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Pruritus is a frequent symptom in many dermatological diseases. In this review we want to focus on not only itch problems specific to women, namely, pruritic vulvodermatoses, but also the specific pruritic dermatoses of pregnancy. The specific characteristics of the vulva and the hormonal changes during the different age periods make these dermatoses very particular.

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It seems that vulvar diseases are still underdiagnosed and undertreated. Pruritic vulvar diseases Postherpetic itching + anal a huge impact on quality of life. The most common pruritic diseases will be discussed, such as atopic and contact dermatitis, psoriasis, lichen sclerosis, lichen planus, and infectious vulvaginitis.

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We focus on the diagnostic issue of these diseases and will consider the general principles of therapy. In this review we want to focus on not only itch problems specific to women, namely, pruritic inflammatory vulvar Postherpetic itching + anal, but Postherpetic itching + anal the specific dermatoses of pregnancy.

Considering these dermatoses we have to take into account the following points: The changing level of estrogens leads to changes in hydration, collagen content, and concentration of glycosaminoglycans.

INTRODUCTION

In addition there will be also changes in vulvovaginal pH and microflora compositions [ 1 ]. Vulvovaginal pH is high in childhood, but in puberty the pH starts to decrease from an average of 7 to an average of 4 in adult women. Lactobacilli start to colonize the vulvovaginal area. In the first half of Postherpetic itching + anal hormonal cycle estrogen levels rise and vulvovaginal epithelial cells proliferate.

In the second half of the cycle, which is progesterone mediated, the keratinocytes desquamate. There are also changes of the bacterial flora during the hormonal cycle. Also the pH levels are going to fluctuate and eventually cause Postherpetic itching + anal an increase of pH may activate the proteinase-activated receptor-2 PAR-2 which is a well-known itch mediator. Due to the decrease of estrogens, vaginal pH is going to rise in menopause [ 1 ]. The commonest vulvar dermatosis in both adults and children is dermatitis.

The majority of these patients are atopic [ 2 ]. In prepubertal girls atopic and irritant dermatitis occurs often together. Clinical examination Postherpetic itching + anal erythematous and scaly labia majora with frequently rugosity, due to lichenification.

The labia minora may be erythematous and scaly.

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The itch is constant, and the dermatosis is fluctuating. Irritant contact dermatitis may be due to poor hygiene habits or excess use of soap or prolonged wearing of wet swimming suits. Allergic contact dermatitis is very unusual in children because the exposition to potential allergens is low [ 2 ].

It Postherpetic itching + anal complicate the presentation of other dermatoses. Theoretically there is an increased risk for sensitization: The predominant symptom is itch, but burning and pain may also be present, especially if fissures occur. Clinical examination shows erythema and swelling and in chronic cases lichenification is frequently present Figure 1.

Common irritants include soaps, antiseptics, lubricants, spermicides, tampons, Postherpetic itching + anal pads, and synthetic underwear. Several studies have highlighted the usefulness of patch testing in case of vulval pruritus [ 4 — 6 ].

A prospective study showed a very high rate of contact sensitivity in patients presenting with vulval pruritus. Many relevant allergens did not belong to the European standard series so there is a need for extended patch testing. Topical anesthetics and antibiotics, preservatives, dyes, and perfumes are potential allergens.

In order to get a complete list of all the topical applications that women use, do take into account that women regularly use preparations available over the counter. Excessive cleansing of the vulvar skin, as well as urinary and fecal incontinence, may also precipitate to an irritant dermatitis.

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Finally estrogen-deficient patients are particularly prone to irritant contact dermatitis [ 8 ]. Management consists in the removal of all irritants and potential allergens and application of topical steroids until the skin returns to normal. Lichen sclerosus LS is a chronic inflammatory dermatosis of unknown etiology first Postherpetic itching + anal by Hallopeau in as an atrophic form of lichen planus [ 9 ]. Most cases are seen in prepubertal girls or in postmenopausal women.

A possible association with psoriasis has been suggested [ 10 ]. Classically it is taught that LS does not affect the vagina, in contrast to lichen planus, which is an important clue in the differential diagnosis.

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A few cases of LS with vaginal involvement have been reported [ 9 ]. Atrophy, erosions, fissures, and ecchymoses may also be present.

In advanced cases a loss of genital architecture may occur with subsequent effacement of the labia minora and clitoris Figure 2. In most cases the itch is predominant but some women will complain more of soreness, burning, and pain. Some pediatric cases resolve with puberty, while others may continue to adulthood.

The authors who presented very recently the 2 new cases of LS with vaginal involvement put the question forward if this is not underdiagnosed because the vagina may not be examined carefully for LS or because lesions may be subtle or atypical.

Both presented cases had significant pelvic organ prolapse and so the vaginal mucosa was more chronically exposed. This brings into question whether squamatization of the vaginal mucosa may play a role in the development of the vaginal LS lesions [ 9 ].

Treatment consists of high potency topical corticosteroids, also in younger patients; however, it is proposed to use not the most potent preparations in these younger patients. The prevalence of lichen planus LP in the genital area is much lower than lichen sclerosus [ 11 ]. Differential diagnosis with lichen sclerosus is not always easy. Lichen sclerosus is normally confined Postherpetic itching + anal the vulva while lichen planus may affect the vulva as well as the vagina.

Other localizations such as the scalp, oral mucosa, skin, and nails may help to confirm the diagnosis of lichen planus. Women complain of soreness, itching, burning, and dyspareunia. Three types of vulvar lichen planus have been described: Erosive LP is characterized by erosions involving the introitus, clitoris and clitoral hood, labia minora and majora.

A lacy white edge to the erosions is regularly seen. Healing erosions may appear as a glazed erythema. Vaginal involvement is very common and presents with vaginal erythema, contact bleeding, erosions, and scarring with Postherpetic itching + anal.

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In rare cases vaginal lesions may be the only manifestation. Very recently diagnostic criteria for erosive LP of the vulva have been published [ 13 ]. The classical type presents with small purple, polygonal papules, with sometimes a reticulate lace pattern.

Postinflammatory hyperpigmentation is rather frequent in the flexures. Hyperkeratotic lichen planus presents as single or multiple white-hyperkeratotic papules and plaques.

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Many patients present with a mix of different clinical subtypes. A very recent study documents that a significant percentage of patients with vulval LP have associated lichen planopilaris [ 14 ].

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The commonest pattern of scalp lichen planopilaris was that of the frontal fibrosing alopecia variant FFA. Treatment consists in the first place of topical steroids. Classical LP is normally treated with a moderately potent topical corticosteroid. For hypertrophic disease a very potent Postherpetic itching + anal corticosteroid is indicated. A hypertrophic lesion that responds poorly to treatment requires a biopsy to rule out a malignant lesion. Erosive vulvovaginal lichen planus is difficult-to-treat dermatosis, which is usually chronic and persistent.

Systemic therapy has to be taken into consideration if local therapy is insufficient. Because of the rare Postherpetic itching + anal of squamous cell carcinoma, a long term follow-up is necessary.

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The clinical presentation of lichen simplex chronicus is also typical on the vulva: Lichen simplex chronicus may occur secondary Postherpetic itching + anal pruritic conditions such as lichen sclerosus or contact dermatitis. It is also important to take neuropathic itch into consideration as etiology of lichen simplex chronicus. This could be associated with sacral spinal compression, postherpetic neuralgia, and diabetic neuropathy [ 1 ].


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