General Principles of Therapy
Peter J. Lynch
This section discusses only the general principles of therapy. The specifics of individual therapeutic agents and their use for a particular disorder are contained with the discussion of the diseases as it occurs throughout this book.
The Patient as a Person
One of the guiding principles of medical therapy is the recognition that a disorder is occurring in an individual person rather than existing as a separate, localized problem. This is particularly true for patients with genital disease where there are immense psychological, social, and sexual considerations associated with almost every problem occurring in this location. For instance, patients are highly likely to have a perception that the cause of their problem relates to improper sexual activity or to inadequate hygiene. Whether this turns out to be true, partially true, or false requires that the clinician search for the presence of anxiety, depression, guilt, or other aspects of psychological dysfunction in all patients with anogenital disorders. If one or more of these problems are identified, the clinician must offer two forms of help. First, one must offer nonjudgmental support, and second, one must either provide personal counseling or must assist the patient to obtain counseling by some other qualified professional. Failure to recognize the patient as a person, and thus overlook these responsibilities, is very likely to compromise the therapeutic outcome even when the disease itself is properly identified and treated correctly from a medical standpoint.
Environmental Factors and Hygiene
The anogenital area represents a very hostile environment for normal function of the mucocutaneous epithelial cells that make up the barrier between us and the outside world. Some of the detrimental factors that are involved include heat, sweat, vaginal secretion, urine, feces, clothing, friction, and improper or excessive hygiene. These factors can cause disease, worsen minor problems, and/or retard normal healing.
Sweat
Epithelial cells can generally withstand rather high temperatures but, unfortunately, with heat comes sweating. And sweat can be remarkably irritating as exemplified by the discomfort experienced when sweat gets in one’s eyes during exercise on a warm day. The retention of sweat in the anogenital region leads to maceration of the mucocutaneous surface and this in turn leads to damage and possibly death of epithelial cells. This damage to the epithelial barrier allows for the exposure of cutaneous nerve endings and results in symptoms of pruritus and/or pain. The presence of this warmth and moisture also fosters the overgrowth, and often infections, due to bacteria and/or Candida sp. Obesity, tight clothing, and prolonged sitting (especially on vinyl or plastic seats) are often responsible for such sweat retention and maceration. It is difficult, but worth trying, to ameliorate these conditions.
Urine, Feces, and Vaginal Discharge
In women, vaginal discharge (whether physiologic or pathologic) or urinary incontinence can cause irritation with subsequent inflammation and damage to epithelial cells. The end result is similar to that described for sweat retention. To make matters worse, women with urinary incontinence or vaginal discharge often end up using panty liners on a continual basis. The result is often even worse maceration. The cause of such vaginal secretions (see Chapter 14) should be determined and treated appropriately. Incontinence may require urologic consultation. In both sexes, fecal soiling can lead to irritation. More careful cleaning after defecation is desirable so that sweat does not liquefy and spread irritating fecal material. Usually, careful use of ordinary toilet paper is sufficient but if that causes too much irritation, Cetaphil Cleanser, Water Wipes, mineral oil, vegetable oil, or a wet soft cloth can be used for anal cleansing.
A change from tight pants (especially jeans) to looser fitting clothing can be helpful in the prevention and treatment of adverse environmental factors. The use of cotton or cotton blend underwear can also be useful. However, and in spite of the frequent admonition to use only white undergarments, the color of one’s underwear has not been demonstrated to be of any particular importance. Hair dryers, even at their lowest settings, should not be used for purposes of drying. It is our opinion that changes in laundering practices, such as double rinsing and avoidance of antistatic products, are not particularly helpful.
Excessive Hygiene
Excessive hygiene, especially in women, is frequently overlooked as an environmental irritant. Hygienic practices are rarely volunteered by patients and are, unfortunately, infrequently asked about by clinicians. A dry, chapped appearance is suggestive of too much cleansing even if a patient’s history regarding washing is not helpful. More than twice daily cleansing of the anogenital area is unnecessary and is usually detrimental. Soap and water applied with the hands or with a washcloth suffices; scrubbing is never warranted. Water Wipes may also be suitable. A handheld showerhead can be used by those who are otherwise unable to reach the anogenital area.
Additional information on environmental irritation can be found under “Irritant Contact Dermatitis” in the eczematous disorders section of Chapter 5.
The Therapeutic Use of Soaks
Soaks serve several purposes. First, they can offer symptomatic relief for both pruritus and pain. Second, they offer a gentle approach to the debridement of any crust that is present. This removal of crust decreases bacterial and yeast overgrowth and removes a mechanical impediment to wound healing. Third, soaks temporarily restore a physiologic moist environment that enhances epithelial healing. Fourth, soaks are one of the few approaches to therapy that can be safely, appropriately, and helpfully suggested by telephone before the patient can be examined.
Dermatologists historically have made somewhat of a fetish with their recommendations regarding esoteric and complicated solutions for soaks. But in reality, soaks for problems occurring in the anogenital region can be accomplished very simply by partially filling a bathtub with ordinary tap water. A sitz bath-type chair may be used for those who cannot easily get in and out of a bathtub. The water temperature should be comfortably warm rather than very hot or very cold. Nothing further needs to be added to the water and in fact many of the products sold for such purpose make the floor of a bathtub dangerously slippery. Soaking should occur for a period of 15 or 20 minutes, following which the skin should be patted, rather than rubbed, dry. The soothing effect of a soak is lost within about 30 minutes because the water quickly evaporates from the skin. This evaporative loss can be delayed by the prompt application of a lubricant (see below). Soaks may be repeated several times per day if the buildup of crust is troublesome or if the severity of pain or itching requires it.
Soaks should be considered as “first aid” and not as something to be continued indefinitely. After several days of soaks, weeping and crusting should be markedly diminished, and there will usually be no further improvement in pain or pruritus. Moreover, prolonged use of soaks may lead to detrimental excessive drying of the epithelium. A perceived need for longer use of soaks generally suggests that one’s therapeutic plan requires revision.
General Principles of Topical Therapy
Most topical products are available as creams or ointments. In the genital area, ointments are often preferred because they are less likely to cause irritation and burning as often happens with creams; the down side of ointments relates to their messiness and propensity to cause maceration if too much is applied. If this is the case, creams can be used instead. It is rarely appropriate to use gels, lotions, or solutions in the anogenital area because of their irritating properties.
Most patients have no idea how much of a topical product should be used for any one application. It is reasonable to suggest an amount about the size of a lead pencil eraser (˜0.2-0.3 g). That amount, spread appropriately thinly, will usually cover the external genitalia. Note, however, that if the area to be treated is hairy, a larger amount will be required for each application. One of us (LE) instructs that far far less of a topical corticosteroid be applied, and expects a 15 g tube to last 4-5 months with daily use. Nearly all products are most appropriately applied twice a daily. Thus, if a patient is neither underusing, nor overusing, the product, a standard-sized 30-g tube, should last a month or more. Most products are also available in larger sizes (60-80 g). These larger sizes may be more economical to prescribe if the patient’s disorder requires long-term therapy and if the patient is educated as to how long the larger amount should last.
Patients are often uncertain as to just where the product should be applied. Instructions in this regard should be given not only verbally but also by demonstration. For this purpose, a patient-held mirror can be used if the site is not otherwise visible to the patient.
Lubricants
Epithelial cells are very sensitive to the amount of moisture in and around them. In the section above, we indicated that too much moisture leads to maceration and cell death. Epithelial cells are also very sensitive to too little moisture. When evaporative loss of natural moisture occurs faster than it is replaced by the underlying interstitial fluid, epithelial cells shrink in size and pull apart. In either case, disruption of the barrier layer (which is located in the outer portion of the epithelium) occurs. Such disruption allows for exposure and triggering of sensory nerve endings, resulting in pain and/or pruritus. Lubricants are used to retard evaporative loss and thus provide for a more physiologic environment and faster subsequent repair of the disrupted epithelial barrier layer.
There are two common circumstances in which the barrier layer becomes disrupted because of excessive dryness. First, and as mentioned above, this can occur as the result of excessive washing, utilization of harsh solvents,
or with scrubbing rather than simple washing. The use of soap and water on the genitalia more than twice a day removes the naturally present lipids and leads to excess water loss from the epithelial cells. Second, barrier layer disruption occurs in the presence of disease-related thickening of the stratum corneum. This thickening can occur as the result of underlying inflammation or secondary to the process of lichenification (see definition in Chapter 2). In either of these two situations, interstitial moisture from the underlying dermis cannot adequately diffuse into the outermost epithelial cells. The abnormally dry epithelial cells shrink and the epithelial surface then tends to fissure, allowing even more water loss from these cells. Lubrication, by way of retarding evaporative water loss, restores a more physiologic epithelial environment and helps to alleviate the usually attendant symptoms of itching and/or pain.
or with scrubbing rather than simple washing. The use of soap and water on the genitalia more than twice a day removes the naturally present lipids and leads to excess water loss from the epithelial cells. Second, barrier layer disruption occurs in the presence of disease-related thickening of the stratum corneum. This thickening can occur as the result of underlying inflammation or secondary to the process of lichenification (see definition in Chapter 2). In either of these two situations, interstitial moisture from the underlying dermis cannot adequately diffuse into the outermost epithelial cells. The abnormally dry epithelial cells shrink and the epithelial surface then tends to fissure, allowing even more water loss from these cells. Lubrication, by way of retarding evaporative water loss, restores a more physiologic epithelial environment and helps to alleviate the usually attendant symptoms of itching and/or pain.
Many types of lubricants are available. Those that are petrolatum based (eg, Vaseline) do not sting on application. They do a very good job of preventing evaporative water loss but are messy, sticky and, if thickly applied, may be counterproductive by way of trapping sweat. Products such as these are best used in infants and young children, though some adults find them surprisingly acceptable. Lotions, which lie at the other end of the spectrum, are liquids that can be poured or pumped out of a container. Although these are cosmetically very pleasing on intact mucocutaneous tissue, they contain very little in the way of lipids and therefore do a relatively poor job of lubricating. Moreover, most lotions contain alcohols and other chemicals that can cause stinging on application. This is particularly noticeable when applied to the tender skin of the anogenital region, especially in children. A reasonable compromise is the use of any one of the standard products (“hand creams”) that are inexpensive and easily available. Though most dermatologists have a specific brand they like to recommend, we have found that allowing patients to choose the brand they prefer leads to the best compliance for use.
Steroidal Anti-inflammatory Therapy
Anti-inflammatory therapy is the most important and most often used specific treatment in dermatology. Given the prime role for such therapy, it is dismaying to find that it is often misused. Attention must be given to the route for use (eg, topical, intralesional, or systemic), the dosage, the amount to be dispensed, and the duration of time for which the product is to be used.
Topical Steroid Therapy
Topical steroid therapy represents the mainstay of antiinflammatory treatment (Figs. 3-1 and 3-2). The number of topical steroid products available is unmanageably large. We have found that clinicians only need to be familiar with four of these. All four are available either by brand or
generically. The generic products can be found on most formulary lists. Advice from a dermatologist or pharmacologist might be sought in the event that one’s desired topical steroid is not available and that a substitution is needed. Hydrocortisone and triamcinolone can be purchased at reasonable prices if the patient lacks insurance coverage for medications. Fluocinonide and clobetasol are appreciably more expensive but coupons (such as from GoodRx) are frequently available for somewhat more reasonable prices.
generically. The generic products can be found on most formulary lists. Advice from a dermatologist or pharmacologist might be sought in the event that one’s desired topical steroid is not available and that a substitution is needed. Hydrocortisone and triamcinolone can be purchased at reasonable prices if the patient lacks insurance coverage for medications. Fluocinonide and clobetasol are appreciably more expensive but coupons (such as from GoodRx) are frequently available for somewhat more reasonable prices.
 Fig. 3-1. This patient with lichen simplex chronicus reports years of excruciating pruritus, with resulting remarkable hyperpigmentation and thickening from ongoing rubbing, and even hair broken off at the surface. |
 Fig. 3-2. Two months after beginning clobetasol propionate ointment daily, itching has resolved, thickness is clearing, the texture is nearly normal, and hair has regrown. |
Hydrocortisone is a low-potency steroid. It is available as a 1.0% product (nonprescription strength) or a 2.5% product (prescription strength). Either of these is suitable as initial therapy for eczematous anogenital disorders in infants and children. Safety, even with long-term use, is excellent but their level of effectiveness is correspondingly low.
Triamcinolone acetonide is a mid-potency steroid. It is available in several strengths, but for the most part, only the 0.1% strength needs to be considered. Triamcinolone is appropriate for second-line therapy of eczematous disease in children and initial therapy in adults. Safety, even with long-term use, is quite good.
Fluocinonide is a high-potency steroid. It is available in several strengths, but only the 0.05% strength needs to be considered. It is suitable for second-line therapy of eczematous disease in adults (first line for lichen simplex chronicus) and initial therapy of papulosquamous and other noneczematous disease.
Clobetasol propionate is a super-potency steroid available as a 0.05% product. It is suitable for second-line therapy of lichen simplex chronicus and for first-line therapy of noneczematous disorders such as lichen sclerosus, lichen planus, and psoriasis.
From a standpoint of systemic adverse effects, all of the topical products described above are reasonably safe even for long-term use. When the high-potency and superpotency products are restricted to use on the modified mucous membranes of the vulvar vestibule and the glans penis, safety in terms of cutaneous side effects is also excellent. However, when clobetasol is used on skin (rather than on mucous membranes) or is allowed to spread onto skin due to heat and sweat, there is a fairly high risk for the development of skin atrophy, telangiectasia, and striae (Figs. 3-3, 3-4, 3-5). This is particularly likely to happen when used on (or is inadvertently spread onto) the upper inner thighs. It is not clear whether this can happen with the use of fluocinonide, but caution is warranted.
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