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Clinical manifestations of vulvar disorders include itching, pain or discomfort, irritation, white mucosal patches, lichenification, erosions and intertrigo. The dermatoses, notably dermatitis, psoriasis, lichen planus and lichen sclerosus, are the main cause of vulvar problems. Pruritus vulvae is presented on 412.
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This chronic inflammatory dermatosis of unknown aetiology presents as well-defined, white, finely wrinkled plaques that almost exclusively affect the anogenital skin but spare the vagina. The differential diagnosis is atrophic vaginitis.
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Genital pruritus (main symptom) + soreness + white wrinkled plaques
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Bimodal peak: prepubertal girls, perimenopause
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Purpuric and ulcerated areas
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Lifetime risk SCC 2–6%
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Confirm diagnosis by biopsy. Best to consult with dermatologist.
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Use potent topical steroids for 6 mths, then hydrocortisone 1% long term.
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Chronic vulvovaginal candidiasis
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This is different from acute candidiasis and may represent a localised hypersensitivity to C. albicans. Aim for symptom remission with continuous antifungal treatment up to 6 mths. Relieve itching with hydrocortisone 1%.
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Streptococcal vulvovaginitis
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Usually presents as an acute, beefy red, sore vulva or vagina or a low-grade vulvitis. Take swabs from the vulva or vagina for diagnosis. Treat with oral phenoxymethylpenicillin for 10 d or other antibiotic according to sensitivity. Topical mupirocin may help prevent recurrences.
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This describes the symptom of pain (burning, rawness or stinging) and discomfort where no obvious cause can be found. Conditions include vestibular hypersensitivity (vulvar vestibular syndrome) and dysaesthetic vulvodynia (neuropathic pain in middle-aged to elderly women).
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Provoked vestibulodynia (vulvar vestibular syndrome)
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Severe pain with vestibular touch, inc. vaginal entry, e.g. intercourse, tampons
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Young female usually in 20s and 30s
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Nulliparous: family history
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Superficial entry dyspareunia
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Sexual dysfunction
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Inappropriate tenderness to light touch with a cotton bud.
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Patient education, counselling and support with bland emollients or 2% lignocaine gel prior to intercourse. May require intralesional therapy or anti-neuropathic pain agents or vestibulectomy (as last resort).
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Dysaesthetic vulvodynia
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The typical patient with this neuropathic pain problem is a middle-aged to elderly woman who presents with a constant burning pain of the labia. Examination is usually normal. Causes include pudendal neuralgia, post-herpes simplex infection, referred spinal pain or idiopathic. Treatment options include antidepressants and gabapentin.