Vulvar puritus for one year

A 60-year-old menopausal female presented with vulvar itching for one year. She had noticed a whitish lesion on the vulva that slowly increased in size over the year. She had been unsuccessfully treated with oral fluconazole and topical clotrimazole-mometasone combinations and the plaque had gradually spread to involve the clitoris and peri-urethral area. She was neither diabetic nor hypertensive and had no other systemic complaints. Examination revealed a well-defined non-tender whitish plaque situated on her left labia minora and clitoris (Figure 1). A swab from the plaque did not grow any organism. Routine blood chemistry including a VDRL and HIV ELIZA were within normal limits. A punch biopsy from the lesion was taken and histopathology findings were as seen in (Figures 2 and 3).

Postmenopausal vulvar pruritus--colposcopic diagnosis and treatment

Vulvar pruritus is a common symptom in post-menopausal women and treatment is easy if the diagnosis is duly recognized. The purpose of this study is to show the importance of colposcopic examination and directed biopsies in 27 post-menopausal women with pruritus. Biopsy sites were selected by colposcopy. The prevalence of vulvar pruritus, vulvar pathologies, vulvar dystrophies and vulvar intraepithelial lesions (VIN) were 2.18%, 1.49%, 0.94% and 0.07% respectively. Vulvar dystrophies were treated by topical steroids and success rate was 100%. All patients with vulvar pruritus need examination under colposcopy to define optimal therapy and to exclude atypia or malignancy.

Subcutaneous injection of triamcinolone acetonide in the treatment of chronic vulvar pruritus

OBJECTIVES

We studied the efficacy of subcutaneous corticosteroid injection as therapy for chronic vulvar pruritus.

STUDY DESIGN

Adult women with symptoms of vulvar pruritus > 6 months were studied. After appropriate biopsies and cultures were performed, patients were included in the study group if they experienced limited relief with topical triamcinolone cream. Triamcinolone acetonide (15 to 20 mg) was injected subcutaneously and massaged into the affected vulvar tissue.

RESULTS

Seventy-eight percent of patients (35/45) experienced relief of vulvar pruritus for > 1 month (mean duration 5.8 months).

CONCLUSIONS

We found that subcutaneous injection triamcinolone acetonide provided relief of symptoms of chronic vulvar pruritus.

[The vulvar clinic]

Until recently, vulvar diseases have not been given sufficient attention by gynecologists. This might be attributable to the timidity of patients with chronic vulvar pruritus, tumor or dyspareunia, which delays diagnosis and treatment. In addition, the nomenclature of vulvar disease was complicated by having been adapted from various dermatological disorders. Only following the establishment of the International Society for the Study of Vulvar Disease (ISSVD) and of specialized clinics, has awareness increased and more attention is now being paid to vulvar disorders. The findings in 242 patients seen during the first year of operation of a vulvar clinic were analyzed. The most common presenting symptom was chronic vulvar pruritus. Non-neoplastic epithelial disorder (dystrophy) was the most common histological finding in the 79 women with pruritus, while 2 were diagnosed as having vulvar intraepithelial neoplasia, and 1 had basal cell carcinoma. In contrast, vulvar vestibulitis was the main diagnosis in 34 women referred for vulvar pain (vulvodynia). Vulvodynia was also associated with other inflammatory processes and with human papilloma virus (HPV) lesions (condylomata). The primary finding in 26 women referred for evaluation of a vulvar "tumor" was epidermal cyst. In only 55 (75.5%) of the 73 referred for suspected HPV lesions was the histologic diagnosis confirmatory. In addition, a few vulvar ulcers were associated with HPV. A single treatment with carbon dioxide laser eradicated the HPV lesions in 93% of the cases. The vulvar clinic contributes to the ambulatory gynecological service by concentrating diagnosis and treatment in a single specialized unit and increases understanding of, and interest in vulvar disease.

Lichen planus of the vulva

Lichen planus is an uncommon cutaneous disease that can affect the vulva. Vulvar pruritus and pain are common symptoms in patients with genital involvement. Examination reveals an erythematous, friable vestibule with adherent exudate. Marked resorption of the labia minor and atrophy may occur in time. Diagnosis is based on associated clinical findings involving the oral mucosa and/or the skin and on vulvar biopsy.

Vulval dystrophies: new approaches

In describing vulval skin changes, all terms such as leucoplakia, kraurosis vulvae and lichen sclerosus et atrophicus should be discarded in favour of 'chronic vulval dystrophy'. Initial biopsy is mandatory to establish the precise diagnosis. From a review of the literature and from our own studies we believe that vulval dystrophy is not usually a premalignant condition, a risk of carcinoma exiting only in dystrophic vulvas with associated atypia. For such patients the treatment is local vulvectomy; otherwise, because of the high rate of recurrence of chronic vulval dystrophy following surgery, the treatment should primarily be medical. Gastrointestinal peptides have been isolated from the vulval skin and a working hypothesis of the aetiology of vulval dystrophy is presented.

Treatment of pruritus vulvae by means of CO2 laser

Five women with intractable pruritus vulvae, in whom standard therapy had failed to cure the condition, were treated by CO2 laser beam application. Results at one year were good in one patient and excellent in four.

Angiokeratoma of vulva

A female of 66 who presented with long-standing pruritus vulvae showed angiokeratoma of the vulva as an incidental finding. This benign tumour is uncommon and in a survey of 150 patients over 50 years old (mean age 76.9), no further example was found.

Vulvar pruritus--a symptom, not a disease

Because the underlying causes are so varied, vulvar pruritus must be understood as a symptom and not as a disease entity in itself. Successful treatment depends on proper identification of the underlying disorder.

Puritus vulvae: treatment by multiple intradermal alcohol injections

A Preliminary report is presented on the use of multiple intradermal injections of absolute alcohol in the treatment of intractable pruritus vulvae. Twenty-five patients were followed up for over I year, and of these six (24%) were cured, and thirteen (52%) showed marked symptomatic improvement.