Vulval pruritus: the experience of gynaecologists revealed by biopsy.

Pruritus of the vulva is a common symptom among patients attending to outpatient clinics. In the present study, we aimed to assess pathologies causing vulval pruritus in the reliability of biopsy in a tertiary referral centre. A total of 137 patients undergoing vulval colposcopy because of vulval pruritus were reviewed from the hospital records retrospectively. The mean age of the patients was 47.61 ± 11.88 years and 36.5% of the patients were postmenopausal. In 101 (73.7%) of the patients, macroscopic lesions were present. In 88 (64.2%) of the patients, tolidine-positive stained areas were determined under colposcopy. In total, 68 (49.6%) of the lesions were plain, whereas 51 (37.2%) of them were depigmented. Lichen simplex chronicus, lichen sclerosis and chronic inflammation were the major pathologies associated with vulval pruritus (25.5%, n = 35; 20.4%, n = 28; 14.6%, n = 20). In conclusion, several pathologies out of vulvovaginal candidiasis may lead to vulval pruritus and clinicians should be aware of the importance of biopsy in determining the underlying pathology.

Vulvar puritus for one year.

A 60-year-old menopausal female presented with vulvar itching for one year. She had noticed a whitish lesion on the vulva that slowly increased in size over the year. She had been unsuccessfully treated with oral fluconazole and topical clotrimazole-mometasone combinations and the plaque had gradually spread to involve the clitoris and peri-urethral area. She was neither diabetic nor hypertensive and had no other systemic complaints. Examination revealed a well-defined non-tender whitish plaque situated on her left labia minora and clitoris (Figure 1). A swab from the plaque did not grow any organism. Routine blood chemistry including a VDRL and HIV ELIZA were within normal limits. A punch biopsy from the lesion was taken and histopathology findings were as seen in (Figures 2 and 3).

Prospective study of patch testing in patients with vulval pruritus.

Forty-three patients with the primary complaint of vulval pruritus were recruited to take part in this prospective patch-testing study. A detailed questionnaire was administered to each and patch testing to an extended battery of allergens was undertaken. This included the European standard series, preservatives, corticosteroids and a battery of common over-the-counter topical vulval treatments. Analysis of demographic data and prior treatments used, and various other parameters, were studied in the context of patch-test results. This prospective study reports a very high rate of contact sensitivity in patients presenting with vulval pruritus, with 81.4% of those tested having at least one contact allergen detected. One or more clinically relevant allergens were found in 44% of the subjects patch tested. The variables found to predict a greater likelihood of a contact allergy were a biopsy diagnosis of vulval dermatitis, the use of multiple topical treatments, sexual inactivity and patients with severe pruritus on a self-reported scale. Most importantly, many clinically relevant allergens these patients reacted to were outside the European standard series. This highlights the need for an extended series in this patient population.

Postmenopausal vulvar pruritus--colposcopic diagnosis and treatment.

Vulvar pruritus is a common symptom in post-menopausal women and treatment is easy if the diagnosis is duly recognized. The purpose of this study is to show the importance of colposcopic examination and directed biopsies in 27 post-menopausal women with pruritus. Biopsy sites were selected by colposcopy. The prevalence of vulvar pruritus, vulvar pathologies, vulvar dystrophies and vulvar intraepithelial lesions (VIN) were 2.18%, 1.49%, 0.94% and 0.07% respectively. Vulvar dystrophies were treated by topical steroids and success rate was 100%. All patients with vulvar pruritus need examination under colposcopy to define optimal therapy and to exclude atypia or malignancy.

Subcutaneous injection of triamcinolone acetonide in the treatment of chronic vulvar pruritus.

OBJECTIVES: We studied the efficacy of subcutaneous corticosteroid injection as therapy for chronic vulvar pruritus. STUDY DESIGN: Adult women with symptoms of vulvar pruritus > 6 months were studied. After appropriate biopsies and cultures were performed, patients were included in the study group if they experienced limited relief with topical triamcinolone cream. Triamcinolone acetonide (15 to 20 mg) was injected subcutaneously and massaged into the affected vulvar tissue. RESULTS: Seventy-eight percent of patients (35/45) experienced relief of vulvar pruritus for > 1 month (mean duration 5.8 months). CONCLUSIONS: We found that subcutaneous injection triamcinolone acetonide provided relief of symptoms of chronic vulvar pruritus.

[The vulvar clinic].

Until recently, vulvar diseases have not been given sufficient attention by gynecologists. This might be attributable to the timidity of patients with chronic vulvar pruritus, tumor or dyspareunia, which delays diagnosis and treatment. In addition, the nomenclature of vulvar disease was complicated by having been adapted from various dermatological disorders. Only following the establishment of the International Society for the Study of Vulvar Disease (ISSVD) and of specialized clinics, has awareness increased and more attention is now being paid to vulvar disorders. The findings in 242 patients seen during the first year of operation of a vulvar clinic were analyzed. The most common presenting symptom was chronic vulvar pruritus. Non-neoplastic epithelial disorder (dystrophy) was the most common histological finding in the 79 women with pruritus, while 2 were diagnosed as having vulvar intraepithelial neoplasia, and 1 had basal cell carcinoma. In contrast, vulvar vestibulitis was the main diagnosis in 34 women referred for vulvar pain (vulvodynia). Vulvodynia was also associated with other inflammatory processes and with human papilloma virus (HPV) lesions (condylomata). The primary finding in 26 women referred for evaluation of a vulvar "tumor" was epidermal cyst. In only 55 (75.5%) of the 73 referred for suspected HPV lesions was the histologic diagnosis confirmatory. In addition, a few vulvar ulcers were associated with HPV. A single treatment with carbon dioxide laser eradicated the HPV lesions in 93% of the cases. The vulvar clinic contributes to the ambulatory gynecological service by concentrating diagnosis and treatment in a single specialized unit and increases understanding of, and interest in vulvar disease.

Distrofia vulvar crônica na infância / Chronic vulvar dystrophy in childhood

Foram analisados 10 casos de distrofia vulvar crônica em pacientes até nove anos de idade. Prurido vulvar foi o sintoma mais freqüente nos casos examinados. Todas as pacientes foram submetidas a biópsia vulvar (punch biopsy¿ sob anestesia local, no ambulatório. O diagnóstico histopatológico revelou sete casos de líquen escleroso, dois casos de distrofia hiperplásica e um caso de distrofia mista. Em nenhum corte histológico foram encontradas atipias celulares

Lichen planus of the vulva.

Lichen planus is an uncommon cutaneous disease that can affect the vulva. Vulvar pruritus and pain are common symptoms in patients with genital involvement. Examination reveals an erythematous, friable vestibule with adherent exudate. Marked resorption of the labia minor and atrophy may occur in time. Diagnosis is based on associated clinical findings involving the oral mucosa and/or the skin and on vulvar biopsy.

Vulval dystrophies: new approaches.

In describing vulval skin changes, all terms such as leucoplakia, kraurosis vulvae and lichen sclerosus et atrophicus should be discarded in favour of 'chronic vulval dystrophy'. Initial biopsy is mandatory to establish the precise diagnosis. From a review of the literature and from our own studies we believe that vulval dystrophy is not usually a premalignant condition, a risk of carcinoma exiting only in dystrophic vulvas with associated atypia. For such patients the treatment is local vulvectomy; otherwise, because of the high rate of recurrence of chronic vulval dystrophy following surgery, the treatment should primarily be medical. Gastrointestinal peptides have been isolated from the vulval skin and a working hypothesis of the aetiology of vulval dystrophy is presented.

Treatment of pruritus vulvae by means of CO2 laser.

Five women with intractable pruritus vulvae, in whom standard therapy had failed to cure the condition, were treated by CO2 laser beam application. Results at one year were good in one patient and excellent in four.

Angiokeratoma of vulva.

A female of 66 who presented with long-standing pruritus vulvae showed angiokeratoma of the vulva as an incidental finding. This benign tumour is uncommon and in a survey of 150 patients over 50 years old (mean age 76.9), no further example was found.

Vulvar pruritus--a symptom, not a disease.

Because the underlying causes are so varied, vulvar pruritus must be understood as a symptom and not as a disease entity in itself. Successful treatment depends on proper identification of the underlying disorder.