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Vulvovaginal Diseases: Explore the Infectious and Noninfectious Conditions that Affect Your PatientsTranscriptNCTCFP:Thank you all for joining us today for Vulvovaginal Diseases: Explore the Infectious and Noninfectious Conditions that Affect your Patients. We're going to go ahead and get started a little bit early just for housekeeping information to save plenty of time for the content. Next slide. Great. A quick note, this webinar is now live and being recorded. This webinar will be available for future viewing along with a copy of today's slides. Audio will stream to your computer device. If you prefer to call in, the phone numbers are included in your registration confirmation. You might type questions for our presenter at any time using our Q&A feature. We'll host a Q&A session after the slide presentation. You can also use the chat feature for any comments.NCTCFP:Next slide. A quick note on chatting in the Zoom webinar. To be sure all attendees see your comment or question, please go to "To" at the bottom of your chat feature. Select the down arrow and select "All panelists and attendees." Make sure you're continuing to do that as you chat to our chat box today. Next slide. This webinar offers 1.0 contact hours for nurses. After viewing this live webinar, you'll be directed to a survey with a link for evaluation CE. You'll also receive an email tomorrow with this information, and certificates will be emailed in three to four weeks. There's no commercial support for this presentation. UMKC and ANCC do not approve or endorse any commercial products associated with this activity. Next slide.NCTCFP:The speaker and Planning Committee have disclosed any conflicts of interest. The speaker is an author on UpToDate. The Planning Committee has nothing to disclose. Jacki Witt and Kristin Metcalf-Wilson serve on the Afaxys advisory board and advisory panel, which has been resolved. This presentation is supported by a grant from HHS, OASH, OPA. The contents do not necessarily represent the official views of these groups. Next slide.NCTCFP:AAFP and the American Nurses Credentialing Center Commission on Accreditation have reviewed this presentation for credit. You'll see a CE disclosure that you received beforehand, and you'll also receive it afterwards as well. Next slide. So, there's an image content note, especially for those of us that are working from home and maybe not in a clinic setting. Due to the nature of this presentation, these slides will include medical photographs, various vulvovaginal diseases from real case studies. Next slide.NCTCFP:Perfect. I would now like to introduce our speaker, Dr. Hope Haefner. Dr. Hope Haefner, MD is a Harold A Furlong Professor in the Department of Obstetrics and Gynecology at the University of Michigan Hospitals in Ann Arbor, Michigan, where she received her medical degree. Dr. Haefner is a Board-Certified Obstetrics and Gynecology. She opened the University of Michigan Center for Vulvar Diseases in 1993. It is one of the few clinics in the United States that specializes in treating these conditions. She has a national and international reputation in this field. She is a specialist in philosophy and has a particular interest in high grade squamous intraepithelial lesions of the vulva, lichen sclerosus, lichen planus and HS.NCTCFP:She's the primary author in Vulvodynia Guideline published in 2005. Dr. Haefner is active in vulvovaginal disease research. She was a co-investigator and R01 with Dr. Barbara Reed, The Longitudinal Population-Based Study of Vulvodynia. Dr. Haefner is the past president of the International Society for the Study of Vulvovaginal Disease and the past president of the American Society for Colposcopy and Cervical Pathology. With that, I'll let you take it away, Dr Haefner.Dr. Hope Haefner:Thank you. I'm so honored to be speaking to this number of participants. I'm amazed over 400 participants. We're going to explore the infectious and noninfectious conditions that affect your patient. First, we're going to talk about some clinical features. Occasionally, I'll slip in histology slide but not too many. And then we're going to focus also on the various therapies that are used for these vulvovaginal conditions. I've given you lots of information that you can refer to throughout your careers. I update them. This is a QR scan that goes straight to our website if you're interested; or if you don't happen to use QR codes, you can Google Vulvar Diseases: Resources for Patients and Providers.Dr. Hope Haefner:On that website, we have tons of information, many different lectures that I've given. We have written material. We have 140-some-page handout. We have patient intake forms, etc. Today, we're going to be focusing more on the horses than the zebras, but I may occasionally slip in one zebra or other one unusual condition that might be affecting the vulva. I think it's important to know the anatomy of the vulva at all times. This diagram was actually drawn by Dawn Danby, who happens to be the daughter of Lynne Margesson. Lynne Margesson and I lecture together frequently. Lynne is a dermatologist.Dr. Hope Haefner:I would say the majority of what I know about the vulva I have learned from dermatologists. It's a skin, correct? The vulva is majority skin and hair bearing areas. We see diseases in all of these areas from the mons pubis down to the anus. We use colposcopy in our clinic on a few conditions. For example, one of the things I'm very interested in is the pre-cancers of the vulva, the high-grade squamous intraepithelial lesions of the vulva. But I also happen to look at vagina and cervix too in my practice. For the vulva, all you need is some form of magnification and the colposcope is great for that. But I think for the vagina, cervix and something with depth like into the anus, you need the colposcope. On the vulva, however, all you really need is any form of magnification.Dr. Hope Haefner:This is a magnifying glass we use in our Center for Vulvar Diseases. The big lens is two times magnification, the little one is four times magnification. As I age, I find all I really need to do is take off my progressive lenses to see magnification. When we're looking at HPV-related diseases, we put either 3% or 5% acetic acid on the vulva. So, this would be the patients that have high grade lesions that are HPV-related over 90% of the time. We leave the vinegar on for three to five minutes. Often, I'll tell a silly joke. I think the medical assistants in my clinic could tell the jokes backwards. I've said them so many times. We use copious amounts of vinegar and reapply it often. You have to be careful though. If a patient has a break in the skin, you may not want to use this on that area.Dr. Hope Haefner:Why do we use vinegar? Well, it makes tissue that is non-glycogenated often from the HPV virus turn a white color. We call it acetowhitening. However, in the vestibule, the area between Hart's line and the hymen, that can turn white just because it's a nonkeratinized squamous epithelium. So, if it's a smooth whitening in that area, I don't worry. The other things that can be confused with high grade or low grade condyloma are the vestibular papillae. These are normal finger-like projections that are in many women's entranceway. I'll show you a picture of them.Dr. Hope Haefner:Before we get to that, I'm going to talk about how to do a vulvar biopsy. Anesthesia is very important. We use one or 2% lidocaine with epinephrine. The only time I don't use epinephrine is if I'm doing a biopsy of the clitoris. They consider the clitoris a distal extremity like the nose, the fingers, the toes, etc. You're not supposed to use epinephrine on distal extremities. But on the rest of the vulva, I will use 2% lidocaine with epinephrine. I tend to use a 30-gauge needle, but if it's a real thick tissue, I'll go down to a 27. You inject intradermally. You raise a small bleb.Dr. Hope Haefner:The other things I do to decrease the pain or the stretch the skin, I distract the patient. I already mentioned using a 30-gauge needle. And then after I insert before I inject, because often it's what you're injecting that hurts more than the needle, I pause. Also, you want to make sure the solution you're injecting is not cold. That can be more painful. This is the classic biopsy we use in our Center for Vulvar Diseases. It is a four-millimeter punch biopsy. You can see the number four on it. These come in different sizes. I occasionally will do a three-millimeter punch biopsy when I'm biopsing the clitoris. It's rare that we have to biopsy the clitoris, but on occasion we do.Dr. Hope Haefner:So, on that, I'll use a three-millimeter. It does come in bigger sizes such as five-millimeter, six-millimeter, etc. But we rarely need to go above four millimeters to get an adequate diagnosis on the vulva. It allows a full thickness skin sampling. You have to be careful though and handle the tissue very gently. You must decide prior to doing the biopsy how you're going to get hemostasis, so you have everything ready. We tend to use ingredients that cause hemostasis such as silver nitride or Monsel's solution, but sometimes we'll use sutures. So, if you're going to use a suture, of course, you'll need that handy. This shows on your left, numbing the area and on the right, getting the biopsy.Dr. Hope Haefner:I want to emphasize though you rarely need to go down to the very end of that hub as you see in this diagram. The only time I go to that thickness is when I'm worried about a cancer. You want to biopsy the areas that are abnormal appearing. So, if there's two colors, go with the darkest, the most raised, where it's irregular. If you have bullous lesions, ulcers or sclerotic lesions, consider biopsied at the edge.Dr. Hope Haefner:However, if you have a concern for cancer... I'll never forget one patient that had been referred where she'd had multiple biopsies done at an edge. When I touched, the entire area of, I'll put in quotes, this "ulcer" was firm, and I went right in the center. It was an invasive of squamous cell carcinoma. Always think about where you are on the vulva and the anatomy and communicate that with the pathologist and avoid traumatized areas.Dr. Hope Haefner:Should you use topicals? Should you use stitches? It all depends on the patient, the situation. I tend to use topicals more than stitches, but I confess, I do both. It all depends on their previous experience, whether or not it's bleeding more than I want, etc. So, the ferric subsulfate works very well. Also, you can use aluminum chloride, 35% in alcohol, and then the silver nitrate. For sutures, you want to use a fine suture, a dissolvable. My favorite is the 4'0 Vicryl Rapide. It dissolves within two weeks. But also, at times, I'll use 3'0 or 4'0 Vicryl or 4'0 Monocryl.Dr. Hope Haefner:Another biopsy technique I'd like to share with you is the scissor shave or the suture lift that we call it. This works really well in areas such as the vestibule where the tissue's friable, or as you see in this patient, the perianal tissue. What you do is you know what the area and you put a stitch in, and you just use the suture to lift up the tissue. And then you use Iris scissors to cut underneath it, and then you send the specimen on to pathology.Dr. Hope Haefner:Post-biopsy care's important. We talked about using loose clothing, wash with water frequently. I preach no soap on the vulva, particularly liquid soaps. They're very irritating. Warm water soaks, cool gel packs. I try to avoid having patients use ice packs at all times. I had the misfortune of seeing a patient that had put ice on her vulva nonstop for 48 hours. Mind you, she was treating vulvar pain. Her pain was gone, but the reason her pain was gone was she had gangrene on the entire vulva. Leave the vulva to air, or if you need to cover it, use petrolatum. You rarely need antibiotics for these. Avoid having the patient use any steroids maintenance on the area until it's healed. The healing can take up to two weeks.Dr. Hope Haefner:When you're sending the specimen, communicate with your pathologist, "Where did you do the biopsy? What's your differential diagnosis?" It really helps them narrow down. If it doesn't make sense what the diagnosis comes back as, call them. They also love to receive gross photos of the lesion that you're biopsied.Dr. Hope Haefner:Now, let's talk about some infectious conditions that affect the vulva. This is a 30-year-old gravida zero. She had multiple vulvar lesions as you can see, and they'd been present for several months. I'm going to give you some higher power views to help you make the diagnosis. Focus on her bottom left, you see those two together. Higher power view of that, and you'll notice. Do you see a central indentation in that high-power view? So, what's your diagnosis? Do you think this is a blister from herpes? Is it a squamous cell carcinoma, or could this be molluscum contagiosum? Those of you that think it's molluscum contagiosum are correct.Dr. Hope Haefner:How do you treat it? It's treated with multiple different things. You can freeze it. You can curette it. You can use an agent called Cantharidin, often used in the pediatric population. You can use Podophyllotoxin, Imiquimod, KOH, salicylic acid or topical retinoids. Many things work, basically, you just need to destroy the skin. This molluscum contagiosum is caused by a DNA poxvirus. Many people carry it. Sometimes, particularly in children, you might want to use an oral agent. Cimetidine has been shown to work for this.Dr. Hope Haefner:My favorite treatment for adults is using a 30-gauge needle and I take the needle. I go right in the center and just make a small little line and break the center of it and then scrape out with the rest of the needle the contents. While you think that would be uncomfortable, the majority of time it's not uncomfortable for the patient. If your patient happens to be immunosuppressed, consider Imiquimod, Cidofovir. Interferon alpha is used at times. But the main thing that we have to think about with any viral disease in an immune suppressed patient is recovery of the immune suppressed states. So, can their meds be adjusted? Can they get treated for their HIV, etc, and fix their immunosuppression?Dr. Hope Haefner:This is an unfortunate patient with a herpes lesion, or as I should say, lesions. You see multiple areas of erosions. We're taught that herpes are blisters and then they become ulcers, but actually what they really are the majority of time in the non-immunosuppressed patient is an erosion. How do you diagnose it? Well, first, you have to have a clinical suspicion for it, and then you need to do some virologic test. We do PCR, Polymerase Chain Reaction, in our hospital. I find it to be very accurate and very quick. I have diagnosed it on biopsy before, but it isn't the usual way of doing it. Some people use Cytology, Tzanck smears. I mentioned Lynne Margesson, the dermatologist I lecture with, she does those on occasion. But really the PCR is what we go with the majority of time.Dr. Hope Haefner:I do want to mention serologic testing for herpes. A lot of places say serologic testing is not needed. However, if you happen to be a specialist in vulvovaginal conditions or seeing a large population of patients with herpes, you may need to do this test at times. It's an IGG for Type 1 and Type 2 that you test.Dr. Hope Haefner:So, let's do an audience response. How many different types of herpes viruses can affect humans? Is it A. 2, B. 4, C. 8, or D. 80? Type in your response. Looks like it's close between 2, 8 and 80. I think we can end the polling. So, the majority of you are correct, it is 8. I did mention Type 1 and Type 2, those are for the lower genital tract. Those of you that said 80, perhaps you're thinking about all different species, not just humans, because there are 80 or so HSV types that affect all species. But the correct answer is 8.Dr. Hope Haefner:The one we see in gynecology most frequently is Type 2 that affects the vulva, but Type 1 can also affect the vulva. Many of you are familiar with herpes zoster, the varicella, that's Type 3. Some of you that do pediatrics I'm sure see CMV and EBV. The one that I dread seeing is Kaposi sarcoma, and that's a Type 8.Dr. Hope Haefner:What's the difference between Type 1 and Type 2? Type one tends to affect the mouth, Type 2, the vulva. However, Type 1 can also affect the vulva. Type two doesn't really like much more than the vulva. Occasionally, you can see it in the mouth, and unfortunately, at times it can go to the brain and cause encephalitis which is a devastating condition. Let's talk about Type 1. Besides cold sores, you can go on the trigeminal ganglia in this area here. It can affect the lips, the eyes or it actually can go to the brain. It can go and cause encephalitis, ocular herpes or herpetic whitlows. It does not protect against HSV-2.Dr. Hope Haefner:Whereas two, as I mentioned are the genital ulcers. It's stored in the lumbo-sacral ganglia. They're typically two-thirds of the new general cases. Although one has been on the rise over the last several years. I mentioned this can cause a terrible encephalitis. Interestingly, it does protect somewhat against Type 1. Most often, these are erosions. I wanted to show you this picture to show what an erosion looks like. You may notice though she's got a Foley in place. She came in with her primary herpes outbreak to the emergency room unable to urinate and required fully catheterization and admission for pain medication. Surprisingly though, 80% of people don't even know they have their primary herpes outbreak. They can be all sorts. This is an immunosuppressed HIV positive patient.Dr. Hope Haefner:So, let's talk about getting antibody testing if you happen to do it and how are you going to interpret it? If both are negative, they don't have herpes unless they were just infected. So, you want to do a follow up testing on that population if you're suspicious. If HSV-1 is negative and 2 is positive, you're right, it's most likely genital herpes. If HSV-1 is positive and 2 is negative, it's uncertain, possible genital, possible oral. If Type 1 is positive and 2 is positive, again, we're not quite sure whether it's genital or oral.Dr. Hope Haefner:Treatment. If you haven't ever been to the CDC STD Treatment Guidelines, I highly recommend it. That's the website. They are revising it, and hopefully, in the very near future, a new set will be out. They have all the treatments and dosing for primary, recurrent. The main agents are Acyclovir, Famciclovir, Valacyclovir.Dr. Hope Haefner:The quality of life is improved in patients when you put them on suppressive therapy rather than episodic treatment. Years ago, the guidelines said someone had to have six or more herpes outbreaks on their vulva before you could consider suppression. I have no idea who wrote that, because I can't imagine six outbreaks in a year. Sometimes I've even put people on suppression after a severe single outbreak.Dr. Hope Haefner:Who do you want to think about suppressive therapy on? Discordant couples, patients with multiple partners, if they're pregnant at 36 weeks and known to be positive patients, as I just mentioned, bothered by outbreaks. You have to counsel them though. Even if they're on the suppression, they still may be shedding the virus, but often, it's a lot less to shed.Dr. Hope Haefner:So, herpes viruses are a virus with a bad reputation. HSV-2 infection increases the potential for HIV infection and transmission. Suppression doesn't always eliminate transmission, as I just said. Unfortunately, they've been working on a vaccine for this condition for years for humans, and we're still not there.Dr. Hope Haefner:Let's move on now to another organism that affects the vulva. This is Candida albicans. This patient has a classic white discharge and on microscope you see pseudohyphae. In the interest of time, I won't go through all of the agents. However, there's many different topical agents as well as oral agents. So, if you're interested, CDC has these and their dosing. The prescriptive ones are Terconazole or Botoconazole or Fluconazole.Dr. Hope Haefner:How do we diagnose recurrent vulvovaginal candidiasis? It's three or more in a year of Candida infections. So, we tend to see patients that are referred to us have had multiple infections. So, we do a yeast culture, and we want to identify the species. And then we treat depending on the species. I'll tell you a little bit more about that in a minute. Rarely do you ever need to do sensitivities for yeast.Dr. Hope Haefner:The most common type of yeast is Candida albicans, followed by Candida glabrata. The other ones, in the interest of time, I won't go through all of them, but we see them on our yeast cultures fairly frequently. So, let's talk about the second most common Candida glabrata. The first patient I showed you had thick white discharge. This patient just has a red irritated vulva. That's classic for glabrata. It's hard to see glabrata under a regular microscope. So, that's why I talk about using yeast culture to identify species. If you happen to have a darkfield microscope, great, because this is what you'd see. You'd see these little circles here. This is the Candida glabrata right there.Dr. Hope Haefner:How do you treat it? Well, this is a patient before treatment. This treatment that we give is called boric acid. This is her after treatment. Now boric acid is very lethal if used in children. Actually, at one point in time, they used it as a diaper rash powder. Some children died of boric acid toxicity. It is now available on the internet. If you just type in boric acid suppositories, make sure there are 600 milligrams depositories. You can have patients make their own by filling an O-gel capsule halfway with boric acid, and that's actually rat poison. Yes, that is. You can get it at a hardware store. But part of my concern with filling an O-gel capsule and putting rat poison is if they mix it up and take it by mouth. You don't want that. That capsules got to go in the vagina.Dr. Hope Haefner:So, most of time we use a compounding pharmacy or have them get the suppositories over the internet. Often, we'll use Nystatin. Nystatin powder's great for the green yeast. Anybody know why they call it Nystatin? It was developed in New York State by two PhDs, Dr. Brown and Dr. Hazen in the 1950s. Gentian violet's been used for many years. The only problem with gentian violet is it stains that white cotton underwear. I recommend my patients use a deep purple.Dr. Hope Haefner:If you're going to use it at 1%, it probably should be applied in the clinic. But if you're going to do at .25, .5, the patient can apply it themself. It is Category B in pregnancy. Often, if they have an erythematous irritated vulva, we'll combine the topical antifungal with a steroid. So, the easiest one out there is a mixture of Nystatin and 100,000 units per gram with triamcinolone acetonide ointment, 0.1%.Dr. Hope Haefner:For those of you who are interested in yeast, this is where you can find out the sensitivities and what to use for the various kinds, the International Society for the Study of Vulvovaginal Disease. If you go to the App Store for your iPhone or iPad only, you can spend almost $5. I use it on a daily basis however and find it very helpful.Dr. Hope Haefner:Another condition we see is Desquamative Inflammatory Vaginitis. It occurs in about 8% of women that present to the specialty clinics, the vulvovaginal disease clinics. Interestingly, this is more frequent in Caucasians and I have no idea why that is. The peak occurrence is at the perimenopause. If they're in the menopause, you've got to rule out atrophy first, because it looks exactly the same as atrophic vaginitis. Now DIC is a diagnosis of exclusion. First of all, have you even heard of Desquamative Inflammatory Vaginitis? A, yes, B, no.Dr. Hope Haefner:I think we can end at that. I would say several of you have heard of it. That's wonderful, because I was with the no's several years ago. When I first heard of, I said, "I've never ever seen that. That doesn't exist." The next week, I went back to clinic after knowing what it looked like and guess what? I had been missing it for years. I'll show you what it looks like on wet mound in a minute if you're still wondering what it is.Dr. Hope Haefner:What are the symptoms? Dyspareunia, a sign is a spotted rash on the vagina or cervix. We are taught that those little fine red dots, the strawberry cervix is trichomonas, not really very often. That's less than 5% of the time. The majority of time, it's DIV. These patients often have a purulent discharge. The pH is high. It tends to be over 5, sometimes 5.5. If you do a pH, you get it from the lateral wall of the vagina. Don't touch the cervix, it makes it more alkaline. These patients have, as I mentioned, purulent discharge. They have many polymorphonuclear leukocytes on wet prep. They have tons of parabasal cells. I'll show you in a minute what those look like. They don't have lactobacilli, which are good.Dr. Hope Haefner:So, here's the classic appearance. On low power view, you see all of these small cells here. These are white blood cells, but can you see where my arrow is? Here's one, here's one. These are all parabasal cells. There's another one. The best ones are the smaller ones. These are cells, if you remember histopathology, that are by the basement membrane that have hardly any cytoplasm. So, there's a high-power view of the WBCs and the parabasal cells. We don't know what causes it. The more proposed ideologies, the less we know. They think it's immune mediated. It could be the kallikrein-related peptidase, but we don't know. Everything's genetics these days. Could it be a genetic link? We don't know, or is it a bacterial infection? Well, if it is a bacterial infection, we don't know what bacteria it is.Dr. Hope Haefner:But what I can tell you is we have some good treatments for it. If it's their first experience with this condition, we'll use Clindamycin 2% cream. The dosing is all on your handout, so I won't go into that. You can also use a vaginal suppository. Other things that we'll use as a first line of treatment, hydrocortisone, hydrocortisone cream. You can use a 25-milligram suppository twice a day for three weeks or you can have it compounded at a time 300 to 500 milligram. Usually, I'm doing that when it's recurrent.Dr. Hope Haefner:So, on your handout, we have the multiple treatment regimens and the dosing. One of my favorite one they're recurrent and not getting better is to combine the two. We'll compound intravaginal hydrocortisone in a 2% clindamycin base. You do need to make sure that this is not atrophic vaginitis. So, if they're in the menopausal age group, I'll try them on estrogens first, if they're not contraindicated. If they get better, wonderful, it probably was. If they don't, then it could be the Desquamative Inflammatory Vaginitis.Dr. Hope Haefner:Let's move on to some other conditions. On the left, I bet you see this frequently in your offices. For those of you that do a lot of annual exams, on your right, I bet you see this frequently in your office. On your left is condyloma acuminata. On your right is something called papillomatosis. If you take the cotton swab there and you touch each and every one, they're single basis like your fingers, finger-like projections. Whereas the condyloma, they're broad bases with multiple projections. Many different treatments for low grade, you can freeze them, you can burn them, you can use acids on them. All the dosing is in the CDC STD Treatment Guidelines.Dr. Hope Haefner:I unfortunately need to operate on the extensive ones frequently. We use N-95 masks, because people have been exposed to the laser fumes and developed HPV in their nose and larynx. Now, this patient has high-grade disease, which is HPV-related. I can't tell that just looking at it, but if I were to have done a biopsy, which I did to prove it, she had HSIL. Some of you may not know the terminology of high grade, it's what your pathologists or you may have previously called vulvar intraepithelial neoplasia two or three, or moderate to severe dysplasia. The International Society for the Study of Vulvovaginal Disease has had lots of different terminology throughout time. In '86, it was just like the cervix, VIN 1, 2, 3. And then there's another type and I'll show you a picture.Dr. Hope Haefner:It's called Differentiated VIN that is not related to human papillomavirus the majority of time. In 2004, we changed it. You can see what it's called. In the interest of time, I won't go through all of it, but I'm just going to say that 2004 terminology didn't ever take off very well. The pathologists like the word basaloid, but the general gynecologists thought, "It was complex. What did it mean? Who cared? You're going to use usual treatments. It's VIN two or three. Why are you bothering to change it?" And then we, in this 2004 terminology, still had that lichen sclerosus type differentiated.Dr. Hope Haefner:And then in 2012, I happened to be president of the ASCCP at that time. When a meeting was arranged, Teri [Teresa] Darragh at the ASCCP was very involved in getting over 30 organizations together. Some of you may have been present at that meeting, where we tried to come to consensus, what to call low grade, human papillomavirus and high-grade human papillomavirus conditions throughout all different parts of the body? So, the cervix, the vagina, the vulva, the penis, the anus, etc. But one problem with the last terminology is the lichen sclerosus wasn't in that terminology, right? Because that doesn't tend to be HPV-related. We didn't want to lose that.Dr. Hope Haefner:So, in 2014, the ISSVD published another paper that incorporated that with the new ISSVD terminology. HSIL for years was increasing in incidence. I think what happened is pathologists got really good and aware of HPV and how to read it on slides and how to stain it, etc. They all saw different parts of the body and could train others that we're dealing with males, not females, etc, on what it looked like. We were diagnosing people at younger ages. I do want to tell you, though, in the future, this incidence will decrease tremendously, because of HPV vaccines. Although I have to say the US is far behind many other nations, Australia leads with HPV vaccination.Dr. Hope Haefner:What are the symptoms? Many are asymptomatic. Some have itching or burning. Some are irritated. Some have painless sex. I've already showed you some photos for the signs of it. There's no typical gross appearance. It can be gray, white. It can be brown. It can be red. Let me show you some pictures. So, you saw this one already. This was the gray, white. On histology, for those of you that like pathology, you'll see a koilocyte right here, another one up here. You see abnormal nuclei all the way from the basement membrane up to the surface. That's high grade.Dr. Hope Haefner:It can be brown. Here's the disease. Or it can be red, and this red is rare, but I was confused on her. My first look at her, I thought she had Paget's disease, which is an intraepithelial lesion that's pre-cancerous the majority of time. Although it can be cancer. But when I biopsied her, it was actually HSIL. The other reddened area that you see on the vulva can be lichen planus. American College of Obstetricians and Gynecologists and the ASCCP did publish a committee opinion on the management of vulvar intraepithelial neoplasia. It's an excellent opinion.Dr. Hope Haefner:What happens if you don't treat HPV high grade? Well, Dr. Ron Jones, a friend of mine from the ISSVD published this. It wasn't his study. It was unfortunate experiment. I'll tell you about that in a minute where for 30 years, a provider in Australia didn't treat any women that had HSIL of the cervix, the vagina or the vulva. On the vulva, seven out of eight progressed on to cancer. It took 18 years for one of them, but seven out of eight. So, that convinces you that this needs to be treated.Dr. Hope Haefner:Let's focus on the third bullet. The lifetime risk of invasive vulvar cancer after treatment is 3 to 4%. Interestingly, for cervix, it's only 0.3 to 0.4%. So, the vulva is higher risk than cervix on this. So, how do we treat it? We do surgeries. We can do wide local excision. we can laser blade. We can do electrosurgical excision, or you can use imiquimod but that's off label use. It's important to get an adequate margin. I always say get at least a half centimeter, but if you can, get a one-centimeter margin. The depth is very important in helping you determine what type of treatment you're going to use. So, in the hair bearing area, you would have to go down to about three millimeters to get all of the disease. In the non-hair bearing area, two millimeters.Dr. Hope Haefner:So, what we've decided in the majority of people that do treat this condition, we excise in the hair bearing area and we laser in the non-hair bearing area. We do use imiquimod. I particularly like it on the clitoris, on urethra. Although some people use it to debulk disease prior to doing laser. This was a study published in 2007. It was a double blind, randomized study that use topical imiquimod for HSIL. It's the same dosing that you use for your condyloma. You use it three times a week, leave it on overnight for 10 hours, wash it off in the morning with soap and water. You can use it for up to 16 weeks.Dr. Hope Haefner:Another study, this study looked at a seven-year medium follow-up and found that it was effective to use imiquimod for high grade disease. There is an extract from green tea, green tea called Veregen. The problem with that is it's three times a day. I find it hard for my patients to use something three times a day on the vulva.Dr. Hope Haefner:What about recurrence after treatment? It's a bit disappointing looking at this recurrence rate. None of them are very different whether you do a vulvectomy, a partial vulvectomy, local excision or laser vaporization. Nothing was statistically significant. So, these patients need long-term follow-up. I can promise you unless they stopped smoking, any form of cigarette, it'll be back the majority of time. HSIL can occur on any part of the vulva. This unfortunate patient has it from her anus up to her mons pubis.Dr. Hope Haefner:Let's look at the anus. The best way to look at the anus is in the lithotomy position. Now, that's in the gynecology clinics. Some of you may be disagreeing right now that happened to be in a surgery clinic where you have these wonderful tables that put it at the right height. So, that the knee-chest position, you don't have to stand up to view. In our clinic, our tables don't go to the right height for that.Dr. Hope Haefner:So, what I'll often do is have them actually put their hands under their thighs and lift their legs back, and that exposes the anus very well. This is the knee-shoulder position. I was talking about knee-chest position. Now this position, it's a left lateral or Sim's position. The GI doctors like this position very well. I can tell you. I despise this position, probably because it reminds me of a sigmoidoscopy, I had years before. Also, I find it hard to hold that area open in that position.Dr. Hope Haefner:I don't know if any of you're doing anal cytology, but in the patients that have HSIL of the vulva, we do do anal cytology. We use a Cytobrush, but some people use Dacron swabs for these. It needs to go into about three to four centimeters. You put it until you meet resistance. Count to 10. Although I have to tell you a recent article said to count to 20. It's not the most comfortable test for the patient in the world, that's for sure. You send it in the same media you're doing for your Pap smears of the cervix or the vagina. I do do HPV testing on it. I treat it the same as the ASCCP algorithms do for their cervical vaginal cytology and specimens. Notify your cytology department if you are going to be using this technique, because they're going to need to get some things in order prior to looking at these tests.Dr. Hope Haefner:Here's the anus scope that we use. We put it in with lubrication, and we put acetic acid four by four inside it. Take it out and leave it in for three to five minutes if the Pap smear requires a colposcopy by the guidelines. After three minutes, we take the four by four out and re-insert the anus scope with lubrication and look with the colposcope. We look superior and distal to the dentate line.Dr. Hope Haefner:This is Anal Intraepithelial Neoplasia that was high grade. You see mosaicism just like you do on the cervix. This is an unfortunate patient I was called to see in the ER who had pained by her perineum they said. But when I looked, this was invasive squamous cell carcinoma of the perianal vulvar region. So, I do think the vaccine's going to make changes. I can't wait to see its effect here in the United States. I hope it picks up even more.Dr. Hope Haefner:I mentioned to you VIN Differentiated. This is a patient that has lichen sclerosus. You see the whitening, but on her clitoris and on her left labium minus, you see some raised areas that are white and a little bit of red. If that were biopsied on your right, you'd see a keratin pearl and VIN Differentiated. Unfortunately, this is a terrible condition to have. Depending on what study you look, you can have 30% cancer right then and there underline. One study actually found 90% association with cancer. Our histopathology and our biopsies tend to go more with the 30% association with a cancer. This is treated by wide local excision.Dr. Hope Haefner:Let's move on to another condition. This is a patient that's 15 years old. She'd had dysuria, vulvar burning. She's tired. She got had low grade fever. Her health care provider diagnosed her with HSV and started her on acyclovir without doing a PCR. This is day three, and she's no better. This is what her vulva looks at. Notice some black and yellow areas. What do you think she has? Do you think she has aphthous ulcers, atypical herpes simplex, a drug rash, or was she abused? This is traumatic. Let's see what you think. Alright, let's end the polling.Dr. Hope Haefner:The majority of you are going with trauma or abuse, and I can see why you say that. You see this bruised area potentially. The second though is aphthous ulcers, and actually that is the correct answer. This patient has aphthous ulcers. Now, of course, you need to work it up, and I'll talk to you about that. You need to rule out other things. That's a diagnosis of exclusion. But this was an incredible aphthous ulcer patient, very painful.Dr. Hope Haefner:Higher power view, you see the yellow drainage and then the blackish color. It's just dead tissue overlying it. So, what's the difference? You've heard me say erosion versus ulcer. And ulcer goes into the dermis whereas an erosion is just in the epidermis. There's infectious ulcers, many different infections can do it. Thankfully, LGV, Lymphogranuloma Venereum and Granuloma Inguinale and Chancroid we rarely see. I have to tell you, Ann Arbor is one of the most boring cities in the world. I think I've never seen it here, but we do see herpes and we do see herpes in the immunosuppressed and we do see HIV. Syphilis is pretty rare in Ann Arbor too, but it is on the rise. So, have this in mind if you see it and it's part of the ulcer workup.Dr. Hope Haefner:The other are the noninfectious ulcers, trauma, like many of you thought the diagnosis was, Crohn's disease, Behcet's disease, very rare here in the United States, malignancy. Touch and feel, make sure it's not firm throughout. And then I have pyoderma gangrenosum at the base. It's rarely seen. Although recently I've admitted a patient for wound VAC for her extensive buttock and vulvar pyoderma gangrenosum. But more commonly, it turns out to be the diagnosis of exclusion, the aphthous ulcer. We see them often in younger patients.Dr. Hope Haefner:There's many different synonyms. We're trying to get rid of all these synonyms, so I'm not even going to go through them with you. There's minor that are less than one centimeter, major that are over one centimeter. They can be complex when they're in the mouth, the genital area, and they can be recurrent. The majority are idiopathic, but up to 30%, you can figure out what's causing it, whether it's a CMV, an EBV, mycoplasma, pneumonia, etc. They're often in the lower vagina and on the vulva, but they can be on the cervix. They get covered with this blackish necrotic eschar that I showed you. They have sharply demarcated edges that are reddened, and they can take up to 21 days to heal.Dr. Hope Haefner:You need to rule out some of these things on here. If it's the first, also, you're not going to biopsy it. But if someone has recurrent ulcers, you might want to consider biopsied it. If you have any concern, consult your dermatologist. Think about some of these rare conditions that are listed here. It is a diagnosis of exclusion. Look at the eyes, look in the mouth. Look at the vulva. Test for herpes, syphilis, HIV, rule out yeast. If it's recurrent, also do a CBC with differential. Give them pain control. Have them do sitz baths. Many of them need oral steroids depending on their weight, etc, 40 to 60 milligrams with a gradual decrease in dosing. Give them clobetasol ointment.Dr. Hope Haefner:Always use an ointment on the vulva, not a cream if possible. Some of them have to be admitted for fully catheterization, because they can't urinate, they're in so much pain. If these things aren't working, there's a long list of other things. But again, if you're getting down to dapsone, cyclosporine, TNF-alpha inhibitors, it's time to get in my opinion, a dermatologist or at times a rheumatologist, or if you think it's Crohn's disease, a GI doctor involved.Dr. Hope Haefner:We are in the process of making an ulcer app at the ISSVD. We'll keep you posted, watch their website. It should be out within a year. Lynne Margesson and I started with these diagrams. We've spent at least three years trying to get this finished. It's not an easy algorithm, but we're almost there. In fact, we even have parts ready for the iPhone app, but we've decided instead of making people purchase it, we're going to just put it on the website for everyone to use. If you're interested, it's . I hope it's out by the end of the year.Dr. Hope Haefner:Next, I'd like to move on to the big itch. This is probably 50% of what I see in my clinic. Lichen sclerosus, what is a lichen? I spent the summer of 1979 studying lichens up in northern Michigan, Pellston, Michigan. Lichens are a mixture of fungus and algae, but not on the vulva. They're just called lichen sclerosus lesions, because they resemble lichens in nature. They're not fungus or not algae. They're very common actually. Inflammation is present on biopsy. The prevalence is debated, anywhere from 1 and 300 to 1 and 1000 depending on the type of practice you have. Age range, all ages can get it. We see it though in the two extremes of age, a bimodal distribution.Dr. Hope Haefner:Many patients believe it or not are asymptomatic, but if they are symptomatic, it's itching. Sometimes it's severe. They're scratching. They can't sleep. Many of the children with it have what's known as pruritis ani. Other symptoms, burning, soreness. Some people are having painless sex. Some can even have sex. Some can't defecate without pain. I've had to actually open up labia minora that are agglutinated, because someone can't urinate with this disease. It's a devastating condition. Signs of it are whiteness, ivory white papules.Dr. Hope Haefner:We used to call the cigarette paper appearance, but nobody knew what that was because they weren't using marijuana as much. But now that that's back out, maybe we can start calling it again, cigarette paper appearance. It's a cellophane-like sheen, and they have an hourglass configuration. I'll show you that in a minute. It can be patchy, or it can be generalized. They get fusion of the labia minora, I've already mentioned. They scratch. It feels so good to scratch that they scratch even more and then they get these erosions. I'll show you some pictures of that. They can get urinary retention and tearing. Here's that cigarette paper crinkly appearance. This is some redness.Dr. Hope Haefner:Some telangiectasia or purpura sometimes called. That goes along with it, and extensive whitening and loss of labia minora. You can almost draw an hourglass or figure of eight around this. Often, it will go down even more to the anus then in this patient. This patient has whitening and fusion, and right above her clitoris, you'll see a fissure. Fissures can be lichen sclerosus. Fissures can be herpes. Fissures can be yeast. Fissures can be Crohn's. But when you see a fissure in someone that has no labia minora, hourglass configuration, it's most likely going to be lichen sclerosus.Dr. Hope Haefner:Another patient with loss of labia minora. Clitoral changes, thinned epidermis, a band of collagen. There's the inflammation, that bottom arrow. It can occur on many different parts of the body, neck down to soles. It can be on skin tags, can be on scalp, etc. Here's a patient with it on her abdomen. The good news is this gets pretty much cured fairly quickly with a steroid cream. On the vulvar, you're going to use the steroids ointment. You're also going to tell them to use Blanda emollients, 100% white cotton underwear, no occlusive clothing, no soaps on the vulva, but these patients need some steroids and you can use any steroids you want. But my recommendation is to get comfortable with one regimen.Dr. Hope Haefner:We tend to use clobetasol propionate, which is a class one, the strongest steroids, 0.05% ointment. In severe disease, we'll use it twice a day for a month and daily for two months. And then we'll either maintain them twice weekly to three times weekly with that or go to a nightly triamcinolone, a 79.1% ointment or another class four steroids. These are the different types of dosing and how we dispense them for your interest. Sometimes we try to get them down to a class five, the triamcinolone acetonide ointment point, 0.025% nightly if we can.Dr. Hope Haefner:I actually prefer the nightly rather than three times a week or two times a week, because my patients forget to do something twice a week. If they're doing it every night, they tend to do it. What I say to them, "Do you brush your teeth in the morning or in the evening? Just put the steroids by your toothpaste, just don't confuse the two. I don't want you putting the steroid in your mouth or the toothpaste on your vulva." Although steroids in the mouth are used for lichen planus. So, that wouldn't be a problem, but that toothpaste on the vulva, that's a problem.Dr. Hope Haefner:Tacrolimus is used, but it's painful. So, I won't even go into detail on that. Sometimes we use oral steroids. Occasionally, we'll use intralesional. For really severe itch scratch, we'll use intramuscular steroids. The dosing of the intramuscular steroids is the triamcinolone. Here, you see it, can be in the gluteus muscle. It's triamcinolone acetonide 1 milligram per kilogram up to 80 milligrams into the gluteus. You can use it monthly up to three or four months. It works great for severe disease. Sometimes, we'll do intralesional injections.Dr. Hope Haefner:As I showed you here, we'll use Kenalog, triamcinolone and mix it with bupivacaine and do intralesional injections. So, pediatrics, you're not going to be doing biopsies on these patients. I don't biopsy the classic adults either, but if I'm worried about a cancer, I biopsy. In children, we use it under anesthesia. What we are treating is this condition needs steroids to prevent cancer. Two recent studies have shown how cancer can be found in patients that have lichen sclerosus up to 5% of the time. But if they're treated with steroids, they tend to have a lower occurrence of cancer.Dr. Hope Haefner:In the interest of time, I'm going to go to your second to last slide and just mention vulvodynia. Vulvodynia is a devastating condition. At one point in time, it was 80% of our population in our Center for Vulvar Diseases. Our wait time to see a new patient was two years. We decided that we can't have our patients wait that long, because it worsens their vulvodynia. So, we started doing research with Family Medicine here at Michigan Medicine. Now the Family Medicine Department manages patients with vulvodynia and refers them to us if they don't get better or if they need surgery, which is rare, because often the medical management works well. I've included in your handout, a long handout on vulvodynia alone for you to read if you happen to have patients with this condition.Dr. Hope Haefner:We start with vulvar care measures. We go into topical medications. Many of them are compounded. We often will use oral medications. We'll use tricyclic antidepressants. We'll use anticonvulsants. At times, if it's localized to the vestibule and they failed the topicals or the orals or the physical therapy, I love physical therapy for this condition. But if it's localized and they failed that, we will use Botox on occasion, or we'll do a vestibulectomy with vaginal advancement.Dr. Hope Haefner:Hopefully, this information will help some of your patients with this devastating condition. So, on summary, I've taken you through many different conditions. Some of them infectious, some of them noninfectious. I'd like at this point in time to open up for questions.NCTCFP:Thank you so much, Dr. Haefner. That was great. You have a lot of great questions. So, we'll go ahead and get started. Just everyone knows, we'll go over just a few minutes. This will be recorded. We will post this up within two weeks on our website. So, our first question is can EMLA be used on the clitoris?Dr. Hope Haefner:Yes, it can. We call it LMX, and we use it prior to biopsies. It takes time though, because the vulva has a lot of thickness and absorption. So, often, I'll cover it with tegaderm or sometimes patients can just bring their own cellophane and use it. It takes time though. In the keratinized skin, very thick can take 30 minutes. On the non-keratinized, maybe 20 minutes. But just doing that doesn't mean you shouldn't use your lidocaine with epinephrine. You still need to use your lidocaine with epinephrine. It just decreases the pain of that shot in some patients, not all.NCTCFP:Thank you. So, this is kind of a going order of the presentation. So, if a patient is diagnosed with Type 2 herpes, how long should they take maintenance medication after taking it for 12 months? Should they just take it as needed for outbreaks?Dr. Hope Haefner:So, if they're taking maintenance and it's working well, I say why rack the ship? It's working well. If it's too costly, but acyclovir is not very costly. Acyclovir has very few risks associated with it. If it's taken orally, I'll often let them take it as long as they want. They've done studies out to 10 years on acyclovir. Now if they're tired of taking in one and just give it a try and see are they going to have an outbreak or more, then I'm willing to go that way too. It's their decision. But acyclovir is an easy drug. The one complication with acyclovir is in patients that require intravenous acyclovir. It can cause renal failure. So, if you are using IV on anybody, make sure you check their creatine while you're giving it and before you give it.NCTCFP:Okay, thank you. Is there any difference in the course of HSV-1 of the genitals versus HSV-2 outbreak of the genitals?Dr. Hope Haefner:Yes. If you have to pick which one you're going to get, you would hope for Type 1 if you had to get that. It has less frequent recurrences, and the outbreaks tend to not be as aggressive as HSV-2. Those are generalizations, and really less frequent recurrences that's been proven.NCTCFP:How do you decide between valacyclovir 500 milligrams and versus one gram for HSV?Dr. Hope Haefner:So, it depends if they are getting more frequent outbreaks or if they're immunosuppressed. So, if they're immune suppressed, I'll go straight to the one gram. If they're not immunosuppressed, I'll try them on the 500 milligrams, but if they're breaking through, I have no problem going to one gram.NCTCFP:To your knowledge, is there a guideline that exists related to suppression treatment?Dr. Hope Haefner:Yes, there is. It's in the CDC guidelines.NCTCFP:Perfect.Dr. Hope Haefner:I can't wait to see the new ones come out to see what they've changed.NCTCFP:Yeah. The glabrata yeast slide looks like it was just yeast buds. Can't that be commonly seen in albicans too. I've seen pseudohyphae in yeast buds in microscopy.Dr. Hope Haefner:Maybe some of those yeast buds break off from the pseudohyphae, but usually, we see the pseudohyphae on the albicans. But I look for yeast on patients I'm concerned with. I'll do a wet prep and I'll do a COH, but I have to tell you. Even after looking at and doing a gen path fellowship, I think I missed yeast at times. We need to do the cultures on people you're afraid are having recurrent yeast. You need to see what those species are, in my opinion. So, I think it's kind of a moot point whether it's going to break off and be a glabrata. Unless you have that phase contrast, you probably want to speciate it. You don't need to do sensitivities, but I would just send a culture and do species. Can I say one thing though?NCTCFP:Sure.Dr. Hope Haefner:If you look at sensitivities for all those, you might say to me, "Well, that's a waste of time and money speciating it." If someone just got their first one, just look and see. If you have a question, I'm going to tell you MONISTAT says that they do cover glabrata. A lot of the yeast experts disagree and say actually, in their experience glabrata's resistant to MONISTAT. But then if you're wondering still, you could try boric acid. Boric acid works on both glabrata and albicans. Now, patients can get it right on the internet.NCTCFP:That's perfect, because it leads directly to the next question. Is boric acid treatment vaginally safe during pregnancy?Dr. Hope Haefner:I would not use it during pregnancy. Also, you have to warn your patients about oral sex. I would say if they're going to have oral sex, place the boric acid after the oral sex or use a dental dam.NCTCFP:Yeah, there was another question to ask how long does the patient need to wait post-boric acid until their partner can perform oral sex?Dr. Hope Haefner:I don't think anyone's done that study. So, if you're using twice weekly, I would wait a few days. I would do it right before you put your next one in. But I don't really think anyone's done that study.NCTCFP:I did not see the use of topical acids with molluscum contagiosum, but I had a patient that was treated that way and was wondering if this is not recommended.Dr. Hope Haefner:Yeah, you can use acids on it.NCTCFP:Okay, lichen sclerosus. What is occurring that causes the labia minora to disappear?Dr. Hope Haefner:I wish I knew. So, they used to call it lichen sclerosus et atrophicus. That's because the labia minora disappeared. But being a path lover, the pathologist got together and said, "This is not atrophic under the microscope. You've got to drop et atrophicus." So, we dropped et atrophicus, but every time I see a patient that has fusion over the clitoris and no labia minora, I sit in my mind and think et atrophicus, but it isn't histologically that way.NCTCFP:Someone had a patient complain that the ointment was too hard to spread on aphthous ulcers, because it was so thick and too painful. Are there any suggestions? I know this is the way to go for the vulva, but I wasn't sure how to respond to this.Dr. Hope Haefner:Well, first, I would put that patient then on an oral steroids, short duration. Second, we have many patients that can't tolerate various bases. So, if that patient happens to have time or this is a recurrence, then you can work with a compounding pharmacy. What they'll do is send the patient a bunch of different bases and see which base she likes and then put the steroids in that base.NCTCFP:Thank you. So, I think this is in relation to the EMLA question. There's a couple questions about with or without epi. You said the clitoris was a distal extremity. Should we not use epi?Dr. Hope Haefner:So, that is what we are all taught. I confess, I know this is being recorded, but I'll still confess. One time I did inject the patient with epinephrine and lidocaine cane in the clitoris. After the MA showed me the bottle at the end of the biopsy, I just about panicked. I called her every four hours and she finally said, "Stop bothering me. I'm fine." Her clitoris was fine. And then when you study the blood supply of the clitoris, it's got so many different pathways. I think it might be a myth, but just to be safe, I wouldn't use it. I just use plain lidocaine on the clitoris.NCTCFP:Thank you. Do you treat vaginal Group B strep infections with PO antibiotics?Dr. Hope Haefner:So, it all depends on the population. Pregnant patients, you need to treat that. Most patients in our population, if it comes out on an incidental reason you're culturing, thinking something else and it just came out and they don't have anything that looks like that and irritated, I won't treat it, because 30% of patients carry that bacteria. But if they've got erythema, I think it could be that and it comes out Group B, I'll go ahead and treat it. There's all many different agents you can use. Again, I use all different ways.Dr. Hope Haefner:Our microbiology group has on their website, the 2019 Sensitivities that we go to. I also use Sanford microbiology. Unfortunately, that's about $30 or $35, but I will follow up. Most of them say to use penicillin initially, but you can use clindamycin on those growing resistance on that. So, often it's a difficult patient that's not sensitive either though. So that's when you've got to work on that with your microbiologists and start searching the literature for what else you can try.NCTCFP:Thank you. Are there any routine lab monitoring for a patient on suppressive therapy? I remember up to date recommended standard lab, CBC, CMP. I don't see this commonly in practice and they wanted to clarify the suppressive acyclovir.Dr. Hope Haefner:Okay, I was sitting there wondering, because we're on lichen and I'm thinking, "Huh, steroids?" No, I don't ever get any of those for oral acyclovir. As I mentioned, the only thing I've checked, I've had to admit a patient that had pseudotumor herpes, the most horrible herpes I've ever seen in my life and put her on IV acyclovir. For that patient, yes, we're going to check lights. We're going to check her white count, etc. But routinely, no, I don't get it.NCTCFP:Great. Would you recommend women who have vulva, perineal and rectal condyloma to have an anal Pap smear?Dr. Hope Haefner:So, I don't think I would for that. First of all, the low risk viruses tend to be 6 and 11, but there's some others out there. They don't go on to cancer. So, I'm not too worried I'm going to be missing a cancer or treating to prevent a cancer. So, I would take a look at the anus, having lift their legs back, have them bear down. If you don't see any papillary projections, probably not worth investigating. So, I don't on the low grade. I do on the high grade.Dr. Hope Haefner:You're going to find though that a lot of the gynecologists throughout the US do not do anal Paps. However, I'm really convinced that it's necessary and we're working on publishing that data. I've actually published one paper on that years ago with a GYN oncologist from another institution. There is an Anal Cancer Society out there and they talk about anal Paps in their society too.NCTCFP:Thank you. If you see reoccurring yeast, do you ever test for HIV and HSV?Dr. Hope Haefner:I don't usually. I'm more worried about what's your glucose? What's your hemoglobin A1C? Because we see it in diabetics all the time.NCTCFP:One of the questions was what concentration of Kenalog and bupivacaine that you use for intralesional injections?Dr. Hope Haefner:So, the bupivacaine concentration is either 0.25% or 0.5%. For a large area, if I were going to inject the whole vulva for example, I'd use 0.25%. For a small area, I would use 0.5%. As far as the triamcinolone, it's the vial that's on the slide. It's called triamcinolone. It comes in 10 milligrams per CC or 40 milligrams per CC. So, if you're injecting intralesionally, you're going to use the 10 milligram per CC and dilute it out with either bupivacaine or sterile saline from a vial. On the whole vulva again, you're going to do up to 40 milligrams.Dr. Hope Haefner:If you're going IM, that's when you want to use the 40 milligrams per CC. Because you're going to have to on some patients use two vials, because we go with a milligram per kilogram up to 80 milligrams. So, that's two vials. Never go above 80 milligrams. I would say always go in the gluteus. There are people that have complained that their thighs... This is in the literature that their thighs get indentations that are upsetting to them. So, we go in the gluteus. Not that they still can't look in a mirror and see it, but it's not seen as often on the gluteus.NCTCFP:Only two more questions. Thank you so much. This is so helpful. What condition is in the middle photo on the introductory slide, which I believe is also this slide?Dr. Hope Haefner:I didn't plant that question, but I'm so glad you asked. This is a condition I actually specialize in. It's called hidradenitis suppurativa. It too is a devastating condition. I would say the two populations I think in my lifetime I can help the most with surgery is this condition when it's stage three and then the other I'll get back to in a second is like lichen planus where the whole vagina's agglutinated. But this condition has three stages. It's in the 140, some page handout, a whole bunch of information on it, but it tends to be in their axilla, under their breasts or on their breasts, in their groins, on their buttock. It goes up to the sacrum in many patients. For stage three, while a lot of dermatologists will give some of the TNF-alpha agents, stage three, it doesn't work very well. Surgery is the answer.Dr. Hope Haefner:So, during sabbatical, I'd been residency director for five years. My chair when I decided I was done with that gave me a sabbatical and I had young kids. At that point in time, I couldn't go to Australia, New Zealand, Europe. So, I went 20 minutes away to the hospital my husband works at. He's a hand surgeon and he did grafts and flaps. During that six-month sabbatical, every motor vehicle accident, every diabetic foot flap, we scrubbed in together. He taught me how to do grafts and flaps.Dr. Hope Haefner:So, for this condition, I start them in prone and cut off all the buttock disease and put a wound VAC on and rotate them to lithotomy. Cut off all the disease on the thighs, abdomen, vulva, and do a wound VAC. And then a week later, after we've changed the wound VAC once in between, we do skin grafts and then put a wound back on for five days. We just had a patient that we did last month, and I was so happy to see her back. She's not got recurrence, it's almost all healed. It takes time and sometimes they don't all heal. Sometimes you only get 75% take, but she had almost 100% take and it's done very well.Dr. Hope Haefner:Now, the other thing I mentioned, lichen planus for surgery. If you have patients that have small openings, want to have intercourse and have lichen planus, I have a paper we've published that takes people through the procedure. If you want the protocol for it, I'm happy for you to email me. It's my last name H-A-E-F-N-E-R@umich.edu. I can send the protocol for how to open the vagina, how to put a dilator in and keep it in for 48 hours with a Foley catheter while they go to hotel if they live far away or while they go home, and then come back and 48 hours, take it out. And then they dilate the rest of their life. They use steroids intravaginally, but they are able to urinate without difficulty and some are able to have intercourse.NCTCFP:Thank you. The final question is, do you treat papillomatosis?Dr. Hope Haefner:I do not treat papillomatosis. So, if you remember, those are the finger-like projections with not a broad base. They're just single finger projections, one just like this, versus the condyloma, where you've got the broad base with multiple projections. You don't even have to treat condyloma if it's not bothering the patient, but once they know they have condyloma or if it's extensive, they generally want treatment. But for those papillomatosis, show them in a mirror, take a picture. Show them the picture on their phone. It doesn't need treating. It is normal.NCTCFP:Wonderful. Thank you so much. So, that's all we have time for everyone. Thank you so much for coming-Dr. Hope Haefner:Great questions.NCTCFP:... and for your great questions, yes. So, you will see a survey upon exiting the webinar today. So, make sure you take that to receive your CE within three to four weeks. The recording and a transcript of this presentation will be available on within two weeks. We will also send you a link to the PDF slides, handout, and the survey in the follow-up email. Thanks again and take care everybody. ................
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