UPDATE ON GENITAL DERMATOSES. Sangeetha Sundaram Consultant GUM/HIV Southampton 07/11/2018

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1 UPDATE ON GENITAL DERMATOSES Sangeetha Sundaram Consultant GUM/HIV Southampton 07/11/2018

2 Normal variants Fordyce spots Vestibular papillae Pearly penile papules Angiokeratoma Epidermal cysts Skin tags

3 Inflammatory dermatoses Irritant dermatitis Lichen sclerosus Lichen simplex chronicus Lichen planus Seborrhoeic dermatitis Psoriasis

4 History Itching? Where exactly? Waking up at night scratching? Soreness/burning/raw? Where exactly? When? Pain with sex? Where exactly? When exactly? Discharge? Skin trouble elsewhere? Mouth ulcers? Irritants in lifestyle

5 Examination

6 Irritants Soap and shower gel (even Dove, Simple and Sanex ) Sanitary pads and panty liners (especially when worn daily) Moistened wipes Synthetic underwear Tight clothing Feminine washes Topical medication (creams and gels) Urine, faeces, excessive vaginal discharge Lubricants Spermicides

7 Basic vulval toolkit Stop soap/shower gel (even Dove and Simple and Sanex!) Stop pads/ panty liners (except during menses) Loose cotton pants Emollient soap substitute and barrier ointment

8 Lichen simplex chronicus Itching wakes her at night Scratches in her sleep Always same place(s)

9 Lichen simplex chronicus - Stop soap/shower gel management Stop pads/ panty liners (except during menses) Loose cotton pants Emollient soap substitute and barrier ointment Identify underlying condition(s), if any Dermovate ointment every night for 2 weeks, then alternate nights for 2 weeks, then twice weekly for 2 weeks, then stop Iron supplements if low ferritin levels

10 Lichen sclerosus - management Stop soap/shower gel Stop pads/ panty liners (except during menses) Loose cotton pants Emollient soap substitute and barrier ointment Clobetasol propionate 0.05% ointment (Dermovate ointment) Every night for one month, alternate nights for one month, twice weekly for one month 60% will go into remission Thereafter a regular regimen, eg two nights per week and more often during flares: 30g tube lasting 12 weeks minimum usually lasting for at least 6 months Children: every night for 12 weeks

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13 Erosive lichen planus - management Stop soap/shower gel Stop pads/ panty liners (except during menses) Loose cotton pants Emollient soap substitute and barrier ointment Speculum examination Clobetasol propionate 0.05% ointment (Dermovate ointment) Every morning and night for one month, every night for one month, alternate nights for one month.decreasing as possible, increasing as needed Prednisolone (Predsol) 5mg suppository as pessary every night for one month, decreasing as possible

14 Manangement of Seborrhoeic dermatitis Milder preparations eg Daktacort 2% Ketoconazole or selenium sulphide shampoo Itraconazole 200mg od for 1/52 Consider screening for HIV if severe

15 Psoriasis - management Stop soap/shower gel Stop pads/ panty liners (except during menses) Loose cotton pants Emollient soap substitute and barrier ointment Eumovate ointment nocte or Trimovate cream nocte as required

16 VIN Usual type Undifferentiated Grades 1,2 & 3 Young women Often multifocal Associated with HPV 16 Low risk of progression to SCC Differentiated type Older women Solitary plaque Background of Lichen sclerosus No link with HPV High risk of SCC

17 Differential diagnosis of vulval ulcers Herpes simplex Aphthous ulceration Trauma including scratching Infective (other than herpes) eg syphilis Lipschutz ulcer Part of inflammatory disease (LS, LP) Cancer

18 Management of recurrent aphthous ulceration - vulva Stop soap/shower gel Stop pads/ panty liners (except during menses) Loose cotton pants Emollient soap substitute and barrier ointment Consider underlying systemic conditions (history) Exclude HSV Clobetasol propionate 0.05% ointment (Dermovate ointment) daily from earliest onset to resolution 5% lignocaine ointment PRN Oral prednisolone eg 30mg for 5 days Prophylaxis with colchicine

19 Management Low threshold for biopsy as pre-cancerous conditions can mimic Zoon s Hygiene measures Barrier emollient Topical steroids with antibacterial eg trimovate Circumcision

20 Key messages Take a good history and examine Basic principles: Avoid irritants, recommend emollients Dispel myths around topical steroid use Red flags: - Rapidly growing lumps/bumps - Ulcers that are not typical of herpes - Warts not responding to treatment - Pigmented lesions