Vulvar dermatoses: common problems in dermatological and gynaecological practice

The most commonly encountered vulvar dermatoses present as cutaneous papules or scaly plaques. The two major categories are the papulosquamous disorders, which include psoriasis, seborrhoea and the 'lichens' (lichen planus, lichen sclerosus, lichen simplex chronicus) and chronic or recurrent infections (tinea, Candida, papillomavirus, herpes simplex). These conditions are morphologically similar, and treatment for one condition may affect the appearance of another. Lichen simplex chronicus (LSC, histologically squamous cell hyperplasia) is a secondary dermatosis, a non-specific cutaneous change indicating the presence of pruritus. Candida, tinea, lichen sclerosus, papillomavirus and topical agents have all been implicated in the development of LSC. Chronic vulvar burning (vulvodynia) is rarely associated with cutaneous change other than erythema, but may occur with vulvar dermatoses, occult Candida or papillomavirus infection, vulvar vestibulitis or cutaneous dysaesthesias. Topical preparations are most commonly used to treat vulvar disorders. Treatment trials typically require several weeks of therapy to determine responses. Allergic reactions to components must be distinguished from irritants, and complications of therapy must be recognised and prevented if possible. Overuse of topical medications, especially steroids, may lead to mycotic superinfection or to rebound dermatoses related to steroid withdrawal. Anxious patients may overclean or overtreat sensitive genital skin in the belief that they are unclean or harbour a sexually transmitted disease. In some situations, systemic medication may offer an appropriate adjunct or alternative to topical therapy.