The fairer sex: Managing gynecologic dermatoses requires clinical, personal skills

Tampa, Fla. - Along with knowing when and how to biopsy gynecologic dermatoses, dermatologists must address patients' anxieties regarding these problems, an expert says.

"Many dermatologic problems affecting the vulva tend to look alike, so they often require biopsies for accurate diagnosis," says Christopher G. Nelson, M.D., clinical professor of dermatology, University of South Florida, Tampa, Fla. Before performing this procedure, however, it's important to put female patients at ease, he says.

"Women are used to going to the gynecologist" for problems affecting their genitalia, Dr. Nelson says. "Many times, they are pretty anxious about seeing their dermatologist for these problems" - more so than male patients, typicially.

"Many times, female patients are anxious that they have an infection or that they 'caught' something," he says. To help ease patients' anxieties, Dr. Nelson says, "I spend time talking to them ahead of time, particularly if it's somebody I've never met. I show them that I am a professional, caring physician who is really interested in their problem, and I have every intention of figuring out what it is and making it better."

To that end, he also recommends using good lighting and an exam table with stirrups of the type used by gynecologists, and keeping a nurse in the room during the exam.

Among dermatologic diseases that can affect the genitalia, psoriasis and lichen planus occur most commonly, Dr. Nelson tells Dermatology Times.

For treating psoriasis, he recommends the calcineurin inhibitors tacrolimus and pimecrolimus (off-label), and possibly adding an anti-candidial agent and a mid- to high-potency glucocorticoid for maximum relief.

"On the skin, lichen planus produces itchy bumps, usually on the wrists and ankles," Dr. Nelson says. Because lichen planus has a loose association with hepatitis C, he says, "When we diagnose lichen planus, we generally look for hepatitis C. Or if we have a patient whom we know has hepatitis C, we're not surprised if the patient develops lichen planus."

When patients have visible lichen planus, Dr. Nelson says, it's important to ask if they are experiencing similar problems with the mouth, vagina or vulva. He says that when he asks this question, patients frequently reply, "‘Yes, but I didn't think that had anything to do with my lichen planus.’ So, you must ask them about it," as well as about psoriasis in these areas, because women frequently will not volunteer this information.

If not properly treated, lichen planus vulvovaginal syndrome can result in scarring of the vulva and vagina, including adhesions, vestibular bands and atrophy of the labia minora or prepuce, leading to changes that resemble lichen sclerosis et atrophicus, he says.

When in doubt about the diagnosis of genital dermatoses, Dr. Nelson recommends biopsies to determine if a lesion is cancerous or represents a specific disease such as psoriasis or lichen planus. Furthermore, he says that although biopsy can't confirm an allergy, it can reveal some characteristics compatible with this diagnosis, which would lead one to consider allergy testing.

"Psoriasis and lichen simplex chronicus (a manifestation of the itch-scratch cycle) can look alike," Dr. Nelson says. "So, that's where a biopsy will be really helpful."

Lichen simplex also can look clinically similar to cancers such as vulvar intraepithelial neoplasia, he says.

"I also see a lot of contact dermatitis - people diagnose themselves as having a yeast infection and have a reaction to an over-the-counter remedy,” Dr. Nelson says. As these patients continue using the medication, he says, "They keep getting worse and worse, and they can't understand why."

His recommendations for treating contact dermatitis include identifying and eliminating the offending allergen or allergens, prescribing off-label pimecrolimus or tacrolimus (if possible) and, if these agents fail, topical or even systemic steroids.

Dr. Nelson says his practice also commonly sees chronic infections such as yeast infections and herpes simplex of the genitals. He says the latter is "sometimes hard to diagnose, because it doesn't look typical." Frequently, Dr. Nelson adds, women with herpes simplex virus (HSV) believe they have everything from urinary tract infections to irritation from condoms or bicycle seats (Ashley RL, Wald A. Clin Microbiol Rev. 1999 Jan;12(1):1-8. Review). And many primary care physicians believe the virus is virtually nonexistent in their patient populations, he says.

Tools for detecting HSV include Tzanck smears, which Dr. Nelson says are quick, inexpensive and sensitive if positive, although not type-specific. In contrast, he says cultures are type-specific and more sensitive, though more costly and time-consuming. In either case, he recommends taking samples from lesions in early phases of development (vesicular pustule or wet ulcer). That's because eight to 10 days after lesions form, viral shedding begins to decrease, making it more difficult to detect the virus.

Serologic testing may be required when patients have symptomatic disease but negative biopsy results (or when biopsies have not been performed), he says. Other situations in which one might consider serologic testing include the presence of lesions that look herpetic, but might have another etiology, such as an autoimmune blistering disease, Dr. Nelson says.

"If a patient's partner has herpes and the patient doesn't, or doesn't appear to, one must find out whether they have antibodies against the virus," he says.

Serology also becomes important when treating females, he says. "The worst cases involve females who do not have any antibodies against the herpes virus, and their partners are infected."

Most transmission occurs during asymptomatic viral shedding, he notes. "If a pregnant woman contracts the disease and gets a primary outbreak right around the time she's going to deliver, she has an almost one-third chance of having a baby with neonatal herpes."

Serologic tests for HSV include crude antigen testing and newer glycoprotein-specific testing (based on glycoprotein G). "The crude antigen is an old test based on mathematical algorithms, not actual detection of herpes simplex type 2 antibodies," Dr. Nelson says. Therefore, he recommends calling one's laboratory and asking which test it uses.

"Be sure they're using the glycoprotein G test, and most of the large hospital labs are. But there are still a few around that are using the old technology," he says.

Disclosure: Dr. Nelson reports no relevant financial interests.