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"Vulvar leukoplakia" that is easy to diagnose and difficult to treat, you need to master this information

 When it comes to genital itching, everyone first thinks of vulvovaginitis. But in fact, in addition to vaginitis, vulvar pruritus involves many types of vulvar diseases, such as folliculitis and eczema. What I want to introduce to you today is a common gynecological disease that can cause genital itching-lichen sclerosus of the vulva. Because it is often accompanied by changes and degeneration of the skin and mucous membranes of the vulva, it was also called vulvar leukoplakia, sclerosing atrophy of the vulva, and vulvar dystrophy.


Histopathology is the gold standard for diagnosis


It is generally believed that the age of onset of vulvar lichen sclerosus has two peaks, the most common in postmenopausal women (mean age 52.6 years), followed by prepubertal girls (mean age 7.6 years). At present, the etiology and pathogenesis of the disease are still unclear, and may be related to immunity, heredity, endocrine and metabolism. In addition, oxidation, local irritation, infection, abnormal cell proliferation and balance, cell and blood vessel damage, changes in human epidermal growth factor, lack of trace elements, and psychological factors may also be related to the onset of the disease.


The most common symptom of the disease is intractable itching, which usually occurs at night. In severe cases, it can affect daily life and sleep. Other accompanying symptoms may include vulvar pain, dysuria, dysuria, sexual dysfunction, pain during sexual intercourse and bowel movements. Nearly 10% of patients can be completely asymptomatic, usually discovered by accident or by a doctor during a gynecological examination.


The skin lesions of vulvar lichen sclerosus mainly involve the labia, clitoris foreskin, perineal body and perianal skin, mostly symmetrically distributed, and usually do not involve the hair growth area of ​​the labia majora. The skin of the vulvar lesion area is fragile, mostly manifested as purpura, erosion and chapped. If the lesion is not treated in time for a long time, it can cause invagination of the vulvar structure, loss of the labia minora and clitoral foreskin or front and back joint adhesions, which will eventually lead to the vaginal opening or (and ) Anal stenosis.


Doctors can initially diagnose the disease based on symptoms and physical examination, but the diagnosis usually requires a histological biopsy of the vulva. Special reminder that under the following circumstances, a vulvar skin biopsy should be performed to rule out vulvar intraepithelial neoplasia and malignant tumors:


1. Intractable hyperkeratosis, persistent ulcers, erosions and erythema, new verrucous or papillary lesions, thickened skin and suspected tumor-like or malignant lesions.


2. According to the standard treatment effect is not good.


3. Combined with cervical or vaginal intraepithelial neoplasia.


4. Unexplained pigmentation or decline.


Topical topical corticosteroids as first-line treatment


Except for some prepubertal patients who may be relieved naturally, most patients with vulvar lichen sclerosus require active intervention and treatment. Because the disease is easy to diagnose and difficult to treat, and early diagnosis and early diagnosis can improve the long-term prognosis, it is emphasized that even if there are no symptoms, treatment should be given to delay the progression of the disease and improve the long-term prognosis.


At present, the domestic academic circles (including obstetrics and gynecology and dermatology) have not yet unified the understanding of this disease, and there are great regional differences in treatment options. On the whole, for the treatment of this disease, we must first pay attention to lifestyle changes, including:


1. Choose loose and breathable cotton underwear, and don't wear airtight chemical fiber underwear to avoid moisture and friction of the vulva;


2. Keep the skin of the vulva clean and dry;


3. Disable irritating drugs, detergents or soaps to clean the vulva;


4. Light diet, avoid tobacco and alcohol, and do not eat spicy, irritating or allergic foods;


5. Avoid scratching;


6. Apply petroleum jelly, cod liver oil, vitamin E and other moisturizing creams to keep the skin moisturized.


Secondly, drug therapy can be carried out on the basis of non-drug therapy, including local topical drugs and systemic drugs.


Glucocorticoid is its first-line treatment, 0.05% clobetasol propionate ointment is the first choice. Topical glucocorticoids are divided into two stages: induction therapy and maintenance therapy: choose 0.05% clobetasol propionate ointment in the induction therapy stage, once a day for 4 weeks, then once every other day for 4 weeks, and finally every week 2 times, lasting 4 weeks, 3 months in total. Maintenance treatment stage, once a week, lasts for life. If symptoms or signs recur as the frequency of medication decreases, the frequency of medication needs to be re-adjusted and increased. After the clinical symptoms are relieved, the dosage will be gradually reduced to maintain.


0.1% tacrolimus cream and 1% pimecrolimus can be used as second-line treatment drugs. Most literature reports that the symptom improvement rate of such preparations is about 34%, and the lesion clearance rate is about 24%. Long-term oral use of tacrolimus has the risk of inducing lymphoreticular endothelial cell tumors and vulvar cancer. Therefore, the US Food and Drug Administration (FDA) recommends continuous use for no more than 2 years. Topical 0.1% tacrolimus cream is used for treatment, and the recommended duration is limited to 16 to 24 weeks.


The effective rate of drug treatment is about 80%, most of which can only improve symptoms but cannot be cured, and long-term medication is required.


For patients with obvious symptoms of nervousness, itching and insomnia, the use of systemic sedative, sleeping and anti-allergic drugs under the guidance of a doctor can also have a certain relief effect. In the past, topical progesterone, testosterone propionate, estrogen, oral retinoic acid or photosensitizer treatments that have been widely used in the past are not recommended for routine use due to lack of evidence of clinical benefit.


Patients can also choose physical treatments such as fractional laser, photodynamic, and focused ultrasound under the evaluation of doctors. If medication or physical therapy is ineffective, or the disease is at risk of malignant transformation, surgical treatment is required. Surgical methods include resection of local lesions of the vulva, simple vulvectomy or vulvar adhesion lysis. Surgical resection alone cannot achieve the goal of radical cure. Generally, drug treatment is still required after surgery.



Finally, I remind everyone that lichen sclerosus of the vulva is a chronic progressive disease, and the prolonged course of the disease can cause anatomical changes, dysfunction and even malignant changes in the vulva. For this reason, long-term follow-up is extremely important. The follow-up time is generally 3, 6, and 12 months after treatment, and then every 6 to 12 months. Patients should pay attention to avoid local mechanical damage in daily care, such as not wearing tights or hard seat. In addition, because urine can induce and aggravate the condition, it is necessary to avoid skin contact with urine as much as possible, wipe it dry after urination, and use moisturizing cream before and after urination or swimming to maintain skin moisturization.

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