9 Eczema is a very common inflammatory skin condition with endogenous and exogenous causes. The major symptom is itch. The terms eczema and dermatitis are used interchangeably but ‘dermatitis’ is often used when the inflammation is caused by the application of an exogenous agent, such as an irritant, or when there are allergic causes. Eczema does occur on the vulva but there is a tendency to overuse this diagnosis for any itchy, red lesions. It is always important to specify the type of eczema and to differentiate it from psoriasis and candidiasis, which can look similar. The genital skin is often spared in those with the most common form of eczema, atopic eczema. The three common forms of the disease that occur on the vulva are seborrhoeic eczema, allergic contact dermatitis and irritant dermatitis. These will be considered separately but there are some common principles applicable to all types of vulval eczema. The pathophysiology is due to a defect in the barrier function of the skin. This leads to the characteristic features of dryness, erythema and inflammation (Figure 9.1). Figure 9.1 Chronic eczema showing inflammation and dryness. The histological features of eczema on the vulva are the same as those elsewhere, but may vary depending on whether the condition is acute or chronic. An eczema or dermatitis is characterized by intercellular oedema (spongiosis). In acute cases, accumulation of fluid can lead to the development of small intraepidermal vesicles. Lymphocytic infiltration of the epidermis (exocytosis) is another feature. Secondary infection is common with all forms of eczema and the intense inflammatory reaction seen as a consequence can sometimes cause confusion from the histological point of view. In chronic eczema, the epidermis thickens, with features similar to the hyperplasia seen in psoriasis. Seborrhoeic eczema is common and the mild form of scaling of the scalp (commonly known as ‘dandruff’) may affect up to 20% of the population at some point. There is evidence for the role of the yeast organism, Pityrosporum ovale, as a pathogenic agent in seborrhoeic eczema. The disease is usually more florid and severe in the immunosuppressed. The histological features can be nonspecific with hyperkeratosis and some neutrophil exocytosis. Yeast organisms are frequently seen on PAS staining. Itching is the most common symptom but soreness and discomfort may occur. The signs of seborrhoeic eczema affecting the vulva are often subtle and may just consist of mild erythema on the inner aspects of the labia majora and minora. Superficial scaling may be seen on the rims of the labia majora and keratin debris can build up in the interlabial sulci. It is very important to differentiate this from the ‘cheesy’ discharge seen in candidiasis. It is important to examine other sites as seborrhoeic eczema rarely occurs only on the vulva. Fine scaling on the scalp and inside the ears will often be found and the axillae and central chest may be involved. The diagnosis is usually clinical and so a biopsy is rarely needed. An emollient should be used as a soap substitute. A mild topical steroid (grade I/II) can be applied daily for 2 weeks, then reducing in frequency to as required for recurrent symptoms. A combination treatment of a topical steroid and an antibacterial or anticandidal is helpful. Some patients sometimes have recurrent candidiasis, which occurs with eczema and these often need oral anticandidal treatment to allow the inflammatory problem to settle. General measures, such as cutting the nails, are helpful in all types of eczema. This will at least limit the likelihood of breaking the skin even with significant scratching. Dermnetz: British Association of Dermatologists: An allergic contact dermatitis can affect the vulva but it is rarely a primary problem and most commonly occurs as a secondary issue when the patient develops a contact sensitivity to a topical treatment or one of its constituents. A helpful clue in the history is that of an acute worsening of symptoms with application of treatment. If the perianal area alone is involved then an allergic contact problem is more likely. Common causes are given in Table 9.1. Table 9.1 Common causes of contact dermatitis on the vulva.
Eczema, Allergy and the Vulva
Seborrhoeic eczema
Incidence
Pathophysiology
Symptoms
Clinical features
Basic Management
When to Refer
Practice points
Further reading
Useful Web Sites for Patient Information
Allergic Contact Eczema / Dermatitis
Introduction
Example
Topical treatments
Antibiotics, local anaesthetics
Local anaesthetics
Benzocaine
Antibiotics
Neomycin
Preservatives
Parabens, methylisochlorothiazolinone
Fragrances
Propolis
Rubber accelerators
Carba mix
Cosmetics
Nail varnish
Incidence
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