Lynette J. Margesson

The vulvodynia guideline

Objective. To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia. Materials and Methods. Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition. Results. Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient. Conclusions. Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Contact dermatitis of the vulva

ABSTRACT:  Vulvar diseases rarely stand alone. They are often caused or worsened by primary irritant or allergic contact dermatitis, and this should be considered when evaluating any vulvar complaint. All irritants should be avoided in all women, and those with vulvar dermatoses should be patch tested to help define or rule out allergens.

A randomized, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff

BACKGROUND Ketoconazole is highly effective against the yeast Pityrosporum ovale, an organism believed to be involved in the pathogenesis of dandruff. OBJECTIVE Our purpose was to evaluate the safety and effectiveness of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo and placebo shampoo in patients with moderate to severe dandruff. METHODS Features assessed included adherent and loose dandruff scores, presence or absence of irritation, itching, yeast cells, and global improvement rating by the investigator. RESULTS A total of 246 patients were included. Mean total adherent dandruff score declined throughout the treatment period with both ketoconazole 2% and selenium sulfide 2.5% shampoos significantly better than placebo at all visits. Ketoconazole was statistically superior to selenium sulfide at day 8 only (p = 0.0026). Both medicated shampoos were significantly better than placebo for reducing irritation and itching. Of the nine adverse experiences reported during the treatment phase, all involved patients treated with selenium sulfide 2.5% shampoo. CONCLUSION Both ketoconazole 2% shampoo and selenium sulfide 2.5% shampoo are effective in the treatment of moderate to severe dandruff; however, ketoconazole 2% shampoo appears to be better tolerated.

Approach to the diagnosis and treatment of vulvar pain

Vulvar pain is a common problem, affecting up to 16% of women. The pain and discomfort seriously impacts their quality of life, and is compounded by the increasing frustration encountered in their search for appropriate medical advice. Their pain can be localized or generalized, constant or intermittent, with or without visible changes. For practitioners, the correct diagnosis and treatment of vulvar pain is a challenge. There is an extensive differential diagnosis, from problems that are simple and immediately visible to those that are much more complex and truly invisible. This review provides an approach to the diagnosis of vulvar pain. It outlines the wide range of etiologies for vulvar pain, and provides details of the most vexing in a comprehensive look at vulvodynia, including definition, theory, diagnosis, and therapy.

Practice Gaps “Down There”: Failures in Education, Physical Examination, Recognition, Diagnosis, Therapy, Follow-up Care, and Cancer Surveillance in Lichen Sclerosus

Although lichen sclerosus (LS) in the vagina is rare,1 this vulvar conditionaffects 1% to 3%ofwomen. In this issueof JAMA Dermatology, Zendell and Edwards2 report 2 new cases of LS. Although most patients are perimenopausal or postmenopausal, children are not spared. Because it is usually asymptomatic, patients are seen with advanced disease, having flattened labia minora, narrowed introitus, a scarreddown clitoris, and sexual dysfunction. This can occur as early as age 20 years, and therapy at this advanced stage is problematic. The “lucky” ones develop symptoms early and seekhelp. With topical superpotent corticosteroidointment (not cream), the early disease can be rolled back, and even themost symptomatic can improve. Lichen sclerosus is chronic, recurrent, and prone to fadingoutof theeverydayconsciousnessof thosewhohave it and those who care for it. Detection is important, therapy started early is effective, and follow-upmonitoring is essential. Practice gaps in these 3 areas are evident daily in our clinics. Symptomaticpatients report itching, burning, soreness, or pain. Toooften, the irritation is ascribed to “yeast” and is selftreated with partial success using over-the-counter topical medications. Almost never do women cite asymptomatic whitenessof thevulva, themostcommonphysical finding.Cultural taboos limit examination by the patient and by her caregivers. In a world in which many women never look at their own vulvas, this is understandable. But, symptoms or not, somebody shouldperformanannual vulvar examination.Unfortunately, evenwith regular Papanicolaou smears, patients withobviousLSaremissed.Foryears,mylectureshavepointed out that “the vulva is like a small town—everybody passes through, but nobody stops to look.” The other half of the detection gap is that many examiners do not recognize normal vulvar anatomy. In medical and nursing schools and in residency programs, normal vulvar anatomy and vulvar disease should be taught. It may be possible to patch up thismonstrous training gap by developing a video application to teach women about this problem and to convey the basics of self-examination. The therapy gap is also a major concern, with physicians using outmoded testosterone ointment or ineffective lowdose cortisone creams. Long-term superpotent topical corticosteroid ointments are appropriate. ManypatientshavehadLSundetected for decades. These women are seen with advanced disease, often accompanied by significant comorbidities (overactive bladder, urinary incontinence, thyroid dysfunction, and vulvar pain). The follow-up gap, an easy trap in an asymptomatic disease, ismoreworrisome.The threat here is squamous cell carcinoma. Yearly cervical cancer screening used to be the sole effective stimulus to look “down there.” Cessation of regular Papanicolaou smears at age 65 years means that womenwho reach the Papanicolaou-free years will often miss their annual opportunity to have asymptomatic LS and cancer discovered.3 Althoughnobodydies of LS,wewhoworkdown there are findingmoreof these easily palpable tumors, requiring extensive and often destructive surgery. Patients could readily detect themmuch earlier with a simple soapy finger. Unfortunately, thesemalignantneoplasmsaremissedbecause nobody looks andwomen do not examine the area.We dermatologistsneedto look, learn,andteachself-examination.