Vulvar disease, related disorders needn't intimidate dermatologists

Key Points

National report - Although treating patients with vulvar disorders can be challenging, confidence and compassion go a long way toward helping these patients.

Sometimes, dermatologists allow themselves to be intimidated by the idea that vulvar and mucosal problems differ vastly from the usual issues they treat, says Ginat Mirowski, D.M.D., M.D., associate professor of oral pathology, medicine and radiology, Indiana University School of Dentistry, Indianapolis. However, she says, "If we take a deep breath and consider how we would approach this problem if it were on the skin, the exact same tools and approach usually will provide the answer."

Bethanee J. Schlosser, M.D., Ph.D. agrees. "Dermatologists possess the skills and knowledge needed to fully evaluate, diagnose and treat patients with vulvar symptoms and disorders. Dermatologists should have confidence in their skill set when approaching these patients, but it is important to recognize that vulvar symptoms and examination findings may be multifactorial. Therefore, a systematic approach to the vulvar examination and diagnostic evaluation of these patients is important.

Managing misconceptions

According to Dr. Mirowski, "Patients come with a lot of misconceptions, hangups and baggage regarding the vulvar area," along with copious slang terms that dermatologists should be comfortable navigating in a discussion.

"We must try to separate out the fears and misconceptions," because any discussion of intimate body areas can be fraught with emotion, she says. "I often talk to the patient alone, without her husband, so that I can approach issues objectively. You have to know the slang; you have to be comfortable asking the questions" to uncover the truth behind a patient's complaint.

"Sometimes, it's actually better to talk to the person who doesn't have the problem alone. The spouse may tell you things the patient won't," she says.

Similarly, she says that when dealing with vulvar contact dermatitis, "Ask, ask, ask. If you're not getting the answer you need, be willing to explore more." When a dermatologist asks patients what products they use in the vulvar area, she explains, "They'll tell you, 'Nothing.' Really? Do you use any moisturizer, medication, soap, lubricant, condoms or spermicidal jelly?" All of these items contain common allergens that patients may not be aware they're being exposed to, she says.

"People can be allergic to toilet paper," including the fragrances it contains or the formaldehyde used to make it, Dr. Mirowski says. Other women can be allergic to personal hygiene products - their own or their partner's. For example, "Let's say a man uses an aftershave that the woman is allergic to. If you don't know that she's been coming in contact with the aftershave because of their sexual habits, it's not something she may be willing to share with you - or something that she may even have conceived of." Without direct but tactful questioning by her physician, Dr. Mirowski says, such allergies could be missed.