Last month three of our PTs, Allison, Malinda, and Stacey attended the Vulvovaginal Disease Update 2014. Vulvar dermatoses affects millions in the United States often greatly interfering with a woman’s quality of life. And as pelvic floor PTs, it’s certainly an issue that can overlap with the musculoskeletal impairments that we treat. Therefore, this annual conference, which is hosted by the North American chapter of the International Society for the Study of Vulvovaginal Disease, is one we tune in to.
Below are some must-read nuggets from the PHRC delegation in attendance:
“Vagisil makes you Ill” and other Lessons in Vulvar Skin Irritants
Stacey listened to Dr Aruna Venkatesan, MD, who spoke on chronic vulvar itching.
Dr. Venkatesan pointed out that when there is any kind of skin irritation involving the vulvar tissue it can be due to urine, fecal matter, menstrual blood, or washing too much. In addition, an allergy can cause irritation.
One of the irritants that she pointed to was the common “feminine hygiene” product Vagisil. In fact, “Vagisil makes you ill” is a common refrain among physicians who treat vulvar dermatoses. Dr. Venkatesan explained that although in the beginning of use the product can help anesthetize the tissue, in the long run it can cause irritation.
Also interesting was the fact that “Baby Wipes,” another commonly used hygiene product can cause skin irritation. Many who suffer with urine or fecal incontinence use Baby Wipes. The major irritant in Baby Wipes is methychloroisothiazolinone. (For more info on this topic, check out this article.)
Other irritants she listed include “carbonmate,” which is a substance that can leach out of the elastic band in underwear when bleached, fragrances found in soaps, detergents, or feminine hygiene products or spermicides.
Vulvodynia: Causes, Diagnoses, and Therapies
Allison heard Drs. Catherine Leclair, MD and Hope Haefner, MD speak about vulvodynia.
One important takeaway from the lectures was that providers are finding that symptoms of vulvodynia come from both the brain and the periphery (the area where the pain is present).
For her part, Dr. Haefner discussed research that showed that those with vulvodynia tended to be more sensitive all over their bodies compared to control subjects.
In addition, Dr. Haefner stressed that vulvodynia is a complex diagnosis and that recognition of multiple factors is important to appropriate patient evaluation and management.
For her part, Dr. Leclair spoke at length on therapies used to treat vulvodynia.
She began with vulvar care measures. For one thing, she said that cotton underwear is recommended and that no underwear should be worn at night. In addition, vulvar irritants and douching should be avoided, she said, adding that the patient should use mild soaps for bathing and not apply soaps to the vulva. Also, if menstrual pads are irritating, 100% cotton pads may be helpful.
Plus, adequate lubrication for intercourse is a must. Lubricants she recommended include: olive oil, Replens, Astroglide, KY Liquid, Probe, Pjur Women, Slippery Stuff, uncooked egg whites, vegetable oil, Vitamin E oil, Surgilube, Sylk (Kiwi fruit vine), Moist Again Natural Feeling, and Lubrin, Femigel Natural, a product from tea trees.
Treatments she discussed include topicals, such as lidocaine and topical amitriptyline, medications, such as tricyclic antidepressants, like amitriptyline (Elavil®) and nortriptyline (Pamelor®); other antidepressants, such as Cymbalta, and anticonvulsants, such as Gabapentin (Neurontin®).
One thing she emphasized is that physicians should encourage patients to get to the goal dosage of these medications as there is research to back up their effectiveness in treating this patient population.
In addition, she recommended pelvic floor PT when there is a musculoskeletal component to the patient’s symptoms. Lastly, she spoke of the success of trigger point steroid and bupivacaine injections for some patients with localized vulvodynia.
Facts about Lichen Sclerosus, Lichen Plantus
Malinda heard Dr. Joanna Badger, MD, speak on lichen sclerosus and Dr. Aruna Venkatesan, MD, speak about lichen planus.
One important takeway from the lichen sclerosus discussion was the importance of screening for the condition. Lichen sclerosus is a chronic, destructive, inflammatory skin condition with a preference for the skin of the genitalia. However, it does not affect the mucosal layers so it does not spread to the vaginal canal.
Clinical features of the condition include a hyperpigmentation of the skin with raised white patches appearing, tissue that may appear like wrinkled paper, and a red or purple discoloration of the skin. In addition, there is a chance of a reabsorption of the labia minora into the labia majora and a fusing of the clitoral hood. Symptoms can also appear on other parts of the body, such as the back, shoulders, neck and abdomen.
Although the cause of the condition is unknown, the hypothesis is that it is an autoimmune disease. The largest group affected are postmenopausal women. Common symptoms include itching, burning, and pain with sex. Dr. Badger stressed that with lichen sclerosus scratching can make symptoms worse.
Frustratingly, the condition is often misdiagnosed as being vaginal atrophy. Although the condition is not curable it is treatable with topical steroids. However, any anatomical changes that occur are not reversible.
Dr. Badger cautions that although some patients and physicians are hesitant about steroids, “lichen sclerosus can be potentially more harmful to the skin than topical steroids.”
For her part, Dr. Venkatesan spoke about lichen planus.
Lichen planus is an inflammatory skin condition, characterized by an itchy, non-infectious rash of small, many sided flat-topped pink or purple lesions that can affect the vulva and vagina (unlike lichen sclerosus, lichen planus can affect mucous membranes). Other parts of the body may also be affected, including the mouth, nails, scalp, arms and legs.
The cause of the condition is unknown. However, it can be triggered by taking certain medications, including thiazide diuretics, antimalarials and phenothiazines (a group of tranquilizing drugs with antipsychotic actions). Like lichen sclerosus, some specialists believe it is autoimmune in nature. A higher-than-normal percentage of people with hepatitis C and other liver diseases have lichen planus.
Like lichen sclerosus, lichen planus is most often controlled with topical steroids. Lichen planus symptoms on the skin can take up to two years to go away. However, once gone they hardly ever return. Oral lichen planus can take much longer to go away.
If you have any questions about any of the topics discussed in this post, please don’t hesitate to leave them in the comment section!
All our best,
Stacey, Allison and Malinda