A Practical Guide to Vulval Disease Diagnosis and Management

This book is a practical guide to the diagnosis and management of vulval disorders. It offers guidance for all those who are treating patients with vulval disease at trainee and specialist level, helping to improve management for the patient and prevent delays in diagnosis, including referrals to specialists. 

It contains key information about diagnosis, investigation and basic management, with a section on signs and symptoms guides the reader to the correct chapter for the treatment of that disease. The experienced authors include updated classification and terminology of vulval disease with an explanation of how this should be useful in clinical practice and guidance as to when the patient should be referred on to a specialist.

As vulval diseases are different to those of the rest of the skin patients with vulval disease present a large unmet need, often with delays in diagnosis due to a lack of training from physicians. This practical guide provides the specialist knowledge required for diagnosis and treatment of these conditions.

Dr Fiona Lewis, Consultant Dermatologist, St John’s Institute of Dermatology and Wexham Park Hospital (Frimley Health Foundation Trust), UK.

 Dr Fabrizio Bogliatto is Head of the Lower Female Genital Tract Disease Out-patient service in the Obstetrics and Gynaecology Department of the Chivasso Civic Hospital in Turin, Italy.

 Dr Marc van Beurden was trained in the Academic Medical Center in Amsterdam and did his fellowship in gynaecologic oncology in the Netherlands Cancer Institute, where he holds his current position as consultant since 1997.

Acknowledgements xvii

1 The Normal Vulva 1

Normal Vulval Anatomy 1

Normal Vulval and Vaginal Flora 4

Further Reading 4

Normal Anatomical Variants 4

Normal Changes Over the Lifetime 6

Further Reading 7

2 Taking a History and Examination 9

Taking a History 9

Examination of the Vulva 11

Further Reading 13

3 How to Take a Vulval Biopsy and the Importance of Clinico‐Pathological Correlation 15

Incisional Biopsy 16

Fixation of the Biopsy 20

Further Reading 21

4 Basic Histology of the Vulva 23

Special Histological Stains 24

Immunohistochemical Stains 26

Other Tests 27

Further Reading 28

5 Investigations in Vulval Disease 29

Investigations for Infection 29

Investigations for Allergy 32

Investigations for Inflammatory Disease 33

Imaging Investigations 34

Useful Web Sites for Patient Information 34

Further Reading 34

6 Topical Treatment in Vulval Disease 35

Introduction 35

General Principles 35

Lotions 35

Gels 36

Ointments 36

Creams 36

Pastes 36

Topical Treatments Used for Vulval Disease 36

Antiseptics 41

Antibacterials 42

Antifungals 42

Barriers 42

Others 42

Practice Points 44

Further Reading 44

Useful Web Sites for Patient Information 44

7 Symptoms in Vulval Disease 45

Pruritis (Itch) 45

Causes of Vulval Pruritis 46

Soreness 46

Pain 47

Dyspareunia 48

Discharge 48

No Symptoms 49

Useful Web Site for Patient Information 49

8 Signs in Vulval Disease 51

Differential Diagnosis Based on Appearance 51

Algorithms 51

Further Reading 56

9 Eczema, Allergy and the Vulva 57

Seborrhoeic Eczema 57

Allergic Contact Eczema / Dermatitis 59

Clinical Features 60

Irritant Eczema / Dermatitis 62

Urticaria 64

Allergic Contact Urticaria 64

References 65

10 Psoriasis 67

Introduction 67

Incidence 67

Clinical Features 68

Basic Management 69

When to Refer 72

Practice Points 73

Further Reading 73

Useful Web Sites for Patient Information 73

11 Lichen Simplex 75

Introduction 75

Epidemiology 75

Incidence 75

Pathophysiology 75

Histological Features 76

Symptoms 76

Clinical Features 76

Basic Management 77

When to Refer 78

Practice Points 78

Further Reading 79

Useful Web Sites for Patient Information 79

12 Lichen Sclerosus 81

Introduction 81

Incidence 81

Pathophysiology 81

Histological Features 82

Symptoms 83

Clinical Features 83

Associated Disease 90

Risk of Malignancy 90

Basic Management 92

Follow Up 92

When to Refer 92

Practice Points 93

Further Reading 93

Useful Web Sites for Patient Information 93

13 Lichen Planus 95

Introduction 95

Epidemiology 95

Incidence 95

Pathophysiology 95

Histological Features 96

Clinical Features of Lichen Planus 96

Vulval Lichen Planus 98

Risk of Malignancy 99

Basic Management 100

When to Refer 101

Practice Points 102

Further Reading 102

Useful Web Sites for Patient Information 102

14 Hidradenitis Suppurativa and Crohn’s Disease 103

Hidradenitis Suppurativa 103

Further Reading 110

Useful Web Sites for Patient Information 110

15 Disorders of Pigmentation on the Vulva 111

Introduction 111

Postinflammatory Pigmentation 111

Post‐Traumatic Pigmentation 111

Acanthosis Nigricans 111

Melanosis 114

Pigmented Lesions 115

Lentigines 116

Benign Naevi 116

Atypical Genital Naevi 117

Seborrhoeic Keratoses 117

Pigmented Basal Cell Carcinoma (see Chapter 22) 118

Hypopigmentation 118

Vitiligo 118

When to Refer 119

Practice Points 119

Further Reading 119

Useful Web Sites for Patient Information 120

16 Other Dermatoses 121

Genetic Disorders 121

Auto‐Immune Bullous Disease 123

Drug Eruptions 126

Further Reading 126

Useful Web Sites for Patient Information 126

Stevens–Johnson Syndrome 127

Toxic Epidermal Necrolysis 127

Manifestations of Underlying Disease 128

Further Reading 129

Acrodermatitis Enteropathica 129

Practice Point 130

Further Reading 130

Inflammatory Ulcers 130

Practice Point 130

Behcet’s Syndrome 130

Further Reading 132

Useful Resources 132

Lipschutz Ulceration 132

Further Reading 133

Others 133

Further Reading 135

Vulvovaginal Adenosis 135

Further Reading 135

Langerhans Cell Histiocytosis 136

Further Reading 136

17 Vulval Infection – Sexually Transmitted 137

Normal Flora 137

Trichomoniasis 137

Lymphogranuloma Venereum 139

Gonorrhoea 140

Clinical Features 140

Syphilis 141

Chancroid 142

Donovanosis (Granuloma Inguinale) 143

Herpes Simplex Infection 144

Human Papillomavirus Infection 147

Molluscum Contagiosum 150

Scabies 152

Pubic Lice 153

18 Vulval Infection – Nonsexually Transmitted 155

Bacterial Infections 155

Bacterial Vaginosis 155

Erythrasma 157

Staphylococcal and Streptococcal Infections 158

Folliculitis 159

Bartholin Abscess 159

Other Staphylococcal Infections 161

Cellulitis 161

Other Streptococcal Infections 161

Vulvovaginal Candidiasis 162

Tinea Cruris 165

Viral Infections 166

19 Vulval Intraepithelial Neoplasia 167

Introduction 167

Epidemiology 167

Aetiology 168

Prevention 168

Histological Features 168

Symptoms 169

Clinical Features 169

Management 173

Progression 174

Melanoma In Situ 176

When to Refer 176

Practice Points 176

Further Reading 177

Useful Web Site for Patient Information 177

20 Extramammary Paget’s Disease 179

Introduction 179

Epidemiology 179

Histological Features 179

Classification 180

Symptoms 181

Clinical Features 181

Management 183

Recurrences 185

Progression 185

Follow Up 186

When to Refer 186

Practice Points 186

Further Reading 186

Useful Web Site for Patient Information 187

21 Vulval Squamous Cell Carcinoma 189

Introduction 189

Epidemiology 189

Aetiology / Histology 189

Symptoms and Clinical Features 190

Management 191

Surgery 191

Complications 192

Radiotherapy 193

Follow Up 193

Prognosis 193

When to Refer 194

Practice Points 194

Further Reading 194

Useful Web Site for Patient Information 195

22 Other Vulval Cancers 197

Basal Cell Carcinoma 197

Malignant Melanoma 199

Other Malignant Tumours and the Vulva 202

Further Reading 202

23 Vulvodynia 203

Definition 203

Epidemiology 203

Pathophysiology 205

Psychological Aspects of Vulvodynia 205

Histology 206

Symptoms 206

Signs 206

Diagnosis 207

Management 207

Further Reading 209

Useful Web Sites for Patient Information 209

24 Psychosexual Aspects of Vulval Disease 211

Clinical Psychological Assessment 212

Further Reading 212

25 Benign Lesions 213

Epidermoid Cysts 213

Comedones 213

Syringomata 213

Hidradenoma Papilliferum 215

Lymphangioma / Lymphangiectasia 216

Further Reading 216

Index 000

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