Vulval lichen sclerosus: An Australasian management consensus.

BACKGROUND/OBJECTIVES: Vulval lichen sclerosus (VLS) is a chronic inflammatory skin condition predominantly affecting the anogenital region in women and children. To date, there is lack of agreement amongst experts on a severity scale to aid assessment, research and treatment stratification on VLS. Furthermore, literature on best practice for long-term management of VLS is lacking. The aim of this consensus is to provide broad guidelines on the short and long-term management of VLS. METHODS: An initial focus group of Australasian experts in vulval dermatology developed a draft consensus statement for the management of VLS. Based on the results of the draft statement, a consensus panel of 22 Australasian experts, comprised of the initial and additional members, participated in an anonymous four-stage eDelphi process. Round 1 involved generation and voting on statements from the draft consensus statement developed by the focus group. In Rounds 2, 3 & 4, panel members were presented formal feedback from previous rounds and asked to indicate their level of agreement. Consensus was reached if there was ≥70% agreement on the importance of an item in the 4 (agree) to 5 (strongly agree) range. RESULTS: The expert panel, with a total of 504 collective years of experience in the field of VLS, reached consensus on a core set of 51 management statements related to diagnosis, severity, initial and long-term management, follow-up, and complications of VLS. CONCLUSIONS: This study has identified a set of management statements for VLS that may be useful in clinical practice in the Australasian population.

Rituximab causing deep ulcerative suppurative vaginitis/pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a rare cause of purulent vulvovaginal ulceration. Six recent cases of vulvovaginal pyoderma gangrenosum associated with rituximab are described. All cases were seen in the setting of rituximab used for the treatment of B cell non Hodgkin's lymphoma (NHL). Age range was 50-74; symptoms were present for 2-24 months and severe pain, heavy discharge and large, deep purulent ulcers extending into the vagina were seen. This article reviews previous reports of vulvovaginal pyoderma gangrenosum, discusses important differential diagnoses in this setting, and provides evidence supporting rituximab as the cause of pyoderma gangrenosum in this cohort.

Vulvovaginal pyoderma gangrenosum secondary to rituximab therapy.

Rituximab is being used increasingly for the treatment of B-cell malignancies and nonmalignant conditions. Pyoderma gangrenosum is a rare neutrophilic dermatosis, which can be either idiopathic or associated with underlying systemic inflammatory conditions. We present a series of 4 patients who presented with ulcerative pyoderma gangrenosum in the vulvovaginal area after treatment with rituximab.

Postmenopausal vulval disease.

Vulval disease in the postmenopausal age group is relatively common. Some vulval conditions such as lichen sclerosus are more prevalent in the postmenopausal years. Often more than one condition is present at the same time. Accurate diagnosis is essential for effective treatment. The risk of progression to malignancy associated with some of these diseases dictates long-term surveillance.

Prospective study of patch testing in patients with vulval pruritus.

Forty-three patients with the primary complaint of vulval pruritus were recruited to take part in this prospective patch-testing study. A detailed questionnaire was administered to each and patch testing to an extended battery of allergens was undertaken. This included the European standard series, preservatives, corticosteroids and a battery of common over-the-counter topical vulval treatments. Analysis of demographic data and prior treatments used, and various other parameters, were studied in the context of patch-test results. This prospective study reports a very high rate of contact sensitivity in patients presenting with vulval pruritus, with 81.4% of those tested having at least one contact allergen detected. One or more clinically relevant allergens were found in 44% of the subjects patch tested. The variables found to predict a greater likelihood of a contact allergy were a biopsy diagnosis of vulval dermatitis, the use of multiple topical treatments, sexual inactivity and patients with severe pruritus on a self-reported scale. Most importantly, many clinically relevant allergens these patients reacted to were outside the European standard series. This highlights the need for an extended series in this patient population.