Jennifer Bradford

Maternal obesity and pregnancy complications: A review

Obesity in women of reproductive age is increasing at an unprecedented rate in western societies. Maternal obesity is associated with an unequivocal increase in maternal and fetal complications of pregnancy. Excessive maternal weight gain in pregnancy also appears to be an independent risk factor, regardless of prepregnancy weight. Few guidelines exist regarding appropriate weight gain in pregnancy in obese women. We review the association of maternal obesity with pregnancy complications. We also suggest that appropriate diet and lifestyle intervention can enable women with severe prepregnancy obesity to safely achieve quite strict targets for limited weight gain in pregnancy.

Long-term Management of Adult Vulvar Lichen Sclerosus: A Prospective Cohort Study of 507 Women

IMPORTANCE Adult vulvar lichen sclerosis (VLS) may be complicated by loss of vulvar structure and vulvar carcinoma. There is a lack of evidence as to the ideal method to maintain long-term remission and prevent complications. OBJECTIVES To determine whether long-term preventive topical corticosteroid (TCS) treatment of VLS, with a target outcome of induction and maintenance of normal skin texture and color, reduces the risk of vulvar carcinoma, relieves symptoms, improves function, and preserves vulvar architecture, and to evaluate the adverse effects of treatment. DESIGN, SETTING, AND PARTICIPANTS A prospective longitudinal cohort study was conducted in 507 women with biopsy-proved VLS from January 2, 2008, through September 26, 2014, in the private practice of a dermatologist and a gynecologist in Sydney, Australia. INTERVENTIONS Preventive treatment using TCSs of various potencies, adjusted to meet a target outcome of normal skin color and texture, with regular long-term follow-up by a dermatologist or gynecologist. MAIN OUTCOMES AND MEASURES Symptoms or signs of VLS, scarring, development of malignant neoplasms, and adverse effects. RESULTS The mean age at presentation was 55.4 years (range, 18-86 years); duration of symptoms at presentation, 5.0 years (range, 0.1-40.0 years); and duration of follow-up, 4.7 years (range, 2.0-6.8 years). Remission was induced with a potent TCS, followed by regular preventive TCS treatment of a potency titrated to achieve the target outcome. Patients were followed up at least annually. A total of 150 patients (29.6%) did not carry out the advised treatment and were considered partially compliant. A total of 357 patients (70.4%) adhered to treatment instructions and were considered compliant. Biopsy-proved squamous cell carcinoma or vulvar intraepithelial neoplasia occurred during follow-up in 0 of the compliant patients vs. 7 (4.7%) of the partially compliant patients (P < .001). Suppression of symptoms occurred in 333 (93.3%) compliant patients vs. 87 (58.0%) partially compliant patients (P < .001). Adhesions and scarring occurred during follow-up in 12 (3.4%) compliant patients and 60 (40.0%) partially compliant patients (P < .001). Reversible TCS-induced cutaneous atrophy occurred in 4 (1.1%) compliant patients and 3 (2.0%) partially compliant patients. CONCLUSIONS AND RELEVANCE This prospective, single-center, longitudinal cohort study of adult patients with VLS suggests that individualized preventive TCS regimens that achieve objective normality of skin color and texture and are used by compliant patients who attend regular long-term follow-up visits may modify the course of the disease. There was a significant difference in symptom control, scarring, and occurrence of vulvar carcinoma between compliant and partially compliant patients. The adverse effects of TCSs were minimal.

Long-term management of vulval lichen sclerosus in adult women

Background:  Adult vulval lichen sclerosus (VLS) is usually a lifelong disease with an estimated remission rate after treatment of only 16% [Arch Dermatol 2004; 140 (6): 709]. Although superpotent topical corticosteroid (TCS) is the validated gold standard treatment to induce remission, little data are available on how remission should be maintained.

Management of vulvovaginal lichen planus: a new approach.

Objective This study aimed to report on a novel approach to therapy in a large private dermatogynecology practice using multimodal therapies with adjunctive use of systemic agents where necessary. Materials and Methods This was a retrospective audit of the presentation and management of 131 patients with a clinical diagnosis of vulvovaginal lichen planus. Results The most frequently presenting symptoms were genital soreness, itch, and burning. Of the 131 patients, 39 (30%) had extragenital disease, mainly oral. Eighty-four (64%) had no external disease. Twenty-two (17%) had introital erosions as the only visible abnormality. Fifty-five (42%) had some degree of labial fusion. Two had full-thickness vulval intraepithelial neoplasia (VIN). Remission induction was achieved in most patients with superpotent topical steroids, but 53 (40%) of 131 patients used oral prednisolone either as an adjunct therapy or alone. All compliant patients achieved symptomatic and objective disease control in a mean of 7.5 weeks. Of the 131 patients, 48 (37%) required multimodal therapy to maintain their initial improvement. Forty-five (34.3%) patients used topical tacrolimus, usually with topical corticosteroids, for maintenance. Eleven (8.5%) required low-dose weekly methotrexate. Fourteen patients experienced adverse reactions severe enough to lead to the cessation of that treatment. The mean length of follow-up was 6.4 years (range = 1 mo to 15 y). The 2 patients with VIN at presentation have had no recurrence. No other patient has yet developed VIN or carcinoma. Conclusions Long-term symptomatic and objective control of vulvovaginal lichen planus is possible but requires multimodal therapies, flexible treatment programs, and the judicious use of oral agents.

Vulvovaginal candidiasis in postmenopausal women: the role of hormone replacement therapy.

Objective: This study aimed to explore the role of hormone replacement therapy (HRT) in susceptibility to vulvovaginal candidiasis (VVC) in a private vulval disease referral practice. Methods: Between January 2009 and December 2010, 149 healthy, nondiabetic patients with vulvar conditions were compared for significant differences in vaginal swab result, age, and diagnosis between those using and not using HRT. Detailed clinical data were collected from those with VVC. Results: The mean ages of the HRT (n = 70) and non-HRT (n = 79) groups were 62.5 and 62.5 years, respectively. Positive cultures for Candida were found in 34 (48.5%) of 70 patients on HRT and in 2 (3%) of 79 subjects not on HRT (p < .001). Culture-positive, clinical VVC was identified in 34 (49%) of 70 patients on HRT and in 1 (1%) of 79 patients not on HRT (p < .001). Candida species (32 Candida albicans and 2 Candida glabrata) were isolated from the 34 VVC patients, and of these, 23 (67%) had a history of recurrent or chronic candidiasis before menopause. All 34 had been previously treated with antifungal therapy without ceasing HRT and had been unresponsive to treatment or had relapse after treatment. In 27 (79%) of 34 patients, HRT was suspended during treatment. Of those who remained on HRT during treatment or resumed it after treatment, prophylactic antifungal treatment was initiated in 15 (44%) to prevent recurrence. All patients responded to the antifungal treatment provided HRT was suspended or prophylactic treatment was used. Conclusions: Postmenopausal women taking HRT are significantly more prone to develop VVC than women who are not and those with VVC are likely to have been susceptible to it before menopause.

Vulvovaginal candidiasis as a chronic disease: diagnostic criteria and definition.

Objective Although recurrent vulvovaginal candidiasis is defined as 4 or more discrete attacks of vulvovaginal candidiasis per year, there is no diagnostic nomenclature or definition for the many women who are chronically symptomatic. This study aims to establish and propose a definition and a set of diagnostic criteria, which would enable clinicians to promptly identify and treat women with chronic vulvovaginal candidiasis (CVVC). Design Prospective cohort study. Setting Public and private vulvar dermatology outpatient clinics in Sydney, Australia. Participants Data were obtained prospectively from 50 women with presumptive CVVC and 42 controls. Historical and clinical features of CVVC identified by expert consensus were compared between the 2 groups. Diagnostic criteria were then prospectively applied to a further 163 patients to verify their accuracy. Outcome Measures Signs and symptoms diagnostic of CVVC. Results The following characteristics were found to be significantly more common in women with CVVC compared to controls (p ⩽ .001): a history of positive vaginal Candida swab, discharge, dyspareunia, soreness, swelling, cyclicity, and exacerbation of symptoms with antibiotics. Conclusions We propose that CVVC can be confidently diagnosed using the major criteria of a chronic nonspecific and nonerosive vulvovaginitis that includes at least 5 or more properties from the following criteria: soreness, dyspareunia, positive vaginal swab either at presentation or in the past, previous response to antifungal medication, exacerbation with antibiotics, cyclicity, swelling, and discharge. This condition responds reliably to oral antifungal medication.

Surgical division of labial adhesions in vulvar lichen sclerosus and lichen planus.

Objective Vulvar lichen sclerosus (LS) and lichen planus (LP) may cause persistent symptomatic labial adhesions. In the scant literature on this topic, there is no agreement about which operation is suitable, or the role of suppressive medical therapy. We report on simple perineotomy in the context of careful preoperative and postoperative medical suppressions. Materials and Methods Thirty-five patients were identified within a referral vulvar practice, with symptomatic labial adhesions due to LS or LP. After sharp dissection of adhesions and injection of anesthesia, patients doubled the frequency of their preoperative therapy and underwent close surveillance until complete healing had occurred. Suppression of the inflammatory process was continued indefinitely with regular review. Results Mean age was 57 years. Of the patients, 27 had LS and 8 had LP. Of the 35 patients, 28 (80%) had dyspareunia or apareunia. Mean symptom duration was 9 years. Of the 35 patients, 21 had posterior fusion, 11 had anterior fusion, and 3 had both anterior and posterior fusions. Of the 35 patients, 17 had mild fusion, 11 had moderate fusion, and 7 had severe introital stenosis. At the 3-month review, 31 of the 35 patients had no refusion. Mean duration of follow-up was 2 years (range = 3 months to 7.5 years). Of the 35 patients, 29 had no late refusion during this time. Of the 18 patients with dyspareunia, 8 had no pain, and 9 had less pain. Of the 10 patients with apareunia, 1 could have sex without pain, and 6 could have sex but with pain. Conclusion Simple perineotomy is adequate to treat persistent labial adhesions, provided that the inflammatory process is carefully suppressed.

Vulvar Psoriasis in Adults and Children: A Clinical Audit of 194 Cases and Review of the Literature

Objective There are limited data on psoriasis as it affects the vulva in the medical literature. This observational study aimed to describe the symptoms, signs, and management of vulvar psoriasis in adults and children in a private vulvar disease referral practice. Materials and Methods A review of the existing literature on vulvar psoriasis was used to generate inclusion criteria of a chronic noninfective erythematous vulvitis without vaginal involvement. Between January 2009 and October 2011, 201 patients presenting with these criteria were coded as having psoriasis in a computerized database where standardized data were collected. In 194 of these patients, adequate data were available to include in the study. Results Only 12.3% of the patients presented with psoriasis as a provisional diagnosis with a mean symptom duration of 4.5 years (range = 6 weeks to 35 years). The most common presentation was a pruritic, bilaterally symmetrical, erythematous, nonscaly, well-demarcated macular eruption or slightly raised plaque (82.5%). Of the remaining patients, 9.2% presented with only diffuse symptomatic erythema, whereas 8.2% were symptomatic without erythema. In 64.9% of the patients, evidence of psoriasis was found on other parts of the skin. Initial induction treatment with potent topical corticosteroid followed by a maintenance treatment with less potent topical steroids and other psoriasis-specific treatment such as tar creams and calcipotriol resulted in a suppression of disease in 93.8% of the patients during a mean follow-up duration of 8.9 months (range = 1 month to 7.25 years). Conclusions Vulvar psoriasis is a difficult diagnosis that should be considered in patients presenting with a chronic erythematous vulvitis without vaginitis. It is a chronic relapsing skin condition that requires long-term management.

Management of nonsexually acquired genital ulceration using oral and topical corticosteroids followed by doxycycline prophylaxis

BACKGROUND Data regarding the treatment of nonsexually acquired genital ulceration (NSAGU) are limited. OBJECTIVE We sought to provide evidence for the safety and efficacy of topical and systemic corticosteroids followed by doxycycline prophylaxis for acute and recurrent NSAGU. METHODS A retrospective chart review was conducted of patients with NSAGU treated in a private dermogynecology practice. RESULTS A total of 26 girls and women with NSAGU were identified and divided into 2 groups: group A = 17 patients with moderate to severe ulceration treated in the acute stage with oral corticosteroid; and group B = 9 patients with mild ulceration treated in the acute stage with topical corticosteroid. Patients in group A, with a mean age of 27.9 years (range, 11-62 years), were treated with oral prednisolone commencing with 15 to 50 mg per day depending on severity. Sixteen (94%) achieved rapid pain relief and complete healing of ulcers within 16 days. Eight (47%) commenced doxycycline prophylaxis. Women in group B, with a mean age of 42.5 years (range, 26-67 years) were treated with topical corticosteroids. Eight (89%) had a history of recurrent ulcers and 6 (66%) commenced doxycycline prophylaxis. Of all 14 patients on doxycycline prophylaxis, none reported any recurrences during a mean follow-up of 18.3 months. There were no adverse effects caused by prednisolone. One patient experienced mild photosensitivity from doxycycline but continued to take it. LIMITATIONS This was a retrospective case series from a single private practice-based population. CONCLUSION Topical or oral corticosteroids followed by prophylactic doxycycline can be effective in rapidly resolving acute flareups and preventing recurrences of NSAGU. All patients responded to therapy without treatment-limiting side effects.

The aetiology of chronic vulval pain and entry dyspareunia: a retrospective review of 525 cases

There are few published data about the incidence of diagnoses or treatment outcomes, for chronic vulval pain.