Kalyani Marathe, MD, is a pediatric dermatology specialist at Cincinnati Children's Hospital Medical Center in Cincinnati, OH. She particularly specializes in a variety of pediatric skin conditions such as atopic dermatitis, birthmarks, psoriasis, and epidermolysis bullosa. She’s also published many research pieces that primarily focus on vulvar diseases. Dr Marathe met with The Dermatologist to share her insights into her session, “Pediatric Vulvar Diseases: Learnings from our Multidisciplinary Clinic” at 2021 AAD Summer Meeting.

How does vulvar disease impact pediatric patients as opposed to nonpediatric patients?
All vulvar diseases come with a big stigma and people are uncomfortable talking about it. When we have pediatric patients, there's an even bigger stigma and there's a lot more barriers in getting the patients identified.

First, pediatricians are often not comfortable doing sensitive examinations or they're not knowledgeable about what's normal and what's not normal. Second, parents feel uncomfortable doing the examinations on their own children. They don't know what they're looking for. Pediatric genitalia looks different than adult genitalia, and so a mom can't examine her child's vulva and necessarily know what it's supposed to look like.  Additionally, the privacy concerns, and the parents’ concerns when they have to bring in pediatric patients for vulvar concerns, is innumerable. These are the barriers to getting these patients evaluated, so there's often a very big delay in diagnosis.

How can clinicians examine the condition in a way that places pediatric patients at ease?
One, we have to set the stage appropriately. Making sure that we speak to the child directly, that they know they have ownership over their body, that they have agency over the choices that they make regarding their bodies, that they get to decide what happens—if anything actually happens—and that they know that you are only examining them with a parent present.

Make sure they understand why you are doing the exam.  Address who you are, what is the reason you need to examine this part of their body, what are you going to do during the examination, what exactly is going to happen.  Asking both their permission and the parent's permission are important. What I have found is that parents unconsciously have a lot of tension, and they're nervous or stressed out about what this examination is going to be like and when you ask permission, that puts the parents at ease. They feel more comfortable automatically.

If you're going to be using any kind of equipment, always show that to them beforehand. I use a flashlight. We also have a medical photographer who comes in and takes photos of our patients, so we make sure we introduce her first.

Why are we taking photos? What is going to happen to the photos? Who's going to see them? We answer all those questions before the fact.

We try to make the examination very quick and efficient. We always have a sheet where we cover them, or we'll hold the sheet up so that they can pull their underwear down privately. If they say that they don't want any male providers since, a lot of times, we have male residents, then we send them out of the room.

Basically, we listen to whatever the child says. If the child says, "No, I absolutely will not do this examination," then we do not examine them. We do not ever force a child to do a genital examination. If it’s necessary to do an examination, then we can do so under anesthesia.  Never force a child to do a genital exam.

I have honestly never had that happen, where the child outright says no. A lot of times, we'll talk it over first. Then, we'll let them talk to the parent privately, and when we come back, they're usually more comfortable doing it.

Eliminating unnecessary people, making sure that the parent is always there in the room where they act as the chaperone, then being very clear about what we're going to do and what tools we're going to use for the examination seems to make the difference.

In what ways could pediatric vulvar disease be linked to child abuse?
A lot of times, we get referred patients to rule out child abuse, but then things like lichen sclerosus can look like abuse since it has a bruised appearance. If there are any red flags at all, we refer these patients to our child abuse specialists.

Most of the time, it's just their disease that's making the skin look atypical. Sometimes, they've had a child abuse workup before they even come to see us. An important thing is asking the child what do they call their body parts and making sure that we are teaching them the correct terminology. That has been shown to reduce the delay in reporting of sexual abuse.

I had a patient once who told me that they referred to her private area as her “pound cake.” She was complaining to her teacher about having a problem with somebody touching her pound cake. The teacher obviously didn't understand what that meant, and so that led to a delay in diagnosis of sexual abuse.

That's the kind of thing that we want to correct. We want to provide them with the correct  terminology, so that they're saying the right words, and this will allow abuse to be identified earlier.

What key factors should physicians keep in mind when examining a pediatric patient for vulvar disease?
Keep in mind, prepubertally, you can see inside the vagina without a speculum or anything. You should be able to examine the vaginal opening including the hymen without doing much retraction.

I'll place the patients in a frog leg position. They lay down on their back, bring their feet together, pull them toward their butt, and then let their knees flop out like a frog. We call this butterfly legs, because that's usually more appealing to the little girl patients. That gives us an entire view of the vulva.

If you then take your gloved hands and put them on the buttocks and retract posteriorly, you can essentially see inside the vagina. You don't have to do anything else. The other thing you can do is you can grasp each side of the labia majora and pull toward you. This is not painful.

 If there's any labial adhesions, you're not going to tear the tissue apart, so you won't hurt them. You can't hurt them doing either of those things, and that's helpful, so you will still be able to see everything.

The next thing that we do is have them put their knees together and pull their knees up towards their chest and that gives us a good view of their perianal skin.

For us, tracking things with photos has been incredibly helpful because we are often looking for subtle changes in the tissue’s pigmentation or texture. We're also looking for side effects of the topical steroids.  If the parent is applying the medication, they're seeing the skin every day, making it hard to determine if there are changes. They're not registering any subtle differences over time.

At my clinic, we're seeing 10 vulvas in a row. It's very hard to differentiate and to remember exactly which one of them had which features. The photography makes a huge difference, and it helps us to track how things are going over time.

Then, we bring the photos into the room with the parent, so they can see what we are seeing. Instead of showing them on the patient, which is keeping the patient in a vulnerable position for longer, the patient can be dressed and sitting there. They are allowed to look if they want to. They don't have to if they don't want to. A lot of times, they're not comfortable looking.

We can show the parents the photos, and it gives them a chance to see it without further invading the child's privacy.

Are there any other tips you'd like to share with your colleagues regarding pediatric vulvar disease or pediatric health in general?
First, have all kids sit in the bathtub with plain water every night because nonestrogenized skin is very thin and delicate, so it gets irritated very easily.

Since the vagina is wide open, it's so easy for a piece of toilet paper to get stuck in there, or a little bit of urine to get in there—even stool if they're wiping back to front. Any of those can cause a lot of irritation. Having them sit in the bathtub allows water to clean that area without having to do anything traumatic.

A lot of pediatricians will tell parents, "Don't do bubble baths." The parents interpret that to mean don't do baths at all and that showers are better than baths, but a plain water bath is actually the best thing. We also agree no bubble baths, because they're too irritating. We have them stand up to shower to wash their hair or do any other washing with soap at the end so they're not sitting in soapy water.

Second is having little girls pee with their legs apart. A lot of people don't realize that, because little girls' labia majora are very thick, big, and fat since they don't have labia minora yet, what can happen is if they pee with their legs closed together most of it gets out, but some of it doesn't come out completely. It goes back up into the vagina.

Even a couple of drops of urine in the vagina make it really irritated. Making sure that they sit with their legs apart will allow the urine to completely come out. That way, they don't get that irritation.

These are 2 things that clinicians should keep in mind when working with pediatric patients.