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Cases:Your Diagnosis Is?

Hope K. Haefner, MDProfessor

Michigan Medicine

Department of Obstetrics and Gynecology

Ann Arbor, Michigan  USA

Libby Edwards, MDMid‐Charlotte Dermatology and ResearchCharlotte, North Carolina  USA

Disclosures

• Hope K. Haefner, MD was previously on the advisory board of Merck Co., Inc.

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Written Information Available:

University of Michigan Center for Vulvar Diseases (Google)

http://obgyn.med.umich.edu/patient-care/womens-health-library/vulvar-diseases

Then, click on Information on Vulvar Diseases

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Course Objectives

At the end of this lecture, the participant should be able to:

1.   Identify the clinical features of various vulvovaginal conditions

2.   Become familiar with a variety of treatments for skin diseases

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Gross and Histologic Images

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Test FormatThe image shown represents 

which vulvar condition?

Test FormatThe image shown represents 

which vulvar condition?

Vulvar intraepithelial neoplasia

Melanoma

Molluscum contagiosum

None of the above

C

B

A

D

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41 y.o. G2P2 c/o painful intercourse 

Present for 3 years  

Cyst was needle drained in the office

Grown since last visit and hurts with intercourse 

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Your Diagnosis Is?

A. Bartholin duct cystB. Gartner duct cystC. Skene duct cystD. Rectocele

Your Treatment Is?

A. Cyst wall biopsy with KevorkianB. Marsupialization of cystC. Excision of cystD. No treatment needed

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38 yo G1P1 with clitoral mass

• Increasing in size for the past 28 years

• Enlargement at clitoral location noted at her last delivery 3 years ago

• Past workup by an endocrinologist included an MRI of her adrenals/kidneys and a testosterone work up which were negative 

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S100 Confirmatory Staining

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Your Diagnosis Is?

A. Sarcoma

B. Lipoma

C. Plexiform schwannoma

D. Normal clitoral tissue

Video

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76 y.o. hx of vulvar irritation and lichen sclerosus

• Added onto clinic for new onset of severe pain in her vulvar area

• Intense burning pain over her vulva and buttock

• Primary MD saw her 2 days previously‐recommended that she use warm or cold compresses and topical lidocaine

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Your Diagnosis Is?

A. Aphthous ulcers

B. Shingles

C. HSV 2

D. Erosive lichen planus

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How many different typesof herpes exist that affecthumans with disease?

A. 2

B. 4

C. 8

D. 80

Which type causes shingles?

A. HSV 1B. HSV 2

C. HSV 3

D. HSV 8

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http://en.wikipedia.org/wiki/Herpesviridae

How many people in the US develop shingles?

A. 1 out of every 3 people 

B. 1 out of every 4 people 

C. 1 out of every 5 people

D. 1 out of every 6 people 

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• Reduce the risk of developing shingles and the long‐term pain from post‐herpetic neuralgia (PHN) by getting vaccinated (age 60 years)

• Antiviral medicines—acyclovir, valacyclovir, and famciclovir to shorten the length and severity of the illness

• Analgesics (narcotics, gabapentin),wet compresses, calamine lotion, and colloidal oatmeal baths

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62 y.o. woman with vulvar irritation

• First noted lump on vulva in 2011

• It grew and she underwent a biopsy.

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Your Diagnosis Is?  Part 1

Lichen planus

Lymphangiomas

Lichen sclerosus

HGSIL

A

B

C

D

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Your Diagnosis Is?  Part 2

Lichen planus

Lymphangiomas

Lichen sclerosus

HGSIL

A

B

C

D

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They can become black in color.  The theory behind this color change is 

secondary to:

Association with diabetic skin  changes

Premalignant changes (compound nevi)

Scar changes from frequent rupture 

Hemorrhage

A

B

C

D

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Skin Closed with Interrupted Sutures

Doing well   

No Recurrence for 1.5 yearsSmall recurrence recently noted

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Skin GraftNo recent follow up‐ was doing well but only saw her 3 months out from surgery (multiple personality disorder)

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50 y.o. G3P2 with vulvar pain and irritation (right > left)

• Her gynecologist had given her an antifungal and she had not improved

• Her pain is severe‐ she is unable to spread her legs apart

• She has been treated with antibiotics and antifungals without resolution of her pain

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Your Diagnosis Is?

a. Candidiasisb. Lichen sclerosusc. Scabiesd. Camera needs a new flash

Anything else you want to see?

a. Yesb. No

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She can’t tolerate an in office biopsy. She is taken to the OR for biopsy/excision. She is on coumadin. To minimize her

bleeding you:a. Stop the coumadin. Take her to the OR when

her coag labs are normal.b. Stop the coumadin. Convert to heparin as

an inpatient, then stop heparin and take to OR.c. Stop the coumadin. Start on Lovanox and

take to the OR.d. Keep her on coumadin. Excise with a fine

tip Bovie in OR for diagnosis.

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Dx- invasive keritinizing squamous cell carcinoma,moderately differentiated. Invasion

extends into subcutaneous fat without definitive vascular space involvement. Depth of invasion

approximately 5 mm. You recommend:

a. Wide local excisionb. Laserc. Radical vulvectomy and unilateral

LNDd. Radical vulvectomy and bilateral LND

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Summary

When patients do not respond to therapy

–Reconsider the diagnosis

–Check for infection ‐ fungal, bacterial, HSV

–Consider contact dermatitis to a medication, over washing, etc.

–Evaluate for carcinoma

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Great Job!

Questions and Answers