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Dx: Vulvodynia and Lichen Sclerosis Atrophicus


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Observation:
Vulvodynia

N.H.S. Choices
states:
"Vulvodynia is persistent, unexplained pain of the vulva, the skin surrounding the vagina. There is usually no obvious cause, but much can be done to help relieve the pain so that it no longer causes problems.
  The pain of vulvodynia is often described as a burning, stinging or raw sensation. Some women describe a feeling of a needle being stuck in their genitals.

Vulvodynia can be:
*unprovoked vulvodynia – pain that is constantly in the background or that comes on spontaneously, with no particular trigger
*provoked vulvodynia – pain triggered when the vulva is lightly touched (for example, after inserting a tampon or during sex)

The pain can also be limited to the vulva (localized) or may be more widespread (generalized), spreading to the urinary tract, the bottom or the inside of the tops of the thighs.
  It can be made worse by activities such as cycling or horse riding, which put prolonged pressure on the vulva."

[Editor] A compounding pharmacy can make up a preparation that might include amitriptyline 2%/ Baclofen 2% and Gabapentin 5% to be applied three times per day. Whether this is locally effective or there is enough absorption to give systemic levels is not known. A second new treatment is compounded 1% naltrexone, which might give relief in less than 1 hours. a 2% testosterone cream can be added. This information was supplied by an independent pharmacist to offer the reader one more example of specific options of compounding.

[Editor] Dr. Schlosser who has financial arrangements with Allgergan and Galderma Laboratories states: "The standard first-line therapy for VLS is highly potent corticosteroids. In contrast, topical testosterone, once widely used "has no role in this disease"." Second-line treatments include topical calcineurin inhibitors (tacrolimus or pimecrolimus), the synthetic vitamin D cream (calcipotriene) and topical retinoids. Oral steroids can be used in difficult cases (but only 4 of 150).

Lichen Sclerosis:
The Merck Manual Home Edition states:
"Lichen sclerosus is a disorder that tends to cause itching and can cause scarring in the area around the anus and genitals.The cause of lichen sclerosis is unknown, but it may involve the immune system attacking some of the body's own tissues (called an autoimmune disorder).
  This disorder typically affects the area around the anus and genitals, but it can rarely be found on other areas of the body. At first, the skin around the anus and genitals tends to bruise and may blister. Itching, sometimes severe, is typical. After some time, the skin can thin, lose its normal color, and develop cracks and scales. In some people, the disorder develops differently, causing skin thickening. Eventually, any form of lichen sclerosus that is chronic can scar, causing distortion of the normal structures of the area.
  Sometimes the appearance of lichen sclerosus in a child can resemble the effects of sexual abuse. Rarely, squamous cell carcinoma (a skin cancer) develops.

Doctors typically base the diagnosis on how the rash looks and where it appears on the body. Occasionally, doctors do a biopsy (examination of a tissue sample under a microscope).

Strong corticosteroid creams or ointments may need to be applied to the skin. Because this disorder is typically incurable and causes scarring, people are treated long-term and examined periodically for skin cancer."

Medications Used in Treatment:
1. Corticosteroids: Temovate
2. Topical Calcineurin inhibitors: tacrolimus or pimecrolimus
3. Vitamin D analog: Dovonex/ alcipotriene
4. Topical Retinoids: Retin-A
5. Low Dose Naltrexone:
6. Androgens: mixed androgen injections
7. Progesterones:

Surgical Treatments:
1. Excision:
2. Laser:
3. Cryosurgery:

The Germans reported successful treatment of 9 girls and 22 women with cryosurgery after other non-surgical therapies had failed.

*[Editor] Lichen Sclerosis is a chronic disease that is most commonly seen on the female genital skin of elderly women. Treatment is with the same medications as Vulvodynia: surgery should be reserved for symptomatic patients that fail to respond to multiple medical treatments...high recurrence rate after surgery. The risk of developing squamous cell carcinoma approaches 5%..close surveillance.. is needed.

*[Editor] Testimonial : Kim was treated at 35 years of age for vulvodynia. The treatment at that time was topical testosterone and then laser excision. Eighteen years later it returned; she suffered with constant pain. The classical appearance of punctuation from pinpoint blood vessels near the skin were seen. The patient was treated with testosterone: 1) topically with a topical anesthetic and 2)with mixed androgen injections weekly based on H.E.R. blood panel. Within two weeks she was almost pain free and able to resume marital relations. The frequency of the cream and the injections were reduced as the symptoms had resolved.