Gliflozin (SGLT2 inhibitor) induced vulvitis.

INTRODUCTION: Sodium-glucose co-transporter 2 (SGLT2) inhibitors, or gliflozins, are used as mono or combined therapy in the management of diabetes. Genital infections are the most common reported adverse effect, as a result of induced glycosuria. Cutaneous features of patients experiencing vulval symptoms while on SGLT2 inhibitor therapy have not been clearly described in published literature. We have observed a specific inflammatory vulvitis with psoriasiform features in patients taking SGLT2 inhibitors, related to candidiasis in most cases. METHODS AND RESULTS: Demographic and treatment outcomes of 11 patients with characteristic inflammatory changes after starting SGLT2 inhibitors were extracted from electronic records. Ninety-one percent (n = 10) had candidiasis, treated with fluconazole. Six (54.5%) were able to continue SGLT-2 inhibitors through the addition of topical treatments, but five patients had to discontinue the drug. CONCLUSIONS: SGLT2 inhibitors can result in characteristic inflammatory vulvitis. Treatment with topical agents and single-dose antifungals may allow patients to continue their therapy to achieve improved glycemic control. In resistant cases, discontinuation of the drug is necessary. We highlight this effect so that early treatment can be initiated to alleviate symptoms and recognition of underlying cause.

Vulvar Silicone Granuloma.

We report a case of vulvar silicone granulomas following injection of liquid silicone into the labia. The patient is a 51-yr-old female who presented with vulvar pain and enlarged, indurated labia majora. In the past, she had undergone bilateral labial cosmetic augmentation with a silicone-based filler injected directly into the labia and into the gluteal regions. This had been performed in a nonmedical setting. At surgery, oblong firm soft tissue masses were removed from both labia. Microscopically, the lesions demonstrated replacement of the subcutaneous adipose tissue by fibrous tissue containing innumerable round empty spaces of different sizes, either within or surrounded by macrophages and occasional foreign-body giant histiocytes. The clear vacuoles corresponded to silicone fluid which had been dissolved during tissue processing. There are only rare case reports of vulvar silicone granuloma in the literature, and these were due to migration of silicone to the vulva from distant sites. Our report details a case of vulvar silicone granuloma secondary to direct injection of liquid silicone material into the labia.

Vulval fixed drug eruption due to paracetamol.

Paracetamol is a readily available non-prescription analgesic. Fixed drug eruption (FDE) is a well-reported side effect of paracetamol, usually the classic, pigmenting type. In women, it may present as a chronic, erosive vulvitis. We describe a case of FDE due to paracetamol presenting as a chronic erosive vulvitis in an older woman taking multiple medications. Diagnosis was delayed because paracetamol is available without prescription, taken intermittently and may be omitted from the clinical history. Cessation of paracetamol led to prompt resolution of symptoms. Consideration should be given to paracetamol as a cause of FDE presenting as a chronic erosive vulvitis.

Vulvitis attributed to hypersensitivity to estrogen. A report of 11 cases.

BACKGROUND: Vulvitis that is refractory to all treatment remains a therapeutic challenge. Hypersensitivity to progesterone and estrogen has been recognized as a rare cause of premenstrual dermatoses. Such hypersensitivity seemed to be the cause of vulvitis in the patients described below. CASES: Nine women had treatment-resistant cyclic vulvitis and two patients had vulvitis develop after commencing hormone replacement therapy (HRT). These patients demonstrated delayed-type hypersensitivity responses by intradermal testing to endogenous estrogens, with two of the patients also reacting to intradermal testing with progesterone. A group of 19 healthy control subjects with no history of vulvar symptoms did not react to any test substance. Ten subjects with other vulvar dermatoses also did not react to any test substance. Of the nine patients with cyclic vulvitis, one recovered at menopause, and three responded to therapy aimed at lowering endogenous estrogen levels. One was able to control symptoms with a potent topical corticosteroid, and four elected not to be treated. Both patients with HRT-related vulvitis recovered when HRT was ceased. CONCLUSION: Hypersensitivity to estrogen appears to be implicated in chronic, cyclic vulvitis and vulvitis related to HRT in these patients. This is the first report of vulvitis due to estrogen hypersensitivity. The problem may not be rare and should be considered in patients with unexplained cyclic vulvitis unresponsive to standard therapy or in those developing noncandidal vulvitis on HRT. Specific therapy aimed at suppressing or antagonizing estrogen may be required in these patients.

Efficacy of nonoxynol 9 contraceptive sponge use in preventing heterosexual acquisition of HIV in Nairobi prostitutes.

OBJECTIVE: To determine the efficacy of the nonoxynol 9 contraceptive sponge in preventing sexual acquisition of the human immunodeficiency virus (HIV). DESIGN: Prospective, randomized placebo-controlled trial. SETTING: Research clinic for prostitutes in Nairobi, Kenya. PATIENTS AND INTERVENTIONS: One hundred thirty-eight HIV-seronegative women were enrolled, of whom 74 were assigned to nonoxynol 9 sponge use and 64 to placebo use. These two groups did not significantly differ with respect to demographic characteristics, sexual practices, or prevalence of genital infections at enrollment, except for a lower number of sex partners per week and a higher initial prevalence of genital ulcers among women assigned to nonoxynol 9 sponge use. Among the 116 women who returned for follow-up, the mean durations of follow-up were 14 and 17 months for the two groups, respectively. MAIN OUTCOME MEASURE: HIV seroconversion. RESULTS: Nonoxynol 9 sponge use was associated with an increased frequency of genital ulcers (relative risk [RR], 3.3; P less than .0001) and vulvitis (RR, 3.3; P less than .0001) and a reduced risk of gonococcal cervicitis (RR, 0.4; P less than .0001). Twenty-seven (45%) of 60 women in the nonoxynol 9 sponge group and 20 (36%) of 56 women in the placebo group developed HIV antibodies. The hazard ratio for the association between nonoxynol 9 sponge use and HIV seroconversion was 1.7 (95% confidence interval [CI], 0.9 to 3.0). Using multivariate analysis to control for the presence of genital ulcers at enrollment, the adjusted hazard ratio for the association between nonoxynol 9 sponge use and seroconversion was 1.6 (95% CI, 0.8 to 2.8). CONCLUSIONS: Genital ulcers and vulvitis occurred with increased frequency in nonoxynol 9 sponge users. We were unable to demonstrate that nonoxynol 9 sponge use was effective in reducing the risk of HIV infection among highly exposed women.

Chemoprevention of cervix cancer: Phase I-II: A feasibility study involving the topical vaginal administration of retinyl acetate gel.

A Phase I-II clinical trial has been conducted with a retinyl acetate (RA) gel applied cervicovaginally in women having a histopathologic lesion diagnosed as mild or moderate dysplasia. With informed consent, volunteer subjects were observed and followed with Pap smears and colposcopy in a standardized protocol involving a self-administered 7-day treatment course for three successive menstrual cycles. Varying dosages of RA including placebo, 3, 6, 9, and 18 mg per 6 g of an inert vehicle were employed. A total of 50 subjects were monitored for local and systemic side effects. No intolerable side effects or disturbing toxicity was reported or detected at any of these doses. With the 18-mg dosage, significant discomfort was reported by all women. Despite associated side effects and a considerable patient effort involved in carrying out the self-administration of the gel, a high level of compliance was achieved in this trial. It has been established that women will voluntarily participate in an intervention clinical trial to determine whether retinyl acetate is an alternative method of therapy of presumed precancerous lesions of the cervix. The analysis of the side effects of the gel at the various dosage concentrations favors the selection of the 9-mg dosage for a multicenter Phase III clinical trial to determine efficacy.

Human cutaneous vulvar reactivity to irritants.

To better understand the cutaneous reactivity of vulvar skin, two chemical irritants were applied topically to 21 subjects. The forearm of each subject served as a comparative control. Test sites remained open and were read at 24 hours. A significantly increased response to the irritants was noted on the vulvar skin.