Orna Reichman

Boric acid addition to suppressive antimicrobial therapy for recurrent bacterial vaginosis

Background: Recurrent bacterial vaginosis (RBV) is extremely common and a source of frustration to patient and practitioners alike. In the absence of curative therapy, practitioners resort to retreating each individual episode. It has been suggested that vaginal biofilm in BV facilitates persistence of bacterial pathogens. Accordingly, topical boric acid (BA) aimed at biofilm removal was added to nitroimidazole induction and maintenance therapy creating a triple phase regimen to reduce symptomatic recurrence of BV in high-risk patients. Method: Uncontrolled, nonrandomized, retrospective chart review of patients with RBV treated with 7 days of oral nitroimidazole; followed by 21 days of intravaginal BA 600 mg/day and if in remission treated with metronidazole gel twice weekly for 16 weeks. Outcome was determined using Amsel criteria. Results: Fifty-eight women were treated for a total of 77 episodes of RBV. Sixty episodes of BV were available for a follow-up evaluation 4 to 12 weeks after enrollment, having completed both nitroimidazole and BA therapy and before initiating vaginal metronidazole gel. Cure after nitroimidazole and BA therapy ranged from 88% to 92%, 7 and 12 weeks after the initial visit, respectively. Cumulative cure at 12, 16, and 28 weeks from initial visit was 87%, 78%, and 65%, respectively. A failure rate of 50% was documented by 36 weeks of follow-up. No adverse effects of BA were observed. Conclusion: Clinical experience with a triple phase maintenance regimen for women with RBV was encouraging but requires validation in a prospective randomized controlled study.

Prognosis and treatment of desquamative inflammatory vaginitis.

OBJECTIVE: Desquamative inflammatory vaginitis is a clinical syndrome frequently unrecognized, characterized by vaginal rash and purulent discharge. We describe patient outcomes and treatment at follow-up in a case series of 98 women diagnosed with this syndrome. METHODS: We performed a chart review of 130 patients diagnosed with desquamative inflammatory vaginitis between 1996 and 2007 in a referral university-based vaginitis clinic. Clinical findings, laboratory findings, and treatment were documented during the first 12 months and at 2 and 4 years. RESULTS: Of the 98 patients reviewed, 97 were white; mean age was 48.6 years (plus or minus 10.2 years), and 50% were postmenopausal. All patients were symptomatic with vaginal inflammation and 72% had vestibular findings. Treatment with topical 2% clindamycin (54%) or 10% hydrocortisone (46%) dramatically relieved symptoms within 3 weeks (median) in 86% of patients. Treatment was discontinued (median 8 weeks) in 53 patients experiencing clinical remission accompanied by normal wet mount appearance; however, 17 (32%) relapsed within 6 weeks. At 1 year, cure was achieved in 25 patients (26%), 57 (58%) were asymptomatic but remained dependent on maintenance treatment, and 16 (16%) were partially controlled only. A favorable initial response to therapy was associated with positive clinical prognosis by 20 weeks of follow-up (P=.01). CONCLUSION: Desquamative inflammatory vaginitis is a chronic inflammatory process involving both vagina and vestibule, occurring almost exclusively in white women, that responds well to topical anti-inflammatory therapy, although long-term maintenance therapy frequently is required. LEVEL OF EVIDENCE: III

Onset of Vulvodynia in a Woman Ultimately Diagnosed With Creutzfeldt-Jakob Disease

BACKGROUND: Vulvodynia, defined as vulvar pain or burning in the presence of normal vulvar appearance, is common and is associated with chronic pain syndromes and psychiatric disorders. CASE: A postmenopausal woman complained of vulvar burning. Causes for vulvar burning including yeast infection, estrogen deficiency, and contact dermatitis were excluded. Vulvovaginal examination was normal. Subsequently, she complained of headaches, insomnia, and depression. She developed ataxic gait with rapidly progressive dementia. Brain biopsy confirmed the diagnosis of Creutzfeldt-Jakob disease, and 3 weeks later she lapsed into coma and died. CONCLUSION: This report is unique in that a rare disease, known to result in neuronal damage, mimicked symptoms of vulvodynia in its initial phase. This supports the hypothesis that vulvodynia is a neuropathic syndrome originating in the nervous system.

Chronic vulvar fissure--a rare manifestation of mycosis fungoides.

Background. Vulvar fissures are a common cause of vulvar pain and discomfort. The differential diagnosis of the underlying process is broad, and some cases remain undiagnosed. Mycosis fungoides, the dominant component of cutaneous T-cell lymphoma, rarely present as fissures. We report a case of a chronic vulvar fissure due to mycosis fungoides. Case. A 55-year-old woman was referred to the vaginitis clinic for evaluation of a chronic vulvar fissure, 6 cm in length, located at the left interlabial sulcus. A detailed history and examination for other skin lesions revealed an erythematous pruritic patch on left breast that had been present for years. Repeat biopsies from both sites showed a dense dermal lymphocytic infiltrate composed predominantly of CD3- and CD4-positive T cell with minimal epidermotropism. A T-gamma polymerase chain reaction analysis demonstrated a clonal T-cell rearrangement. Based on a diagnostic algorithm that combines clinical features, histopathology, and molecular biology, a diagnosis of mycosis fungoides was confirmed. Conclusions. Patients presenting with vulvar lesions should always be suspected of having an underlying dermatosis, and a detailed examination for other skin lesions should be performed. In the presented case, once both skin lesions were linked clinically, repeat biopsies of both sites led to a confirmed diagnosis of mycosis fungoides.