosed and mistreated as genital warts.

▸ Angiokeratomas. These asymptomatic reddish or bluish papules are benign.

Source: Dr. Klemperer

CORONADO, CALIF. — Patience, persistence, and asking patients the right questions are key to diagnosing vulvar disease, Dr. Erika Klemperer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Does it itch? Is it the type of itch you want to scratch? Does scratching make it feel better or worse? The answers to these questions, along with a thorough examination and possibly a biopsy, may bring clarity to what otherwise might be a challenging clinical evaluation.

“The vulvar anatomy is just skin, but it's unique,” said Dr. Klemperer, a dermatologist in private practice in Santa Barbara, Calif.

Conditions that may be obvious elsewhere on the skin can look different in the vulvar region, either because of moisture, pigmentation, skin fragility, or complications of yeast, bacteria, or contact or irritant dermatitis. That's why, after Dr. Klemperer has taken the time to put patients at ease, she asks them specific questions about their symptoms.

Pruritus that makes a patient want to scratch points to the possibility of lichen simplex chronicus or lichen sclerosis. If scratching feels good, the diagnosis leans toward lichen simplex chronicus. If scratching makes things worse, think lichen sclerosis, she said.

When patients complain of pain, Dr. Klemperer asks more questions. Erosive disorders should enter the differential diagnosis if patients complain of a raw sensation. Burning pain opens up the possibility of vulvar pain syndromes.

Finally, it pays to ask patients what they have used, on order of another physician or on their own, to treat their symptoms, because treatments may be driving the primary or secondary diagnosis. It took five visits for one patient with necrotic ulcers to admit she had been scrubbing her vulva with Lysol disinfectant thinking if she got clean enough, her symptoms would resolve.

As this case illustrates, the psychologic component of vulvar disease cannot be overstated. By the time some women see a dermatologist, they may have long endured profound symptoms, often becoming desperate in their attempts to self-treat their symptoms or seek help from other clinicians. Their self-esteem and sexuality may be affected, and they may fear a diagnosis of a sexually transmitted disease or cancer.

“These women are often miserable. [They] need extra time. They need a really supportive environment,” she said.

A complete examination of the genital region under magnification and with proper lighting may reveal obvious or very subtle signs to guide the diagnosis. Manipulating the skin folds is important, since they may obscure fissures and erosions, the fernlike patches of lichen planus, or scarring.

But typical signs of skin disease may not be present in the vulvar region, Dr. Klemperer cautioned.

A thorough mucocutaneous examination will often reveal better clues, such as the classic skin changes of psoriasis that demystified the diffuse erythema on one patient's vulva.

Unusual morphology and often nonspecific clinical vulvovaginal findings mean that biopsy is important to an accurate diagnosis, she explained.

Vulvar skin's unique physiology also makes it more permeable, more susceptible to irritant activity, and more sensitive to stimuli, such as itch and pain. It has a unique microbial ecology and increased blood flow—important considerations when weighing therapeutic options, she said.

Know What's Normal to Catch What's Abnormal

Normal anatomic variants of the vulva include:

▸ Vulvar erythema. There is a “huge variation” in the pinkness of the vulva by ethnicity, skin type, and simple differences between individuals. “Redness can be normal. The important thing is change,” Dr. Klemperer explained.

▸ Vestibular papillae. These 1- to 2-mm, soft, filiform papules are sometimes misdiagnosed as condylomata.

▸ Labial papillae. Generally seen on the tips of the labia minora, these may have a cobblestone appearance. They are normal.

▸ Fordyce's spots. These often occur on the medial aspect of the labia minora. Like the yellowish, globular papules seen in the mouth, they are common sebaceous glands.

▸ Labia minora variations. The labia minora can appear as “little vestigial remnants or large, redundant skin.” They may be asymmetric.

▸ Syringomata. Commonly seen on the labia majora, these 2- to 5-mm, skin-colored or hyperpigmented papules are often seen in clusters. They are frequently misdiagnosed and mistreated as genital warts.

▸ Angiokeratomas. These asymptomatic reddish or bluish papules are benign.

Source: Dr. Klemperer

CORONADO, CALIF. — Patience, persistence, and asking patients the right questions are key to diagnosing vulvar disease, Dr. Erika Klemperer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Does it itch? Is it the type of itch you want to scratch? Does scratching make it feel better or worse? The answers to these questions, along with a thorough examination and possibly a biopsy, may bring clarity to what otherwise might be a challenging clinical evaluation.

“The vulvar anatomy is just skin, but it's unique,” said Dr. Klemperer, a dermatologist in private practice in Santa Barbara, Calif.

Conditions that may be obvious elsewhere on the skin can look different in the vulvar region, either because of moisture, pigmentation, skin fragility, or complications of yeast, bacteria, or contact or irritant dermatitis. That's why, after Dr. Klemperer has taken the time to put patients at ease, she asks them specific questions about their symptoms.

Pruritus that makes a patient want to scratch points to the possibility of lichen simplex chronicus or lichen sclerosis. If scratching feels good, the diagnosis leans toward lichen simplex chronicus. If scratching makes things worse, think lichen sclerosis, she said.

When patients complain of pain, Dr. Klemperer asks more questions. Erosive disorders should enter the differential diagnosis if patients complain of a raw sensation. Burning pain opens up the possibility of vulvar pain syndromes.

Finally, it pays to ask patients what they have used, on order of another physician or on their own, to treat their symptoms, because treatments may be driving the primary or secondary diagnosis. It took five visits for one patient with necrotic ulcers to admit she had been scrubbing her vulva with Lysol disinfectant thinking if she got clean enough, her symptoms would resolve.

As this case illustrates, the psychologic component of vulvar disease cannot be overstated. By the time some women see a dermatologist, they may have long endured profound symptoms, often becoming desperate in their attempts to self-treat their symptoms or seek help from other clinicians. Their self-esteem and sexuality may be affected, and they may fear a diagnosis of a sexually transmitted disease or cancer.

“These women are often miserable. [They] need extra time. They need a really supportive environment,” she said.

A complete examination of the genital region under magnification and with proper lighting may reveal obvious or very subtle signs to guide the diagnosis. Manipulating the skin folds is important, since they may obscure fissures and erosions, the fernlike patches of lichen planus, or scarring.

But typical signs of skin disease may not be present in the vulvar region, Dr. Klemperer cautioned.

A thorough mucocutaneous examination will often reveal better clues, such as the classic skin changes of psoriasis that demystified the diffuse erythema on one patient's vulva.

Unusual morphology and often nonspecific clinical vulvovaginal findings mean that biopsy is important to an accurate diagnosis, she explained.

Vulvar skin's unique physiology also makes it more permeable, more susceptible to irritant activity, and more sensitive to stimuli, such as itch and pain. It has a unique microbial ecology and increased blood flow—important considerations when weighing therapeutic options, she said.

Know What's Normal to Catch What's Abnormal

Normal anatomic variants of the vulva include:

▸ Vulvar erythema. There is a “huge variation” in the pinkness of the vulva by ethnicity, skin type, and simple differences between individuals. “Redness can be normal. The important thing is change,” Dr. Klemperer explained.

▸ Vestibular papillae. These 1- to 2-mm, soft, filiform papules are sometimes misdiagnosed as condylomata.

▸ Labial papillae. Generally seen on the tips of the labia minora, these may have a cobblestone appearance. They are normal.

▸ Fordyce's spots. These often occur on the medial aspect of the labia minora. Like the yellowish, globular papules seen in the mouth, they are common sebaceous glands.

▸ Labia minora variations. The labia minora can appear as “little vestigial remnants or large, redundant skin.” They may be asymmetric.

▸ Syringomata. Commonly seen on the labia majora, these 2- to 5-mm, skin-colored or hyperpigmented papules are often seen in clusters. They are frequently misdiagnosed and mistreated as genital warts.

▸ Angiokeratomas. These asymptomatic reddish or bluish papules are benign.

Source: Dr. Klemperer