Lipschütz Ulcer and SARS-CoV-2: What We Currently Know?

BACKGROUND

In recent years, several interesting case reports have been published which describe the possible role of SARS-CoV-2 infection or vaccination in the etiopathogenesis of Lipschütz ulcer. Our aim is to analyze this association and provide a rapid algorithm that is of support to gynecologists and dermatologists both in the diagnosis and in setting up the therapy. To do so, in this paper, we describe an interesting case of acute vulvar ulcer triggered by SARS-CoV-2 infection and review the related literature.

METHODS

We conducted a literature review including papers published between October 2021 and April 2023, and we described the case of a patient referred to our clinic with Lipschütz ulcer and SARS-CoV-2 infection.

RESULTS

In almost all cases analyzed, a correlation with SARS-CoV-2 infection or vaccination was found; ulcers usually manifest after 2 to 4 weeks and are associated with flu-like symptoms. A concordance in review papers, as well as in our case report, was also found about the treatment, which is mainly symptomatic.

CONCLUSIONS

Previous infection or vaccination for SARS-CoV-2 should be included as possible etiopathogenetic factors in the onset of Lipschütz ulcer.

Therapeutic Choices for Genitourinary Syndrome of Menopause (GSM) in Breast Cancer Survivors: A Systematic Review and Update

(1) Background: Genitourinary syndrome of menopause (GSM) is a medical condition that can affect breast cancer survivors (BCS). This is a complication that often can occur as a result of breast cancer treatment, causing symptoms such as vaginal dryness, itching, burning, dyspareunia, dysuria, pain, discomfort, and impairment of sexual function. BCS who experience these symptoms negatively impact multiple aspects of their quality of life to the point that some of them fail to complete adjuvant hormonal treatment; (2) Methods: In this systematic review of the literature, we have analyzed possible pharmacological and non-pharmacological treatments for GSM in BCS. We reviewed systemic hormone therapy, local hormone treatment with estrogens and androgens, the use of vaginal moisturizers and lubricants, ospemifene, and physical therapies such as radiofrequency, electroporation, and vaginal laser; (3) Results: The data available to date demonstrate that the aforementioned treatments are effective for the therapy of GSM and, in particular, vulvovaginal atrophy in BCS. Where possible, combination therapy often appears more useful than using a single line of treatment; (4) Conclusions: We analyzed the efficacy and safety data of each of these options for the treatment of GSM in BCS, emphasizing how often larger clinical trials with longer follow-ups are needed.

Vulvodynia: Pain Management Strategies

Background: Vulvodynia is defined in this international consensus as persistent vulvar pain that occurs for >3 months without an identifiable cause and with several potential associated factors. At present there is no univocal consensus in the therapeutic treatment of vulvodynia. The methods of intervention are based on various aspects including, above all, the management of painful symptoms. Methods: a research on scientific database such as “Pubmed”, “Medline Plus”, “Medscape” was conducted, using the words “women’s genital pain” and “vulvodynia” for the review of the scientific evidence on the assessment and treatment of women’s genital pain. Results: Among the drugs with pain-relieving action, the most effective in the treatment of vulvodynia would seem to be those with antidepressant and anticonvulsant action, even if their mechanisms of action are not known and there are still insufficient studies able to demonstrate their real validity. Among the least effective are non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. However, the ideal would seem to use a combined treatment with multiple types of drugs. Conclusions: Future studies are needed to draw up a unique therapeutic action plan that considers the stratification of patients with vulvodynia and the variability of the symptom.

Are We Facing a New Colposcopic Practice in the HPV Vaccination Era? Opportunities, Challenges, and New Perspectives

The combination of primary and secondary prevention has already influenced the colposcopic practice by reduction in HPV (human papillomavirus) vaccine-type HSIL (HIGH-GRADE SIL), colposcopy referral numbers, colposcopic positive predictive value (PPV) for CIN2+, and by modification of referral pattern, colposcopic performance, and procedures. Different strategies, both isolated and combined, have been proposed in order to maintain the diagnostic accuracy of colposcopy: patient risk stratification based on immediate or future risk of CIN3+ or on HPV genotyping after a positive screening test. Data are needed to support alternative colposcopic strategies based on vaccination status and on the application of artificial intelligence where the patient’s risk stratification is implicit in precision medicine which involves the transition from an operator-dependent morphology-based to a less-operator dependent, more biomolecular management. The patient’s risk stratification based on any combination of “history” and “test results” to decrease colposcopy workload further reduce colposcopic and histologic morphological approaches, while adding genotyping to the risk stratification paradigm means less cytologic morphologic diagnosis. In Italy, there is a strong colposcopic tradition and there is currently no immediate need to reduce the number of colposcopies. Instead, there is a need for more accredited colposcopists to maintain the diagnostic accuracy of colposcopy in the vaccination era.

Oral administration of Lactobacillus crispatus M247 to papillomavirus-infected women: results of a preliminary, uncontrolled, open trial

BACKGROUND

Vaginal microbiotas can be clustered into five different possible categories (CST I to V), according to their bacterial dominance. In CST I, the dominance of Lactobacillus crispatus seems to correlate with better vaginal health and with a lower incidence of sine causa infertility, preterm delivery, bacterial vaginosis, and viral (including human papillomavirus; HPV) infection. According to the same method of classifying the vaginal microbiome, CST IV (non-Lactobacillusdominated) demonstrates a higher incidence of disorders.

METHODS

In an open, non-controlled study, we enrolled 35 HPV-positive women who mostly (N=24) demonstrated CST IV status, with the other individuals categorized as having either CST III (N=10) or CST II (N=1) microbiotas.

RESULTS

After 90 days of oral treatment with a probiotic (L. crispatus M247) we observed a reduction of approximately 70% in HPV positivity and a significant change in CST status with 94% of women now classified as CST I.

CONCLUSIONS

Despite the limitations of our study, it is the first demonstration that it is possible to intervene orally with an L. crispatus probiotic to bring about a change in CST status and, in parallel, increased HPV clearance.

Effect of transcutaneous electrical nerve stimulation on the postpartum dyspareunia treatment

AIM

This article will evaluate the safety and efficacy of intravaginal transcutaneous electrical nerve stimulation (TENS) for the treatment of vulvar pain and dyspareunia during the postpartum period related to perineal trauma caused by episiotomy.

METHODS

From January 2007 to January 2009, 45 women presenting with postpartum dyspareunia related to perineal trauma after a vaginal delivery were educated on the importance of the pelvic floor and its part in continuing dyspareunia. The treatment consisted of weekly applications of intravaginal TENS in an outpatient setting and daily home therapy with myofascial stretching and exercises of the pelvic floor musculature. The results were evaluated using the cotton swab test, the Marinoff Dyspareunia Scale and the Visual Analog Scale, and the anovulvar distance was assessed prior to and at the end of the treatment period.

RESULTS

Of the women included in the study, 84.5% reported an improvement of dyspareunia after only five applications of TENS, with a total remission of symptoms (in 95% of patients) at the end of the protocol. At follow-up, eight months after the end of treatment, all patients were pain free.

CONCLUSIONS

Therapy with intravaginal transcutaneous nerve stimulation and pelvic floor relaxation exercises is safe and effective in the improvement of vulvar pain and dyspareunia in women with postpartum perineal trauma due to episiorrhaphy, after spontaneous delivery.

[Use of transcutaneous electrical stimulation and biofeedback for the treatment of vulvodynia (vulvar vestibular syndrome): result of 3 years of experience]

AIM

The safety, tolerability and efficacy of physical therapy with biofeedback and trans electrical nerve stimulation (TENS) with intravaginal probe for the treatment of vulvar pain and vulvar discomfort in women with vulvodynia, is evalued in the present study. Vulvodinia is a cronic syndrome of unexplained vulvar pain. Patients typically present with a history of intermittent or continuous, localized, vulvar pain, frequently accompanied by sexual dysfunction like entry dispareunia, burning and hiching localized to the vulvar vestibule.

METHODS

From January 2005 and June 2007, a total 145 women diagnosed with vulvodynia presented in the ambulatory for the Diagnosis and Treatment of Vulvar Pain and Pelvic Floor Dysfunction, Clinical ''Santa Famiglia'', Rome. Patients were treated with weekly biofeedback (BFB) and transcutaneous electroanalgesia (TENS), in association with functional electrical stimulation (FES) and home-therapy with stretching exercise of pelvic floor.

RESULTS

Hundred forty-five women completed both the biofeedback and trans electric nerve stimulation treatment for a total of 10 application, with a improvement of vulvar pain in 75.8% of cases.

CONCLUSION

The pelvic floor relaxation with biofeedback and ellectroanalgesia is safe and effective in improvement in vulvar pain and dyspareunia in women with vulvodynia.

[Topical imiquimod cream in the treatment of external anogenital warts: personal experience]

AIM

The clinical effects of home-therapy with 5% imiquimod cream in the treatment of cutaneous anogenital warts are evaluated.

METHODS

From March 2000 to January 2002, 57 women presenting clinical cutaneous external genital and perianal warts were selected in the base-population observed at our clinical of vulvar pathology and sexually transmitted diseases, AIED Rome. The patients were divided into 2 groups: Group A, with new cutaneous viral lesions and Group B with recurrent anogenital warts pre-treated with CO2-laser therapy. A total of 36% (20) of all patients presented contemporaneous HPV lesions of cervix and/or vaginal wall. The follow-up was carried out at 4 weeks, 3 months and 6 months, evaluating the safety, clinical efficacy and tolerance of women. The Pearson chi2 test was used to evaluate trends significance. All lesions were photo-documented.

RESULTS

Sixty-four per cent (64%) of the patients had complete clearance of anogenital warts within 16 weeks, for 3 times per week self-application of imiquimod, with clinical remission at short term (6/8 weeks) (chi2=1.42; p<0.05); 12% had partial clearance (<50%) and 20% had a clearance of about 75%. The coexistent lesions of cervix and/or vaginal walls had a high remission (>50%) and required surgical additional therapy with CO2-laser; 28% of patients (16/57) experienced mild to moderate drug-related side effects. There was a significant increase in the severity of local skin reactions due to the increased time and number of applications.

CONCLUSION

These data confirm that imiquimod cream at the dose regimen of 3 times per week, is effective and well tolerated in the treatment of cutaneous external warts and is associated to a reduction of coexistent mucous viral lesions due to enhancement of local immune response.