The various types of vulvar dermatitis that arise can be confusing to the untrained eye. It is not uncommon for dermatologists to find themselves faced with vulvar dermatitis of some kind, but they are often unskilled at not only treating this very specialised area of the body but in the identification of the particular conditions.
Painful sex (dyspareunia) is the most common outcome of any type of vulvar complaint ranging from a simple case of contact dermatitis to more advanced disease with an immunological component such as lichen sclerosus. Vulvar dermatoses is a differential diagnosis of sexual pain.
Understanding the uniqueness of the vulva is the first step in understanding the conditions affecting it.
Symptoms of vulvar dermatitis
- Pain
- Fissuring
- Bleeding
- Itching
- Painful sex (dyspareunia)
- Lesions
- Scarring
- Fusion
- Blistering
The vulva – why it’s flesh is unique
- Epithelium: The skin on the vulva is different in many ways to skin on any other part of the human body – the epithelium (tissue) is from all three embryological layers.
- Immune: Specific proteins and antigens required for reproduction mean immunologically, this area of the body is responsive in some unique ways.
- Labia majora: subcutaneous tissue on the labia major is loose, allowing for oedema (swelling).
How dermatitis affects the vulva
Some variations are asymptomatic, whereas others are completely disabling. Vulvar dermatoses can be incredibly hard to treat, causing significant disruptions to the lives of the women suffering them.
Differential diagnosis (what else could it be?)
These conditions can look similar or the same as certain types of precancerous states, extramammary Paget’s disease, cancers, ulcerations from sexually transmitted infections, plasma cell vulvitis (rare), genital psoriasis, a yeast infection, or vulvar Crohn’s.
Emotional component of vulvar conditions
Treating these conditions requires extra emotional support, since losing one’s ability to receive or participate in any kind of sexual experience (which in many cases is true for any type of vulvar complaint) is a huge blow. Do not underestimate the impact.
The avoidance of sexual relationships completely and a lack of discussion about the vulva problems compound the emotional toll. Grieving is important and encouraged.
Vulva hygiene and care
- Cotton underwear, no g-strings (thongs)
- Hypoallergenic laundry detergent and soaps
- Avoid allergens and irritants (perfume, soap, any feminine hygiene products or douches)
- Unscented pads and tampons
- Rinse with warm water after urination
- Wash and dry very gently
- Use lukewarm water and just the fingers to wash vulva, outside skin only
- Wear loose-fitting clothing, avoid tight garments
- Do not use wipes, washes, or other cleaning products
- Vaginal dilators may work to keep the vagina open
- Dermatographia (an allergy to touch) may also be suggested as a possible cause of vulvar dermatitis.
Evaluations of vulvar dermatitis
A comprehensive history needs to be taken. The naturopathic evaluation focuses on different elements than standard western medical practice, however, to diagnose the condition, the standard western medical diagnosis must take place.
This evaluation will include history, symptoms past and present, anything that makes it better or worse, sexual practices, sexual history, medications, and lifestyle factors such as exercise.
Physical examination of the vulva will be thorough and systematic. Photographs should be taken. Malignancies must be ruled out. A physician may see areas of pigmentation, scarring, ulceration, narrowing of the vaginal entrance, or an intractable clitoral hood (phimosis of the m clitoris).
Vaginal pH and swabs will add information regarding microflora, with yeast infections and bacterial vaginosis often being present with vulvar dermatoses.
A biopsy may be very useful to determine the exact condition. The mouth, eyes and skin should also be examined – mucous membranes tend to exhibit similarities in disease. LP and LS can co-exist in the same patient.
Dermatitis (irritant or allergic) and lichen simplex chronicus
Lichen simplex chronicus in the vulva is the result of the itch-scratch-itch cycle, with underlying conditions possibly being seborrheic dermatitis, intertrigo, tinea or psoriasis, however often the cause is unknown. Any itching of the vulva can result in lichen simplex chronicus.
Without an immune response, this condition is known as vulvar contact dermatitis and can result in burning, itching, and irritation. Any substance that interferes with the protective coating on the skin, the top layer of skin, or damages cell membranes can cause this type of irritation, therefore all treatments should aim to restore this layer.
Typical irritants are perfumes, soaps, detergents, fabric softeners, tampons, pads, adult diapers, wipes, sprays, deodorants, bubble baths, bath oils, coloured/scented toilet paper, and abrasive fabrics – cloths, sponges, etc, and urine and semen.
Over-cleaning, trapped sweat/moisture, and sports or activities that cause friction on the vulva (horse-riding, bicycles) can be triggers.
Vulvar allergic contact dermatitis is a hypersensitivity reaction causing inflammation after direct contact with an allergen, within 12-24 hours. Allergens can include nickel (zips, snaps), preservatives, perfumes and latex. Medication is also a common trigger.
It is important to note that lichen simplex chronicus may also be known as:
- Neurodermatitis
- Pruritus vulvae
- Vulvar dystrophy
- Vulvar atypia
- Atrophic dystrophy
- Mixed dystrophy
- Vulvar intraepithelial neoplasia
- Squamous hyperplasia
- Hyperplastic dystrophy
As you can see with the plethora of names for this condition, diagnosis and cross-referencing with other practitioners can get complicated. Be clear when receiving your diagnosis.
These names all mean different things to pathologists, dermatologists and gynaecologists. This condition occurs from scratching or rubbing, and with the application or contact with irritants.
Lichen sclerosus (LS)
Lichen sclerosus has no known cause, tends to affect postmenopausal women (indicating unconfirmed hormonal link), with oral contraceptives possibly causing early onset in susceptible younger women, due to antiandrogenic properties.
Research into infections and viruses has proved inconclusive. LS is linked with autoimmunity and genetics, but weakly so – around 21 per cent of LS sufferers have an autoimmune disease, most often a thyroid disease.
Over 40 per cent of sufferers have one or more autoantibodies and 22 per cent have a family history of the disease. Damage to skin (infection, friction, irritation, trauma) can trigger LS, with recurrence near vulvectomy scars common.
Erosive lichen planus (LP)
- Vulvovaginal gingival syndrome (severe lichen planus)
- Papulosquamous lichen planus (LP)
- Hypertrophic lichen planus
Lichenoid conditions are lifelong but can be treated if caught early. If you suspect you have a lichenoid condition, please see your doctor immediately for a proper diagnosis, then go about finding the best ways to support your immune system and health.
References1
- 1.Burrows LJ, Shaw HA, Goldstein AT. The Vulvar Dermatoses. The Journal of Sexual Medicine. Published online February 2008:276-283. doi:10.1111/j.1743-6109.2007.00703.x
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