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Spend Extra Time and Effort on Vulvar Dermatoses.

NEW YORK -- Examining patients with vulvar diseases requires a sensitivity to both the physical and psychological aspect of these diseases, Dr. Maria L. Turner said at a dermatology meeting sponsored by the Mount Sinai School of Medicine.

She offered several pearls for facilitating examination and diagnosis:

* Spend more time with these patients. Vulvar conditions are a sensitive issue and most women are not eager to talk about the problem. Meet the patient and take the history while she is fully dressed, suggested Dr. Turner, chief of the dermatology consult service at the National Institutes of Health in Bethesda, Md.

* Use a structured form or questionnaire. Because it can be difficult to spend extra time with a patient given the constraints of practice today, it's useful to have the patient fill out a questionnaire while they are waiting to see you. It also is easier to ask pointed questions about a sensitive subject in written form. Using these forms additionally gives the physician something to refer back to later on.

* Have an assistant help you. An assistant can hand you tools and help with equipment. It's also a good idea to have a chaperon in the room, advised Dr. Turner.

* Consider cultural backgrounds. Women may not complain of their vulvar symptoms because of cultural influences.

* Forget acetic acid washes. Imagine putting vinegar on a vulva that is inflamed, Dr. Turner said. This is just too painful.

* Part the labia majora to examine the vulvar vestibule. Vulvar diseases are sort of orphaned, Dr. Turner said. Dermatologists look at the labia majora, but they don't look behind it. Gynecologists open the labia majora, but once they insert the speculum, the vulva falls behind the speculum.

* Be gentle. Most patients with dermatitis or vulvitis will have a split at the fourchette, a very easily traumatized area. If you're not careful, you'll tear it apart even more, she said.

* Perform wet smears. They are much more informative than cultures, except when considering sexually transmitted diseases. Half of the bacteria in a healthy vagina is lactobacilli, which only a wet smear will reveal.

Perform a KOH test to diagnose Candida species, and remember 20% of asymptomatic women carry Candida. Take snip biopsies from the edges of the eroded lesions, not from the erosions themselves. Then suture the biopsy site with 6-0 absorbable catgut. It will heal in a few days; if it is left open, it takes 2 weeks to heal and the patient is uncomfortable.

* Take photographs. These are useful for follow-up examinations and teaching.

* Look for other clues, such as oral lesions, to make the diagnosis. Once the vulva is eroded, all of the diseases look alike, Dr. Turner said. The presence of oral lesions may point toward a diagnosis of Behcet's syndrome, inflammatory bowel disease, or aphthosis.

Once the disease is diagnosed and a course of treatment has been determined, consider how long you think it will take for the patient to heal.

If you tell the patient how long it will be before the treatment will take effect, she will feel confident that you know what you're doing and she won't have expectations that can't be met, Dr. Turner said.

When you're dealing with recalcitrant conditions such as lichens planus, you may not want to tell the patient at the first visit that it's going to be a very difficult condition to treat. But you will eventually have to tell her she may need life-long treatment.

At first, simply reassure patients that you can help them, she said.

Consider psychological counseling and sexual counseling for patients with chronic problems. They may want to find other ways to achieve sexual satisfaction without having vaginal intercourse.

Avoid overuse of therapeutic agents such as topical steroids, antibiotics, and antifungals, Dr. Turner said.

Most patients, by the time they see you, have been overtreated, she said. Often they have used over-the-counter medications for an extended period.

Extensive use of antibiotics will change the bacterial flora and kill the lactobacilli, which are very fragile and are needed to maintain an acidic environment. Once the lactobacilli are gone, anaerobic bacteria take over and bacterial vaginosis and yeast become secondary problems, she said.

Advise patients to avoid local therapy and overcleansing. For the vulvar vestibule, stick with plain ointments instead of lotions, which invariably contain some alcohol. Lotions can be used near the groin area or on the hairy portion of the labia majora.

Tell your patients to use plain water to dean the area. Women tend to think they have to wash the area frequently and use unnecessary antiseptics and strong soaps, Dr. Turner said.
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Publication:OB GYN News
Date:Apr 15, 2000
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