The vulva is a specialized area of skin that can encounter a wide variety of concerns, often superimposed in one individual, creating a complex clinical picture. Dr. Vlada Groysman is a national expert in the diagnosis and treatment of skin conditions affecting the female genital area. Dr. Groysman received specialized training in vulvar dermatology. This area may be affected by conditions seen elsewhere on the skin but presenting differently here, such as lichen sclerosus, lichen planus, lichen simplex chronicus, psoriasis and eczema. Additionally, the vulva may be affected by a variety of infections and other vaginal or gynecologic issues. Skin cancers of all types may occur here, and may appear different than in other areas of skin. Dr. Groysman also treats vulvodynia, which is nerve pain affecting the vulva. To schedule a visit for vulvar concerns, please contact our office by phone, as this has special scheduling considerations.
Lichen planus is a skin disease that sometimes affects the vulva, vagina, and inside of the mouth. Although lichen planus more often affects skin on the outside of the body, most patients who have lichen planus of the genital area do not have involvement of other outside skin surfaces.
What does Lichen Planus look like?
Skin affected by lichen planus can either be white, or can have superficial ulcerations. The genital areas that are white are usually itchy, whereas those areas with superficial ulcerations usually are sore and painful.
What is the cause of Lichen Planus?
The cause of lichen planus is believed to be an over-active immune system. The immune system is that part of the body that protects us from infections. Lichen planus is one of several skin diseases that occurs when the immune system becomes over-active and attacks skin.
What is the treatment of lichen planus?
The treatment for lichen planus is aimed at fooling the immune system so that it doesn’t attack the skin. Although some medications, especially oral cortisone, or prednisone, depress the immune system a great deal and induce healing for the skin, this degree of immune suppression is dangerous when used for a long time, and leaves a patient susceptible to uncontrolled infections. Therefore, prednisone is used only briefly to help heal skin, and only if absolutely necessary. Then, we try to control lichen planus with topical cortisone creams or ointments, or other medications that do not suppress the immune system to a dangerous degree.
Before the skin heals, minor infections of the areas involved with lichen planus sometimes occur. For this reason, some patients are given medication to prevent this, or are advised to call for worsening symptoms.
For patients who do not respond well to topical cortisones applied to the area, there are other treatments that can be used. This includes topical or oral cyclosporine, and other medications that partially suppress the immune system.
Untreated or severe lichen planus sometimes produces scarring. When the vagina is involved, the vaginal walls can scar together so that intercourse is no longer possible. Because of this, either regular intercourse or the insertion of a vaginal dilator on a daily basis should be performed so that scar tissue does not close the vagina.
Often, multiple visits and several different medications are required to control lichen planus. Although the treatment of white skin caused by lichen planus is usually easy, lichen planus that has produced sores and ulcerations is sometimes difficult to treat and requires multiple visits and trial-and-error therapy. However, most patients improve significantly.
Lichen sclerosus is a skin disease that occurs most often on the vulva. The cause is unknown. However, many physicians believe that it occurs when the immune system, that part of your body that fights off infection, becomes overactive and attacks the skin.
What are the symptoms of Lichen Sclerosus?
Lichen sclerosus usually causes itching, and in later stages, easy bruising, tearing, and pain. Skin affected by lichen sclerosus is usually white, and sometimes there is a fine, crinkled texture. If untreated, lichen sclerosus often causes scarring, and the opening of the vagina can narrow. Usually, lichen sclerosus does not affect other skin, but about one woman in ten has a few scattered white spots in other areas. Those spots almost never itch or cause symptoms in any way.
How do you treat Lichen Sclerosus?
- Topical Steroids
A very high potency cortisone ointment usually returns the skin to its original color and texture, although it does not reverse scarring. Most women need three to five months of daily ultra-potent cortisone treatment. Women are generally examined every month while using this medicine daily, because sometimes the skin can thin from too much cortisone. After the skin has returned to a normal texture, the cortisone is used about three times a week to prevent return of lichen sclerosus. Also, women should follow-up with their doctor, once the disease improves every 6 months. This is to watch for return of lichen sclerosus or signs of side effects from the cortisone. Also, patients with untreated lichen sclerosus have a slightly increased risk of skin cancer in the vulvar area. With regular checkups and use of the topical steroid, this should not become a problem.
Protopic or Elidel are immunomodulators and have the biggest advantage of not thinning the tissue. They work on halting inflammation in the skin. Protopic or Elidel are not specifically approved for lichen sclerosus or vaginal pain, and are approved for psoriasis/eczema, but we use it for vulvar problems. It is used for maintenance therapy and not as a first-line treatment.
- Topical Hormones
While, topical steroids help with the pain, itch and inflammation, and calm the disease down – they do not repair the damaged skin. Proper use of topical estrogen, in many patients can help to restore color, texture, elasticity and even repair structural damage, as well as help unfuse fused tissue.
Lichen Simplex Chronicus
Lichen simplex chronicus (LSC), itchy vulvar rash, atopic dermatitis, eczema, neurodermatitis, and dermatitis are different names for the same problem. LSC is an itchy skin rash that occurs in people like you who have sensitive skin. Normal mild irritations of daily living such as soap, water, perspiration, stress, and rubbing from clothes cause irritation. Although some people feel irritation as soreness, people with LSC feel irritation as an itch. Then, scratching causes more irritation and makes the skin itch even more, until the rubbing and scratching actually turns into LSC.
Because people with LSC have skin that is easily irritated, there is no cure for LSC. However, cortisone creams and very careful skin care to minimize irritation usually control the problem.
What is the treatment for Lichen Simplex Chronicus?
- A very important part of the treatment is careful skin care to avoid irritation. Washing the skin is the most common irritation for skin. Washing dissolves the natural oils in the skin and allows tiny, invisible cracks that itch. Therefore, hot water and harsh soaps should be avoided. Usually clear water suffices, with no soap. Rough fabric and tight clothes can increase itching. Overheating also makes itching worse, and sweat can be very irritating, so patients with LSC should stay as cool as is comfortable. Panty liners are irritating for many women as well. Douches, perfumes, deodorants, and medications other than those prescribed by a health care provider should be avoided because of the possibility of allergy or irritation.
- Cortisone (steroid) ointment or cream is extremely important in the treatment of LSC. This medication helps to soothe irritation and inflammation as well as to help the itch. Cortisones are applied very sparingly (more does not work better than less) and they are applied only to the areas of scaling, redness, or itching. The cortisone should be used until the skin feels normal to the touch and then often it can be discontinued. Although cortisones are useful in the treatment of LSC, simply applying the cortisone without attention to avoiding excess washing and irritation often does not clear LSC.
- Medication at night to sleep without scratching is important. As long as the skin is being scratched or rubbed, it will not heal. Night-time sedation with an antihistamine such as Benadryl (diphenhydramine), Atarax (hydroxyzine), or amitriptyline (Elavil) induces sleep at night without scratching. As the itching stops, this medication can be discontinued.
- Sometimes, when there is weeping or crusting of the skin or a vaginal discharge, infection is present, so that antibiotics or medication for yeast is important in some patients.
The treatment of eczema is a lot of work. It is important to follow these instructions carefully until the itching has disappeared, and then gradually decrease the frequency of cortisone use and nighttime medication. Flares of skin disease from stress and new irritations occur in many people.