and changes in these outside the normal physiological range for the vulva and vagina can cause epithelial damage and irritation [23]. Ideally, a product that is most similar to the physiological environment should be recommended. When formally tested, many have an acidic pH and high osmolality, but individual components may be more relevant on in vitro testing [24]. Excipients, perfumes, microbiocides, and preservatives such as parabens may be added to lubricants, and so it is always important to consider an allergic contact dermatitis if symptoms occur with their use.
Non‐surgical treatments
Phototherapy and photochemotherapy
Ultraviolet radiation (UVR) has been used to treat skin disease since ancient times. It is mainly used to treat psoriasis, but several other dermatoses will respond [25]. The wavelengths used in treatment are ultraviolet A (UVA) (320–380 nm) and ultraviolet B (UVB) (280–320 nm). Exposure to UVR induces direct DNA damage and a shift of the immune response to Th2.
In phototherapy with photochemotherapy (PUVA; psoralen and UVA), psoralen is either taken orally or applied topically to enhance the effect of the UVA. This treatment causes the most DNA damage and has carcinogenic potential. Its use has been reported in small studies in genital dermatoses [26]. However, it is limited in vulval disease as it difficult to expose the genital area to light in isolation, and there are concerns about the carcinogenic risk.
Photodynamic therapy (PDT)
PDT relies on the interaction between a photosensitiser, oxygen, light, and the tissue affected [27]. The photosensitisers generally used are aminolevulinic acid (5‐ALA) or methyl aminolevulinate (MAL). These are applied to the lesion and reactive oxygen species are generated, which when activated by blue or red light cause cell death. It can be used systemically, but topical PDT is the most widely used. Only the abnormal cells which take up the photosensitiser are damaged so that the surrounding skin is unaffected, therefore giving good cosmetic results. It has been used to treat lichen sclerosus (LS), lichen planus (LP), HSIL, and extra‐mammary Paget’s disease.
Adverse effects
The photosensitiser has to be left in place for a few hours so the whole treatment can be prolonged. Light exposure is often very painful, and there is a marked inflammatory reaction after.
Resources
Patient information on treatments is available at www.bad.org.uk and www.dermnetz.org. Last accessed September 2021.
References
1 1 Chen, Y., Bruning, E., Rubino, J. and Eder, S.E. Role of female intimate hygiene in vulvovaginal health: Global hygiene practices and product usage. Womens Health (Lond). 2017 Dec; 13(3): 58–67.
2 6 Kai, A. and Lewis, F. Long‐term use of an ultrapotent topical steroid for the treatment of vulval lichen sclerosus is safe. J Obstet Gynaecol. 2016; 36(2): 276–277.
3 7 Chi, C.C., Wang, S.H., Wojnarowska, F. et al. Safety of topical corticosteroids in pregnancy. Cochrane Database Syst Rev. 2015 Oct 26; (10): CD007346.
4 10 Hengge, U.R., Ruzicka, T., Schwartz, R.A. and Cork, M.J. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006 Jan; 54(1): 1–15; quiz 16‐8.
5 23 Edwards, D. and Panay, N. Treating vulvovaginal atrophy/genitourinary syndrome of menopause: How important is vaginal lubricant and moisturizer composition? Climacteric. 2016 Apr; 19(2): 151–161.
9 Bacterial Vaginosis
Gulshan Sethi
CHAPTER MENU
Diagnosis Amsel’s criteria Hay–Ison method Nugent score
Bacterial vaginosis (BV) is the commonest cause of abnormal vaginal discharge in women of childbearing age, with a prevalence varying from 5% to 50%. It was found in 12% of pregnant women attending an antenatal clinic in the United Kingdom [1], and in 30% in women undergoing termination of pregnancy [2].
Pathophysiology
The pH of the normal vagina is preserved below 4.5. BV generally occurs as a consequence of a disturbance in the vaginal flora resulting in an increase in the pH to 6.0. This is associated with overgrowth of Gardnerella vaginalis and the other anaerobic species (up to a thousandfold), together with a reduction in lactobacilli.
Clinical features
The characteristic symptom of this condition is an offensive vaginal discharge, due to the production of amines such as putrescine, cadaverine, and trimethylamine that give off a characteristic fishy odour [3]. Vaginal inflammation is uncommon; hence, the term vaginosis is used rather than vaginitis. Symptoms may be exacerbated by factors which lead to an increase in vaginal pH such as douching, menstruation, and the presence of semen in the vagina. Although BV occurs more commonly in sexually active women, evidence for its sexual transmission is lacking, and treatment of the sexual partners of women with this condition does not prevent it from recurring [4,5]
Diagnosis
The diagnosis may be made by the fulfilment of Amsel’s criteria
