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effective as potent topical steroids in lichen sclerosus and lichen planus.

Adverse effects

When these treatments are recommended, the main emphasis is on the fact that they do not induce skin atrophy; however, they are not without side effects, which are particularly relevant to their use on the vulva. They can induce infection such as herpes simplex [15]. There are also concerns about potentiating malignancy if used in lichen sclerosus and lichen planus [16]. They often sting when applied.

Imiquimod

Imiquimod is an immune response modifier which was originally used in the treatment of genital warts. It has an effect on both the innate and adaptive immune responses and increases cytokine production. It is therefore pro‐inflammatory. They are now used for several conditions including superficial cutaneous malignancy elsewhere (superficial basal cell carcinoma and lentigo maligna), high grade squamous intraepithelial lesion (HSIL), and extra‐mammary Paget’s disease.

Adverse effects

These cause a significant inflammatory reaction and need to be applied much less frequently than in extragenital sites. Patients will often tolerate only once or twice weekly treatment for the vulva. Silver sulphadiazine cream can be used as a soothing rescue if the soreness is particularly severe. Flu‐like symptoms are reported by some patients. Cases are reported where the development of another dermatosis, such as vulval pemphigus, has been linked to the use of imiquimod [17]. Lichen sclerosus and lichen planus have been described after its use in males [18]. It needs to be used with care in patients with a pre‐existing dermatosis, as more severe reactions can occur. One patient with Behcet’s disease using imiquimod to treat genital warts developed very large ulceration with its use [19].

The other adverse effect is a change in pigmentation with imiquimod. Vitiligo‐like hypopigmentation can occur which may be long‐lasting [20].

Potassium permanganate

If the vulval dermatosis is weeping and eroded, then soaks can be useful for a short period. The antiseptic potassium permanganate in low dilution (e.g. 1:10 000) can be very helpful to dry the area so that topical creams and ointments can then be used. A pad of gauze is soaked in this weak solution and then applied to the vulva for 10 minutes two or three times a day for no longer than 48 hours. It is vital to warn the patient that it will cause brown staining on anything that it comes into contact with, such as all containers, clothing, and skin. The discoloration will resolve as the skin renews.

Lubricants

Lubricants are widely used for intercourse, and patients feel very positive about their use [21]. Patients report that they prefer a feeling of wetness, and this is reported more in those over 40 years of age. Lubricants are helpful in patients with vaginal dryness as part of the genitourinary syndrome of menopause, especially if they are not happy or able to use topical oestrogens. They are available as water‐, oil‐, or silicone‐based preparations, but water‐based preparations are better tolerated and give less genital side effects [22]. However, the use of any formulation of lubricant gave increased rates of sexual pleasure.

There is a wide variation in pH and osmolality between products, 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.

Section 2 Infection and the Vulva