Vulvovaginal involvement in Stevens‐Johnson syndrome and toxic epidermal necrolysis: management and techniques used to reduce gynecologic sequelae

Abstract

Background Vulvovaginal involvement in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is common, likely underdiagnosed, and can result in severe sequelae if not managed acutely. There are few studies on acute management of vulvovaginal SJS/TEN. Current recommendations are predominantly based on expert opinion. We aimed to determine the frequency of vulvovaginal involvement in SJS/TEN at a single institution, identify treatment modalities, and assess outcomes at a tertiary care burn center.Methods This is a retrospective review of vulvovaginal SJS/TEN cases between 2009 and 2019. Demographic and clinical data including exam findings, treatment regimens, and outpatient follow-up were collected from the electronic medical record.Results Vulvovaginal involvement was observed in 12.7% (19/149) of cases of female patients with SJS/TEN. The mean age was 38.7 years (SD 23.6), and 21% (4/19) of patients were pediatric (age 9-18). Vulvar involvement was seen in 47.3% (9/19), and vulvar plus vaginal involvement was reported in 42.1% (8/19). Treatment regimens were variable until 2017, at which time institutional guidelines were implemented including application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression.Gynecology follow-up occurred in 15.7% (3/19) of cases. One complication of superficial vaginal agglutination was noted and was successfully treated in the office with blunt dissection. ConclusionThe most common treatment modalities employed at our institution included application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression.While follow-up was limited for our patient population, we propose an algorithm to prevent long-term sequalae of vulvovaginal SJS/TEN. Gynecologic surveillance is recommended to reduce urogynecologic sequelae.

Toxic epidermal necrolysis in adult patients: Experience from the West Australian Collaboration

“…For female patients, the use of intravaginal dilators is recommended as guided by gynaecology. Recommendations from the USA published in 2021 cautioned that complications such as vaginal agglutination or stenosis can occur if vulvovaginal tissue affected by SJS/TEN is not managed appropriately 31 . Consistent with our hospital guidelines, the authors canvass the utility of vaginal moulds or dilators 31 .…”

“…Consistent with our hospital guidelines, the authors canvass the utility of vaginal moulds or dilators 31 . Their guidelines also recommend oestradiol cream (0.5 g) once daily to the external and internal vagina 31 . The rationale for oestradiol is its ability to promote maturation and proliferation of epithelium and reduce the activity of elastase in wound tissue 31 .…”

“…Recommendations from the USA published in 2021 cautioned that complications such as vaginal agglutination or stenosis can occur if vulvovaginal tissue affected by SJS/TEN is not managed appropriately. 31 Consistent with our hospital guidelines, the authors canvass the utility of vaginal moulds or dilators. 31 Their guidelines also recommend oestradiol cream (0.5 g) once daily to the external and internal vagina.…”

“…31 Their guidelines also recommend oestradiol cream (0.5 g) once daily to the external and internal vagina. 31 The rationale for oestradiol is its ability to promote maturation and proliferation of epithelium and reduce the activity of elastase in wound tissue. 31 We will consider the weight of evidence for vaginal oestrogen in the next iteration of our guidelines in 2022.…”

Stevens Johnson Syndrome: Past, Present, and Future Directions Gynecologic Manifestations and Management in SJS/TEN

“…Mucosal surface involvement is often widespread, involving the respiratory, gastrointestinal, and genitourinary tracts ( 2 , 3 ). The reported prevalence of vulvovaginal involvement in patients hospitalized with SJS/TEN is extremely variable, was previously estimated to be as high as 70% ( 2 , 4 – 6 ) and seems to be higher with routine consultation of a specialist in Gynecology. Failure to recognize and treat vulvovaginal SJS/TEN has the potential for severe acute and chronic morbidity ( 4 ), including vulvovaginal adhesions, vaginal stenosis, vaginal dryness, pain, dyspareunia, bleeding, adenosis, and psychological distress.…”