A Practical Guide to Vulval Disease - Diagnosis and Management

This book is a practical guide to the diagnosis and management of vulval disorders. It offers guidance for all those who are treating patients with vulval disease at trainee and specialist level, helping to improve management for the patient and prevent delays in diagnosis, including referrals to specialists. It contains key information about diagnosis, investigation and basic management, with a section on signs and symptoms guides the reader to the correct chapter for the treatment of that disease. The experienced authors include updated classification and terminology of vulval disease with an explanation of how this should be useful in clinical practice and guidance as to when the patient should be referred on to a specialist. As vulval diseases are different to those of the rest of the skin patients with vulval disease present a large unmet need, often with delays in diagnosis due to a lack of training from physicians. This practical guide provides the specialist knowledge required for diagnosis and treatment of these conditions.

Acknowledgements xvii 1 The Normal Vulva 1 Normal Vulval Anatomy 1 Normal Vulval and Vaginal Flora 4 Further Reading 4 Normal Anatomical Variants 4 Normal Changes Over the Lifetime 6 Further Reading 7 2 Taking a History and Examination 9 Taking a History 9 Examination of the Vulva 11 Further Reading 13 3 How to Take a Vulval Biopsy and the Importance of Clinico-Pathological Correlation 15 Incisional Biopsy 16 Fixation of the Biopsy 20 Further Reading 21 4 Basic Histology of the Vulva 23 Special Histological Stains 24 Immunohistochemical Stains 26 Other Tests 27 Further Reading 28 5 Investigations in Vulval Disease 29 Investigations for Infection 29 Investigations for Allergy 32 Investigations for Inflammatory Disease 33 Imaging Investigations 34 Useful Web Sites for Patient Information 34 Further Reading 34 6 Topical Treatment in Vulval Disease 35 Introduction 35 General Principles 35 Lotions 35 Gels 36 Ointments 36 Creams 36 Pastes 36 Topical Treatments Used for Vulval Disease 36 Antiseptics 41 Antibacterials 42 Antifungals 42 Barriers 42 Others 42 Practice Points 44 Further Reading 44 Useful Web Sites for Patient Information 44 7 Symptoms in Vulval Disease 45 Pruritis (Itch) 45 Causes of Vulval Pruritis 46 Soreness 46 Pain 47 Dyspareunia 48 Discharge 48 No Symptoms 49 Useful Web Site for Patient Information 49 8 Signs in Vulval Disease 51 Differential Diagnosis Based on Appearance 51 Algorithms 51 Further Reading 56 9 Eczema, Allergy and the Vulva 57 Seborrhoeic Eczema 57 Allergic Contact Eczema / Dermatitis 59 Clinical Features 60 Irritant Eczema / Dermatitis 62 Urticaria 64 Allergic Contact Urticaria 64 References 65 10 Psoriasis 67 Introduction 67 Incidence 67 Clinical Features 68 Basic Management 69 When to Refer 72 Practice Points 73 Further Reading 73 Useful Web Sites for Patient Information 73 11 Lichen Simplex 75 Introduction 75 Epidemiology 75 Incidence 75 Pathophysiology 75 Histological Features 76 Symptoms 76 Clinical Features 76 Basic Management 77 When to Refer 78 Practice Points 78 Further Reading 79 Useful Web Sites for Patient Information 79 12 Lichen Sclerosus 81 Introduction 81 Incidence 81 Pathophysiology 81 Histological Features 82 Symptoms 83 Clinical Features 83 Associated Disease 90 Risk of Malignancy 90 Basic Management 92 Follow Up 92 When to Refer 92 Practice Points 93 Further Reading 93 Useful Web Sites for Patient Information 93 13 Lichen Planus 95 Introduction 95 Epidemiology 95 Incidence 95 Pathophysiology 95 Histological Features 96 Clinical Features of Lichen Planus 96 Vulval Lichen Planus 98 Risk of Malignancy 99 Basic Management 100 When to Refer 101 Practice Points 102 Further Reading 102 Useful Web Sites for Patient Information 102 14 Hidradenitis Suppurativa and Crohn's Disease 103 Hidradenitis Suppurativa 103 Further Reading 110 Useful Web Sites for Patient Information 110 15 Disorders of Pigmentation on the Vulva 111 Introduction 111 Postinflammatory Pigmentation 111 Post-Traumatic Pigmentation 111 Acanthosis Nigricans 111 Melanosis 114 Pigmented Lesions 115 Lentigines 116 Benign Naevi 116 Atypical Genital Naevi 117 Seborrhoeic Keratoses 117 Pigmented Basal Cell Carcinoma (see Chapter 22) 118 Hypopigmentation 118 Vitiligo 118 When to Refer 119 Practice Points 119 Further Reading 119 Useful Web Sites for Patient Information 120 16 Other Dermatoses 121 Genetic Disorders 121 Auto-Immune Bullous Disease 123 Drug Eruptions 126 Further Reading 126 Useful Web Sites for Patient Information 126 Stevens-Johnson Syndrome 127 Toxic Epidermal Necrolysis 127 Manifestations of Underlying Disease 128 Further Reading 129 Acrodermatitis Enteropathica 129 Practice Point 130 Further Reading 130 Inflammatory Ulcers 130 Practice Point 130 Behcet's Syndrome 130 Further Reading 132 Useful Resources 132 Lipschutz Ulceration 132 Further Reading 133 Others 133 Further Reading 135 Vulvovaginal Adenosis 135 Further Reading 135 Langerhans Cell Histiocytosis 136 Further Reading 136 17 Vulval Infection - Sexually Transmitted 137 Normal Flora 137 Trichomoniasis 137 Lymphogranuloma Venereum 139 Gonorrhoea 140 Clinical Features 140 Syphilis 141 Chancroid 142 Donovanosis (Granuloma Inguinale) 143 Herpes Simplex Infection 144 Human Papillomavirus Infection 147 Molluscum Contagiosum 150 Scabies 152 Pubic Lice 153 18 Vulval Infection - Nonsexually Transmitted 155 Bacterial Infections 155 Bacterial Vaginosis 155 Erythrasma 157 Staphylococcal and Streptococcal Infections 158 Folliculitis 159 Bartholin Abscess 159 Other Staphylococcal Infections 161 Cellulitis 161 Other Streptococcal Infections 161 Vulvovaginal Candidiasis 162 Tinea Cruris 165 Viral Infections 166 19 Vulval Intraepithelial Neoplasia 167 Introduction 167 Epidemiology 167 Aetiology 168 Prevention 168 Histological Features 168 Symptoms 169 Clinical Features 169 Management 173 Progression 174 Melanoma In Situ 176 When to Refer 176 Practice Points 176 Further Reading 177 Useful Web Site for Patient Information 177 20 Extramammary Paget's Disease 179 Introduction 179 Epidemiology 179 Histological Features 179 Classification 180 Symptoms 181 Clinical Features 181 Management 183 Recurrences 185 Progression 185 Follow Up 186 When to Refer 186 Practice Points 186 Further Reading 186 Useful Web Site for Patient Information 187 21 Vulval Squamous Cell Carcinoma 189 Introduction 189 Epidemiology 189 Aetiology / Histology 189 Symptoms and Clinical Features 190 Management 191 Surgery 191 Complications 192 Radiotherapy 193 Follow Up 193 Prognosis 193 When to Refer 194 Practice Points 194 Further Reading 194 Useful Web Site for Patient Information 195 22 Other Vulval Cancers 197 Basal Cell Carcinoma 197 Malignant Melanoma 199 Other Malignant Tumours and the Vulva 202 Further Reading 202 23 Vulvodynia 203 Definition 203 Epidemiology 203 Pathophysiology 205 Psychological Aspects of Vulvodynia 205 Histology 206 Symptoms 206 Signs 206 Diagnosis 207 Management 207 Further Reading 209 Useful Web Sites for Patient Information 209 24 Psychosexual Aspects of Vulval Disease 211 Clinical Psychological Assessment 212 Further Reading 212 25 Benign Lesions 213 Epidermoid Cysts 213 Comedones 213 Syringomata 213 Hidradenoma Papilliferum 215 Lymphangioma / Lymphangiectasia 216 Further Reading 216 Index 000