Vulvar Dystrophies

Vulvo-vaginal symptoms are among the most common reasons that women seek health care; upward of 6 million physician office visits are made by women of all age ranges for vulvo-vaginal symptoms. Despite such staggering statistics, most clinicians are not adequately prepared to diagnose and treat chronic vulvo-vaginal symptoms. Overlapping clinical appearance, symptoms, and pathophysiology, compounded by nonspecific histology on biopsy, are the main causes for confusion. This chapter will focus on the following six nonmalignant vulvo-vaginal conditions that clinically may raise concern about premalignant processes: Lichen sclerosis Contact dermatitis Lichen simplex chronicus Lichen planus Plasma cell vulvitis Desquamative inflammatory vaginitis These conditions share overlapping symptoms of itching and burning to variable degrees. Collectively, these conditions are challenging to care for due to lack of consensus on diagnosis and treatment, intractable and fluctuating clinical course, overlapping morphology and histology, and significant individual variation in treatment response. Additionally, many of these conditions often coexist, posing yet another layer of complexity in deciphering the cause of a patient’s chief complaint. Given the intertwined pathophysiology, it is no wonder that the care of these patients seems more a proverbial shot in the dark than a stepwise methodical process. The diagnostic definition of these six conditions is based on a constellation of symptoms, morphology, and histopathology. As noted in Table 1.1, the primary complaint of the first three conditions is itching, while the primary complaints of the last three are burning, rawness, and pain with intercourse. Thus, using a symptom-based approach, the discussion of these disorders is divided into two parts: conditions with primary complaints of itching (lichen sclerosis, contact dermatitis, and lichen simplex chronicus), and those with primary complaints of burning/rawness sensation (lichen planus, plasma cell vulvitis, and desquamative inflammatory vaginitis). Vulvar intraepithelial dysplasia (VIN), which is often associated with unilateral and focal itching, will be discussed in Chapter 2.