A PRACTICAL GUIDE TO VULVAL DISEASE DIAGNOSIS AND MANAGEMENT A PRACTICAL GUIDE TO VULVAL DISEASE DIAGNOSIS AND MANAGEMENT Patients with vulval disease frequently experience delays in diagnosis due to a lack of training for physicians. A Practical Guide to Vulval Disease: Diagnosis and Management offers practical, up-to-date and expert guidance on the diagnosis and management of vulval disorders. It provides the knowledge required for diagnosis and treatment of these conditions at both trainee and specialist level. Key information about diagnosis, investigation and basic management is included, with a section on signs and symptoms to direct the reader to the appropriate chapter for the particular disease. Current classification and terminology of vulval disease is featured, along with guidance on when a patient should be referred to a specialist. Well illustrated, with 185 high quality photographs, this user-friendly clinical guidebook integrates clinical and histological features of vulval disorders, so the reader can understand the disease from a microscopic to macroscopic level. Written by an experienced author team, A Practical Guide to Vulval Disease: Diagnosis and Management is essential reading for gynaecologists, dermatologists, genito-urinary physicians, general practitioners and nurses, both in practice and in training.

Table of Contents:
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 Childhood 6 Pregnancy 6 Menopause 6 Further Reading 7 2 Taking a History and Examination 9 Taking a History 9 General Medical History 9 Gynaecological History 10 Dermatological History 10 Vulval History 10 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 Bacterial Swabs 29 Viral Swabs 29 Fungal Scrapings 29 Wood’s Light Examination 32 Serological Tests 32 Investigations for Allergy 32 Rast Tests 32 Prick Tests 32 Patch Tests (see Chapter 9) 32 Investigations for Inflammatory Disease 33 Direct Immunofluorescence 33 Indirect Immunofluorescence 34 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 Emollient 37 Topical Steroids 38 Adverse Effects 38 Topical Steroids in Pregnancy 41 Antiseptics 41 Antibacterials 42 Antifungals 42 Barriers 42 Others 42 Podophyllotoxin 42 Imiquimod 42 Calcineurin Inhibitors 43 Tar 44 Emla ® 44 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 Incidence 57 Pathophysiology 57 Symptoms 58 Clinical Features 58 Basic Management 58 When to Refer 58 Practice Points 59 Further Reading 59 Useful Web Sites for Patient Information 59 Allergic Contact Eczema / Dermatitis 59 Introduction 59 Incidence 59 Pathophysiology 60 Patch Testing (see Chapter 5) 60 Symptoms 60 Clinical Features 60 Basic Management 60 Who to Refer for Patch Testing 60 Practice Points 61 Further Reading 61 Useful Web Sites for Patient Information 62 Irritant Eczema / Dermatitis 62 Introduction 62 Incidence 62 Pathophysiology 63 Histological Features 63 Symptoms 63 Clinical Features 63 Basic Management 64 When to Refer 64 Practice Points 64 Further Reading 64 Urticaria 64 Allergic Contact Urticaria 64 Clinical Features 65 Management 65 References 65 10 Psoriasis 67 Introduction 67 Incidence 67 Pathophysiology 67 Histological Features 67 Symptoms 68 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 Genetic 82 Epigenetics 82 Autoimmunity 82 Hormonal Factors 82 Infection 82 Trauma 82 Role of the Skin Immune System 82 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 Classic LP 98 Hypertrophic LP 98 Erosive LP 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 Introduction 103 Epidemiology 103 Incidence 103 Pathophysiology 103 Histological Features 103 Symptoms 104 Clinical Features 104 Basic Management 105 Medical Management 105 Surgery 105 When to Refer 105 Practice Points 106 Further Reading 106 Useful Web Sites for Patient Information 106 Crohn’s Disease 106 Introduction 106 Epidemiology 106 Pathophysiology 107 Histological Features 107 Symptoms 107 Clinical Features 107 Basic Management 109 When to Refer 109 Practice Points 109 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 Management 113 Melanosis 114 Pigmented Lesions 115 History and Examination 115 Other Techniques 116 Lentigines 116 Benign Naevi 116 Atypical Genital Naevi 117 Seborrhoeic Keratoses 117 Pigmented Basal Cell Carcinoma 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 Hailey–Hailey Disease (Familial Benign Chronic Pemphigus) 121 Management 121 When to Refer 121 Practice Points 121 Further Reading 122 Useful Web Site for Patient Information 122 Auto‐Immune Bullous Disease 123 Practice Points 126 Further Reading 126 Drug Eruptions 126 Fixed Drug Eruption 126 Common Drugs Causing a Fixed Drug Eruption 126 Further Reading 126 Useful Web Site for Patient Information 126 Stevens–Johnson Syndrome 127 Symptoms 127 Clinical Features 127 Toxic Epidermal Necrolysis 127 Symptoms 127 Clinical Features 127 Basic Management 127 Further Reading 128 Useful Web Site for Patient Information 128 Manifestations of Underlying Disease 128 Necrolytic Migratory Erythema 128 Symptoms 129 Clinical Features 129 Basic Management 129 Further Reading 129 Acrodermatitis Enteropathica 129 Clinical Features 129 Basic Management 129 Practice Point 130 Further Reading 130 Inflammatory Ulcers 130 Aphthous Ulcers 130 Clinical Features 130 Management 130 Practice Point 130 Behcet’s Syndrome 130 Further Reading 132 Useful Resources 132 Lipschutz Ulceration 132 Clinical Features 132 Basic Management 133 Further Reading 133 Others 133 Graft‐Versus‐Host Disease 133 Further Reading 134 Zoon’s Vulvitis (Plasma Cell Vulvitis) 134 Histology 134 Symptoms 134 Clinical Features 135 Basic Management 135 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 Pathophysiology 137 Clinical Features 138 Diagnosis 138 Basic Management 138 Further Reading 138 Useful Web Sites for Patient Information 138 Chlamydia 139 Clinical Features 139 Diagnosis 139 Treatment 139 Further Reading 139 Useful Web Site for Patient Information 139 Lymphogranuloma Venereum 139 Clinical Features 140 Diagnosis 140 Treatment 140 Further Reading 140 Useful Web Site for Patient Information 140 Gonorrhoea 140 Clinical Features 140 Diagnosis 140 Treatment 141 Further Reading 141 Useful Web Sites for Patient Information 141 Syphilis 141 Pathophysiology 141 Clinical Features 141 Treatment 142 Further Reading 142 Useful Web Site for Patient Information 142 Chancroid 142 Pathophysiology 142 Clinical Features 143 Treatment 143 Further Reading 143 Useful Web Sites for Patient Information 143 Donovanosis (Granuloma Inguinale) 143 Clinical Features 143 Diagnosis 143 Treatment 143 Further Reading 144 Useful Web Site for Patient Information 144 Herpes Simplex Infection 144 Incidence 144 Pathophysiology 144 Clinical Features 144 Differential Diagnosis 145 Diagnosis 146 Basic Management 146 Hsv Infection and Pregnancy 146 Further Reading 147 Useful Web Sites for Patient Information 147 Human Papillomavirus Infection 147 Epidemiology 147 Pathophysiology 148 The Concept of Vulval Subclinical Lesion 148 Histology 148 Clinical Features 149 Diagnosis 149 Treatment 150 Hpv Vaccine 150 Genital Warts in Children 150 Further Reading 150 Useful Web Sites for Patient Information 150 Molluscum Contagiosum 150 Symptoms 151 Clinical Appearance 151 Diagnosis 151 Treatment 151 Further Reading 152 Useful Web Site for Patient Information 152 Scabies 152 Clinical Features 152 Diagnosis 152 Treatment 153 Further Reading 153 Useful Web Site for Patient Information 153 Pubic Lice 153 Clinical Features 153 Treatment 153 Useful Web Site for Patient Information 153 18 Vulval Infection – Nonsexually Transmitted 155 Bacterial Infections 155 Bacterial Vaginosis 155 Clinical Features 155 Diagnosis 155 Treatment 155 Further Reading 157 Useful Web Sites for Patient Information 157 Erythrasma 157 Clinical Features 157 Differential Diagnosis 157 Diagnosis 158 Basic Management 158 Useful Web Site for Patient Information 158 Staphylococcal and Streptococcal Infections 158 Folliculitis 159 Pathophysiology 159 Clinical Features 159 Diagnosis 159 Basic Management 159 Further Reading 159 Bartholin Abscess 159 Clinical Features 160 Differential Diagnosis 160 Basic Management 160 Drainage of the Abscess 160 Marsupialization 160 Further Reading 160 Other Staphylococcal Infections 161 Toxic Shock Syndrome 161 Staphylococcal Scalded Skin Syndrome 161 Cellulitis 161 Clinical Features 161 Diagnosis 161 Differential Diagnosis 161 Other Streptococcal Infections 161 Further Reading 162 Vulvovaginal Candidiasis 162 Pathophysiology 162 Clinical Features 163 Differential Diagnosis 163 Diagnosis 164 Treatment 164 Further Reading 164 Useful Web Sites for Patient Information 164 Tinea Cruris 165 Pathophysiology 165 Clinical Features 165 Differential Diagnosis 165 Diagnosis 166 Basic Management 166 Further Reading 166 Useful Web Site for Patient Information 166 Viral Infections 166 Varicella Zoster (Shingles) 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 190 Surgery 190 Complications 191 Radiotherapy 192 Follow Up 193 Prognosis 193 When to Refer 193 Practice Points 193 Further Reading 194 Useful Web Site for Patient Information 194 22 Other Vulval Cancers 195 Basal Cell Carcinoma 195 Epidemiology 195 Incidence 195 Pathophysiology 195 Histological Features 195 Symptoms 196 Clinical Features 196 Basic Management 196 When to Refer 196 Practice Points 197 Further Reading 197 Useful Web Site for Patient Information 197 Malignant Melanoma 197 Epidemiology 198 Pathophysiology 198 Histological Features 198 Symptoms 198 Clinical Features 198 Basic Management 198 Further Reading 199 Other Malignant Tumours and the Vulva 200 Further Reading 200 23 Vulvodynia 201 Definition 201 Epidemiology 201 Pathophysiology 203 Psychological Aspects of Vulvodynia 203 Histology 204 Symptoms 204 Signs 204 Diagnosis 205 Management 205 Local Topical Pain Modifiers 205 Systemic Pain Modifiers 205 Physical Therapy 206 Psychosexual Therapy 207 Surgical Treatment 207 Further Reading 207 Useful Web Sites for Patient Information 207 24 Psychosexual Aspects of Vulval Disease 209 Clinical Psychological Assessment 210 Further Reading 210 25 Benign Lesions 211 Epidermoid Cysts 211 Comedones 211 Syringomata 211 Hidradenoma Papilliferum 213 Lymphangioma / Lymphangiectasia 214 Further Reading 214 Index 215