Dr. Kelly Tyler discusses what dermatologists should keep in mind when diagnosing and treating vulvar dermatoses
Kelly Tyler, MD, is Assistant Professor at Ohio State Dermatology, Columbus, Ohio
“Amongst dermatologists there is the misconception that patients with genital skin disease are very challenging to treat. That’s really not the case,” said Kelly Tyler, MD, who co-presented the session “A Guide to Treating and Diagnosing Vulvar and Penile Dermatoses” at the 2022 American Academy of Dermatology (AAD) Annual Meeting.
Yes, skin disease might look different on genital skin than on dry skin, according to Dr. Tyler, who is board certified in dermatology and gynecology.
“For instance, psoriasis on the elbow is a plaque-like area with scaling. In the genital area where there is a lot of moisture and friction it is not going to look so well defined. Patients may not have a lot of scale and it might look more like a pink patch than a thick plaque. But at the end of the day, the treatment is going to be similar.”
Dermatologists treating psoriasis in the genital area will likely use a topical steroid but should think about which topical to use in that area, especially if it is in the groin fold or on the hair-bearing skin of the labia majora. Those areas are a little bit more prone to striae and steroid dermatitis, said Dr. Tyler.
“Don’t be afraid to treat genital skin disease. You have all the tools. Once you familiarize yourself with the appearance and how it looks slightly atypical as compared to non-genital skin, that’s really what you need to remember. Trust yourself.”
Dr. Tyler talked about 3 important takeaways when diagnosing and treating vulvar skin disease.
1. Vehicle Matters
“One is, many of these patients have very eroded and inflamed skin. When we’re talking about treating dermatoses on the genital area, you want to be careful about using vehicles of topical steroids that have some alcohol in the base.”
For instance, prescribed creams can cause a burning sensation on inflamed genital skin.
“One of my pearls for my residents and anyone who comes to my clinic is, I prefer to prescribe steroid ointments for the genital area. The ones I use most commonly are clobetasol ointment and augmented betamethasone ointment because they tend to be more potent. When someone has a genital dermatitis on the modified mucus membranes—the labial minora, clitoral hood, perineum, medial labial majora—those areas are very corticosteroid-resistant, so you can use potent topical steroids because patients are at low risk for striae or atrophy.”
2. Don’t Hesitate to Biopsy
“It’s not a pleasant thing to undergo, but a lot of times you can miss things. And if you’re not sure of your diagnosis, the biopsy can really help you clinch the diagnosis.”
Dr. Tyler offers examples of patients she has seen who she thought had lichen simplex chronicus or eczema on their genital skin. They would get better initially with treatment, then come back, she said.
“I would re-biopsy them and, lo and behold, they actually had underlying lichen sclerosus, which is a very different management chronically. If you think you’re missing something and they’re not getting better or if you’re concerned about a skin cancer in that area, you really need to biopsy.”
2. Ask About OTC Treatments
Ask about and look for OTC treatments and secondary processes, said Dr. Tyler.
“Because I also specialize in allergic contact dermatitis and direct our patch testing clinic at Ohio State, I remind dermatologists not to forget about allergic contact dermatitis. These patients with genital skin disease, whether it be on the vulva or on the penis, often apply a lot of over-the-counter treatments. They’re very desperate; they want to get relief; they’re itching all the time. But many of these things—whether they be topical anesthetics, certain creams, or things that have propylene glycol as a preservative in the base—can be very irritating. Not only can they cause irritant contact dermatitis, but these patients can become sensitized and develop allergic contact dermatitis.”
If the patient has a recalcitrant genital skin disease, dermatologists should consider the possibility of concomitant infections, she said.
“It’s very common that these patients have infections. I have my patients with lichen sclerosus on potent topical steroids. Maybe they also have atrophic vaginitis, and I am treating them with a topical estrogen cream. Those things together can put them at risk for candidiasis and yeast infections. Or do they have a bacterial infection from scratching? Always look for secondary processes.”
Diagnosing and treating patients with genital dermatoses is important for addressing more than just the uncomfortable symptoms, said Dr. Tyler.
“Some of these patients, especially those with, for instance, lichen sclerosus have an increased risk of skin cancer in the genital area. We think that relates to increased inflammation in the skin over time. You really need to be on the lookout for squamous cell carcinoma or cancers arising within the skin disease on the genitals.”
Disclosure: Dr. Tyler reports no relevant disclosures.
