2016 European guideline for the management of vulval conditions

Abstract

Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners.Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).

Vulvar itch

“…Patients may be asymptomatic or report itch, dyspareunia, and poor urinary stream. Genital skin may have atrophic scarring with a “cigarette paper” appearance, which can extend to the perianal area with a classic “figure of eight” distribution39 (fig 3). Severe lichen sclerosus can result in loss of architecture with clitoral resorption, fissuring, and erosions.…”

“…Severe lichen sclerosus can result in loss of architecture with clitoral resorption, fissuring, and erosions. Involvement of the vagina excludes lichen sclerosus 3. Left untreated, patients may develop scarring and possible malignant change to squamous cell carcinoma 39…”

“…Vaginal erosions with patchy erythematous friable skin is suggestive of erosive lichen planus. Lesions on the cervix or vagina require further assessment to rule out neoplasia 3711…”

“…Biochemical tests may be relevant in patients with suspected lichen sclerosus and rarely lichen planus because of associated autoimmune diseases (eg, thyroid disease, diabetes) 3. Patch testing is useful if allergic contact dermatitis is suspected and symptoms are not settling after adequate treatment 12…”

“…In patients with severe night itch consider a mild sedating antihistamine—eg, hydroxyzine 35. Improve the skin barrier function with a bland emollient—eg, emulsifying ointment or paraffin based emollients, which are safe and reduce34 symptoms.…”