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++

Probability diagnosis

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Atopic dermatitis/seborrhoeic dermatitis

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Chronic vulvovaginal candidiasis

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Irritant contact dermatitis (e.g. douches, bubble baths)

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Allergic contact dermatitis (e.g. perfumes, topical antimicrobials)

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Fissuring from the above dermatoses

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Trauma: ‘dry’ coitus

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Serious disorders not to be missed

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Cancer:

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  • squamous cell carcinoma

  • lymphomas, etc. → pruritus

  • melanoma

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Infection:

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  • streptococcal vulvovaginitis

  • herpes simplex virus; herpes zoster

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Other:

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  • vulval vestibular syndrome (provoked vestibulodynia)

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Pitfalls (often missed)

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Lichen sclerosus

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Urinary incontinence → ammoniacal vulvitis

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Faecal soiling

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Tinea cruris

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Trichomonal vaginitis

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Atrophic vaginitis

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Aphthous ulcers

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Dysaesthetic vulvodynia

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Psoriasis

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Lichen planus

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Infestations:

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  • threadworms

  • pubic lice

  • scabies

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Masquerades checklist

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Depression

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Diabetes

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Drugs (e.g. antibiotics)

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Spinal dysfunction (?dysaesthesia)

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UTI

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Is the patient trying to tell me something?

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Common: psychosexual problems.

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Key history

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  • Appropriate history including atopic skin diseases.

  • Gynae-urological history (e.g. oestrogen status, faecal or urinary incontinence, vaginal discharge, ‘thrush’)

  • Check allergens and irritants (e.g. panty liners, soap, bubble bath, perfumes, condoms, douches)

  • Sporting activity (e.g. bike riding and costumes)

  • Check psychosexual history (e.g. dyspareunia, partnership issues, depression)

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Key examination

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  • General health

  • Inspection of vulva and rest of skin, scalp nails

  • Vaginal examination

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Key investigations

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  • Vaginal swab

  • Pap smear

  • Consider need for vulval biopsy and patch testing

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Diagnostic tips

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  • The previously named vulvar vestibular syndrome or vestibulitis is now termed provoked vestibulodynia, whereby a vestibule tender to pinpoint pressure and variable erthythema is found, typically, in young nulliparous women.

  • Always biopsy a focal lesion on the vulva.

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