Managing Complex and Sensitive Genital Dermatologic Conditions: A Patient-Centered Approach

During the second day of Fall Dermatology Week, Melissa Mauskar, MD, shared insights on treating patients with genital dermatologic conditions, emphasizing the complexity and sensitivity of this patient population. These patients often endure symptoms for years before seeking medical help, creating physical, emotional, and psychological burdens. Dr Mauskar highlighted both diagnostic challenges and strategies for treating conditions such as lichen sclerosis, genital melanomas, irritant contact dermatitis, and genitourinary syndrome of menopause (GSM).

She started by recounted the story of a patient who had struggled with itching since 1955 but only sought treatment in 2016. The prolonged suffering led the patient to rely on ineffective over-the-counter products, including topical benzocaine, which can cause irritation and allergic dermatitis. Dr Mauskar noted that many patients arrive at the clinic with bags of unused medications that have failed to alleviate symptoms. This illustrates the importance of comprehensive evaluations that address the underlying causes, rather than merely prescribing medications.

A particularly concerning trend is the absence of routine genital exams for older women, especially those over age 65 who may no longer see gynecologists. Dr Mauskar stressed that dermatologists should integrate genital exams into routine body screenings. She demonstrated how subtle lesions, such as genital melanomas, can easily be missed but carry a poor prognosis if overlooked.

Next, she covered the nuances of diagnosing and managing lichen sclerosis, a condition characterized by white, crinkled plaques and loss of normal anatomicl structures. Dr Mauskar stressed that many patients are misdiagnosed and cycle through multiple providers before reaching a dermatologist who can provide accurate treatment. She reviewed findings from a study that showed maintenance therapy with topical steroids prevented progression in nearly 97% of patients, including preventing scarring and skin cancers. Dr Mauskar encouraged maintenance therapy, such as clobetasol, emphasizing its role in preserving skin integrity and preventing the progression of disease.

Another focus of the presentation was GSM, which affects up to 70% of postmenopausal women. GSM symptoms—vaginal dryness, irritation, itching, and pain—can mimic other conditions, leading to misdiagnoses. In response, Dr Mauskar promotes localized treatments, such as topical estrogen, to manage symptoms effectively. She reassures patients of the safety of vaginal estrogen, even for those with a history of breast cancer, citing recent research that indicates no increase in cancer recurrence with these localized treatments. In addition to topical treatments, Dr Mauskar highlights the benefits of lifestyle modifications, such as frequent sexual activity to improve lubrication, and suggests options like pelvic floor therapy.

Next, she addressed the prevalence of irritant contact dermatitis among older women, noting that urinary incontinence can be a significant contributor. Patients often use irritants like wet wipes or fragranced cleansers that worsen symptoms. Dr Mauskar encouraged clinicians to screen for incontinence symptoms and offer practical advice to patients on minimizing irritant exposure.

Lichen simplex chronicus (LSC), another common condition, was also discussed. This condition, characterized by thickened, lichenified skin, results from an “itch-scratch cycle.” Dr Mauskar described a multimodal treatment approach that includes high-potency topical steroids, antihistamines to reduce nighttime itching, and patient education on the importance of breaking the scratching habit. She observed that aggressive early treatment of LSC can help prevent the progression of symptoms and improve patient outcomes significantly.

Erosive lichen planus, with its distinct, well-demarcated erosions and red-bordered lesions, presents both diagnostic and therapeutic challenges. Biopsy at the erosion-epithelium border is essential for diagnosis. Dr Mauskar emphasized a multipronged treatment plan combining topical and systemic therapies to achieve the best outcomes. She noted that about 40% of patients with erosive lichen planus require systemic treatments to manage symptoms effectively.

Dr Mauskar emphasized the importance of educating patients about their conditions and the treatments available. She stressed the importance of using tools like printed instructions, annotated photos, and videos. For example, for conditions like lichen sclerosis, she demonstrates the application of topical medications using Vaseline on her hand to show patients the right amount to use. She noted that patients are often fearful of using steroids long term due to pharmacy warnings; however, she reassures them of the safety and necessity of following prescribed regimens to manage symptoms and prevent complications. She also addresses misunderstandings about over-cleansing, which many patients assume will reduce infections or itching. One patient, attempting to “scrub away” visible skin changes, inadvertently caused further trauma. She stressed that it is important to educate patients about the risks of excessive cleansing and promote gentle hygiene practices to avoid exacerbating their symptoms.

Dr Mauskar’s presentation underscored the importance of a comprehensive, patient-centered approach to managing genital dermatologic conditions. Early diagnosis, careful evaluation, and patient education are critical to improving outcomes for patients who often suffer silently. By empowering patients with information and providing compassionate care, dermatologists can help alleviate long-standing symptoms and improve their quality of life.

Reference
Mauskar M. Women's health in dermatology. Presented at: Dermatology Week; November 13–16, 2024; Virtual.