Intralesional injection of steroid can be helpful in hyperkeratotic lesions such as hypertrophic lichen planus or nodular prurigo. Foam preparations, such as those used in inflammatory bowel disease, are helpful for intra‐vaginal use. Other options include prednisolone pessaries or a small dilator coated with a topical steroid ointment in conditions such as erosive lichen planus.
Figure 8.2 Fingertip unit.
Adverse effects
Most side effects are due to inappropriate use, either in duration of treatment, excessive amounts applied, or from the incorrect potency of preparation for the condition. The potential side effects are local at the site of application or very rarely from systemic absorption [10]. These effects are more of a risk in children where the ratio of the body surface area to body weight is higher.
Local effects
Local effects are atrophy and striae due to reduced synthesis of collagen, telangiectasia, and purpura (Figure 8.3). The telangiectasia are due to dilatation of the capillary vessels. Some of the change may be reversible if the treatment responsible is stopped.
A papular, erythematous eruption is sometimes seen on the thighs, buttocks, and inguinal folds. This has many features in common with peri‐oral dermatitis – a rosacea‐like condition seen on the peri‐oral skin of young females who have been applying topical steroids. The treatment is to withdraw the topical steroid slowly, and oral tetracyclines may be needed at the same time.
If a fungal infection is mistaken for an eczematous process and a topical steroid applied, the scaling is lost and is replaced by papules and nodules without the usual features of tinea cruris. This picture is then termed tinea incognito (see Chapter 19) and may require systemic antifungals for treatment.
Reactivation of viral infection such as human papillomavirus (HPV) and herpes simplex can occur. This can often respond to a reduction in potency of the steroid, and in the case of herpes simplex, a prophylactic dose of aciclovir (200–400 mg twice daily) can be given if intensive potent steroid treatment is needed as in the induction regimen for lichen sclerosus.Figure 8.3 Steroid telangiectasia and atrophy in a patient using excessive quantities of topical steroid.
Contact allergy can occur to the steroid molecule itself. This is more common with the non‐fluorinated preparation [11].
Prolonged use of a topical steroid with occlusive nappies has been implicated in infantile gluteal granuloma.
Systemic effects
Suppression of the hypothalamic–pituitary–adrenal (HPA) axis leading to iatrogenic Cushing’s syndrome can occur if large amounts of a potent steroid are used on large areas continuously, but this systemic effect is exceptionally rare with the amounts used on the vulva. Reports of Cushing’s syndrome have been described in children, but in all cases there was excessive, unsupervised use [12,13], with one case using 60g of an ultra‐potent steroid in 8 weeks, far in excess of recommended amounts. Cushing’s can present with central obesity, a buffalo hump, purpura and striae, proximal muscle weakness, osteoporosis, hyperglycaemia, and sometimes psychiatric disturbance. Investigation with a synacthen test will confirm the diagnosis, and referral for endocrinological advice on management is needed.
Calcineurin inhibitors
The topical calcineurin inhibitors (CNIs) have anti‐inflammatory and immunomodulatory actions. They inhibit calcineurin phosphatase, resulting in the reduction in T‐cell activation and cytokine production. They have been used in several vulval dermatoses [14], but are not as effective as potent topical steroids in lichen sclerosus and lichen planus.
Adverse effects
When these treatments are recommended, the main emphasis is on the fact that they do not induce skin atrophy; however, they are not without side effects, which are particularly relevant to their use on the vulva. They can induce infection such as herpes simplex [15]. There are also concerns about potentiating malignancy if used in lichen sclerosus and lichen planus [16]. They often sting when applied.
Imiquimod
Imiquimod is an immune response modifier which was originally used in the treatment of genital warts. It has an effect on both the innate and adaptive immune responses and increases cytokine production. It is therefore pro‐inflammatory. They are now used for several conditions including superficial cutaneous malignancy elsewhere (superficial basal cell carcinoma and lentigo maligna), high grade squamous intraepithelial lesion (HSIL), and extra‐mammary Paget’s disease.
Adverse effects
These cause a significant inflammatory reaction and need to be applied much less frequently than in extragenital sites. Patients will often tolerate only once or twice weekly treatment for the vulva. Silver sulphadiazine cream can be used as a soothing rescue if the soreness is particularly severe. Flu‐like symptoms are reported by some patients. Cases are reported where the development of another dermatosis, such as vulval pemphigus, has been linked to the use of imiquimod [17]. Lichen sclerosus and lichen planus have been described after its use in males [18]. It needs to be used with care in patients with a pre‐existing dermatosis, as more severe reactions can occur. One patient with Behcet’s disease using imiquimod to treat genital warts developed very large ulceration with its use [19].
The other adverse effect is a change in pigmentation with imiquimod. Vitiligo‐like hypopigmentation can occur which may be long‐lasting [20].
Potassium permanganate
If the vulval dermatosis is weeping and eroded, then soaks can be useful for a short period. The antiseptic potassium permanganate in low dilution (e.g. 1:10 000) can be very helpful to dry the area so that topical creams and ointments can then be used. A pad of gauze is soaked in this weak solution and then applied to the vulva for 10 minutes two or three times a day for no longer than 48 hours. It is vital to warn the patient that it will cause brown staining on anything that it comes into contact with, such as all containers, clothing, and skin. The discoloration will resolve as the skin renews.
Lubricants
Lubricants are widely used for intercourse, and patients feel very positive about their use [21]. Patients report that they prefer a feeling of wetness, and this is reported more in those over 40 years of age. Lubricants are helpful in patients with vaginal dryness as part of the genitourinary syndrome of menopause, especially if they are not happy or able to use topical oestrogens. They are available as water‐, oil‐, or silicone‐based preparations, but water‐based preparations are better tolerated and give less genital side effects [22]. However, the use of any formulation of lubricant gave increased rates of sexual pleasure.
There is a wide variation
