Introduction
Eczema and dermatitis are synonyms for morphologically and histologically identical skin conditions. Atopy refers to a genetic predisposition for hypersensitive allergic IgE reactions to common environmental antigens,1 with allergic rhinitis (hay fever), asthma, and/or atopic dermatitis that looks exactly like eczema. “Eczematous” refers to the characteristic appearance of the skin (see below). Atopic individuals may be more likely to develop eczematous skin reactions to common exposures that would not bother the non-atopic person. (Contact dermatitis in the Atlas). We thus emphasize the important component of vulvovaginal care that stresses the elimination of possible irritants: tight clothing, daily panty liners, panty hose, feminine care products, harsh soaps, or perfumes. At the same time, eczema may occur in those who have no family or personal history of atopy, and atopic dermatitis is rare in the vulvar area.
Another term clear to dermatologists but unknown to lay people is the term lichen simplex chronicus (LSC). Lichen simplex chronicus is closely linked with itching and may occur anywhere on the skin, including on the vulva. Itching causes the individual to scratch or rub, exacerbating the itch sensation. The vicious cycle of itching-scratching-rubbing-itching ends up causing the specific morphological condition of LSC: erythema that may occur in plaques of varying depths, in pustules, excoriations, rough scaling that appears shiny rather than flaking, areas of hypopigmentation or hyperpigmentation, especially in people with naturally dark skin. The final hallmark sign of LSC is lichenification: thickening of the skin with the distinctive pattern of normal skin “hatch-markings” being exaggerated and deepened when compared with adjacent, non-affected skin. In addition, because of scratching, hair may be absent or broken. Lichen simplex chronicus may occur because of itching associated with another skin disease such as lichen sclerosus, or may develop as de novo itching. (See Lichen simplex chronicus in the Atlas).
Histologically, eczema, dermatitis, atopic dermatitis, and lichen simplex chronicus appear the same. A semantic assumption is made by many dermatologists that lichen simplex chronicus is the descriptive term that encompasses localized eczematous conditions in the vulva, atopic dermatitis the term that encompasses generalized conditions, and that the clinician’s job is to come to understand what might have precipitated the condition and treat both the LSC and the originating condition.
Epidemiology
It is impossible to determine prevalence of the eczematous vulvar conditions because they overlap with other conditions and because the defining terminology also overlaps. Atopic dermatitis, the generalized type of eczema that appears on the non-vulvar skin, occurs in 15% of the population in the Western world.
Etiology
The etiology of eczematous dermatitis, also known as lichen simplex chronicus when it appears on the vulva, is unknown, but because it is highly correlated with itching, it can be said that pruritus is the etiology of the condition.
Itching may be primary (with no known cause) or secondary, with a cause discovered in the course of diagnosis. (Pruritus under vulvodynia.)
Symptoms and clinical features
The patient presents with complaint of itching. In some cases, she will have put off making an appointment to the point that itching has been partially replaced by pain from scratching or by burning from urine or fabrics touching the affected areas. Assuming a yeast infection, she may mention vaginal discharge, as well, which may not be relevant to her condition.
Clinical features include:
Erythema in varying degrees, from color barely distinguishable from that of surrounding tissue to deep red. In dark-skinned people, erythema may present as hyperpigmentation, darkening, rather than redness.
Red papules and plaques with poorly marginated borders.
Overlying scale which may be seen as tiny white flakes or may present as barely perceptible roughness of the skin, or as shiny, tight appearing skin
Epithelial disruption in the form of excoriations, fissuring, weeping, crusting or yellow scale2
Lichenification in the form of thickened skin, exaggerated skin markings and lichen type scale which is shiny rather than flaking.
Pathology/Laboratory Findings
Because eczematous conditions can be caused by instigators such as candida, contact with allergens or irritants, and lichen simplex chronicus can also be stimulated by skin response to underlying dermatoses such as lichen sclerosus, careful detective work includes yeast cultures and, if the diagnosis is not clear, biopsy. Acanthosis and spongiosis are most frequently seen on biopsy.
Diagnosis
Diagnosis is accomplished by a combination of scrupulous history taking, clinical observations, and histopathology.
Differential Diagnosis
Differential diagnosis includes psoriasis, seborrheic dermatitis, contact dermatitis, and eczematous candidiasis.
Treatment and management
Treatment for all the eczematous vulvar skin conditions is the same.
- Identify contributing factors such as yeast infection and treat them. Culture for yeast even if it is not seen under the microscope. Because the use of topical steroids, the primary treatment for eczematous vulvar skin conditions, may make women more susceptible to candidiasis, consider treatment for yeast even if it is not seen. (See table below).
- Encourage the wearing of loose, comfortable, non-binding clothing. Examine life style issues that may have brought the condition on. Eliminate irritants or allergens and treat the skin with soothing warm water soaks, patting dry gently.
- Cool gel packs, bags of frozen peas wrapped in soft cloth, or frozen water bottles, similarly softened, may be soothing.
- Application of a thin film of petrolatum can be helpful in sealing in moisture and making the patient more comfortable.
- Scratching must stop! Reduce itching with topical Lidocaine 5% applied up to six times a day as needed to quell the itching.
- Reduce night time scratching with hydroxyzine 10 to 25 to 50 mg orally at bedtime if the patient desires it. Benadryl is sometimes helpful as an alternative that patients may be more familiar with.
- Patients may have developed a habit of scratching that is hard to break, especially because the scratching brings temporary relief or pleasure. Helping them become more aware of the behavior is a first step. Adjunctive treatment with SSRIs (SSRIs in treatment plans) may be of use.
- Steroids, the dose and route of medication dictated by the severity of the condition, are extremely important in the resolution of eczematous skin conditions. In general, topical steroid ointments range in potency from low to mid to super potent. Low grade itching and skin that is not too inflamed can be treated with low potency steroid ointment. More extensive discomfort and skin disruption can be treated with the higher dose ointments. For extensive disorders or those that are unresponsive to topical treatment, intramuscular or oral steroids can be helpful. Intralesional steroids are used in the case of very thick plaques or localized but recalcitrant disease. See table below.
- After the symptoms are controlled, the frequency of application and the potency of the cortisone can be gradually reduced, as indicated, moving from the mid potencies down to a mild steroid such as 1% to 2.5% hydrocortisone or desonide 0.05% ointment. Avoid creams.
See table below.