VULVAR DERMATOLOGIST BIRMINGHAM AL
Nearly one in five women are affected by dermatological issues of the vulva. These issues may cause pain, itching, or even bleeding. And because of anxiety or embarrassment, many women delay seeking treatment or try to self-treat with over-the-counter or home remedies. However, many times these symptoms can be a sign of an ongoing condition such as psoriasis or even Human Papillomavirus (HPV). Because of the connection between HPV and both vaginal and ovarian cancer, a doctor should be consulted as soon as possible.
Our own Dr. Vlada Groysman, M.D. is proud to be the only vulvar dermatologist within the state of Alabama. As the founder and medical director of Cahaba Dermatology & Skin Health Center, she is a national expert in the diagnosis and treatment of skin conditions affecting the female genital area. Dr. Groysman received specialized training in this field and has a special passion for women’s health. A board-certified dermatologist and a diplomat of the American Board of Dermatology, she completed a three-year residency in dermatology from the University of Alabama at Birmingham. She currently serves as a Clinical Assistant Professor of Dermatology at the University of Alabama at Birmingham.
Since the vulva may be affected by a variety of infections and other vaginal or gynecologic issues, skin cancers of all types may occur here. These may appear different than in other areas of skin. They include such issues as lichen sclerosus, lichen planus, lichen simplex chronicus, psoriasis, and eczema. If you need to schedule a visit for vulvar concerns, please contact our office by phone, as this issue has special scheduling considerations.
Dermatological issues of the vulva can be divided into scarring (like lichen planus and lichen sclerosus) and non-scarring (like lichen simplex chronicus). The following are explanations of each.
Lichen planus is a skin disease that sometimes affects the vulva, vagina, and the 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 it on other outside skin surfaces.
WHAT DOES LICHEN PLANUS LOOK LIKE?
Skin affected by lichen planus can either be white or 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 overactive immune system. Lichen planus is one of several skin diseases that occurs when the immune system becomes overactive and attacks the skin.
HOW IS LICHEN PLANUS TREATED?
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 immunosuppression is dangerous when used for a long time. It 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.
Before the skin heals, minor infections of the areas involved with lichen planus sometimes occur. For this reason, the patient will be given medication to prevent this, or will be 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 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 patient in 10 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?
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. Once the disease improves, the patient should follow-up with their doctor every six months. This is to watch for the return of lichen sclerosus or signs of side effects from the cortisone. Also, a patient with untreated lichen sclerosus may have a slightly increased risk of skin cancer in the vulvar area, as noted in a recent Journal of the American Medical Association (JAMA Dermatol. 2020;156(7):813-814). 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.
While topical steroids help with the pain, itch, and inflammation, and calm the disease down, they do not repair the damaged skin. For many patients, the use of topical estrogen 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 vulva rash, atopic dermatitis, eczema, neurodermatitis, and dermatitis are different names for the same problem. Patients with this type of case report an itchy skin rash. Normal mild irritations of daily living such as soap, water, perspiration, stress, and friction 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—a vicious cycle.
Because people with LSC have skin that is easily irritated, there is no cure for it. However, cortisone creams (and very careful skin care to minimize irritation) usually control the problem.
WHAT IS THE TREATMENT OF LICHEN SIMPLEX CHRONICUS?
- A very important part of the treatment is careful skin care to avoid irritation. Washing is the most common irritation for skin. Washing dissolves the natural oils in the skin and allows for tiny, invisible cracks that itch. Therefore, hot water and harsh soaps should be avoided. Usually clear water suffices without soap. Rough fabric and tight clothes can increase itching. Overheating also makes itching worse and sweat can be very irritating, so a patient 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 healthcare 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.
- Nighttime medications to allow the patient to sleep without scratching are important. As long as the skin is being scratched or rubbed, it will not heal. Nighttime sedation with an antihistamine such as Benadryl (diphenhydramine), Atarax (hydroxyzine), or amitriptyline (Elavil) induces sleep at night without scratching. Once the itching stops, this medication can be discontinued.
- Infection is usually present when there is weeping or crusting of the skin or a vaginal discharge. Because of this, antibiotics or medication to combat yeast infection is important in some patients.
Follow these instructions carefully until the itching has disappeared, and then gradually decrease the frequency of cortisone use and nighttime medication.
Looking for a vulvar dermatological treatment in Alabama? Contact Cahaba Dermatology today to set up an appointment. Give us a call at 205-214-7546 or use the link at the top of this site to book an appointment at either of our offices.
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