A (3:05)

Don't go back and do residency eight years later.

B (3:07)

Yeah.

A (3:08)

And I, and the real story behind that, when Dr. Tyler contacted me as like, because it was one of the other faculty at Ohio State in the ob, GYN was like, hey, I've got this. So, you know, you meet with her and. And so as the contact dermatitis person, which by the way, Dr. Tyler now does the patch testing at Ohio State as well as the contact dermatitis person, you get sent a lot of the vulvar disease patients. And I did not want to take care of them, I did not want to see them, I did not want to have anything to do with them. And so when Dr. Tyler like contacted me, I was of course scheming. Like, I'm going to make her come and take over all of these patients. It's going to be great. I'm going to get out of it. And it, it worked. Now she's there and she's all this famous national, you know, woman parts expert. That's the specialty in derb. So let's, let's go ahead and get into our first article. Let's start with Dr. Faris. What do you got?

C (4:03)

All right, so I sort of pulled together because we each on these deep dives usually do one paper. So I just pulled together a couple high yield, like three papers. I'm not going to really like go crazy on them, but I just thought I'd highlight what's come out recently. So one is in the jad and these were quick papers. Estelle et al. Acetretin and methotrexate and vulvar lichen sclerosis. So basically multicenter retrospective chart review of 38 women with vulvar LSD treated at six centers over a 10 year period with either acetin or methotrexate. And you know, what they found was basically 75 and 77% of women improved in very few people. Like people didn't really go into full remission, but Most people had some improvement. It was like two people in acetranin, three on methotrexate went into remission. So how do you judge improvement? There's no like lichen sclerosis PASI score. So it was really just clinical judgment. And you know, the both drugs had kind of similar rates of lab abnormalities. Although if you look at the side effect rate, it was higher for acetretin than it was for methotrexates. So, you know, I thought I'd just throw that in there as two things that can be treated. Dr. Tyler, do you use like either of these drugs when you have patients? I'm sure it's not like your first line treatment, but do you ever use these drugs when you sort of people who've got refractory lichen sclerosis?

B (5:51)

Yeah, I have used methotrexate more for people who have both genital and extra genital. So someone who might be progressing more, they have a lot of extra genital involvement. Methotrexate I think has been my go to for that. Um, acetretin I have, I've used a few times. I do find like the study, you know, these are older patients with other comorbidities and so a lot of times they will want to discontinue due to side effects. So, you know, it's not a lot of my patients, but to be honest, I'm able to control a lot of people mostly on topicals once I make sure they're using it correctly.

C (6:27)

Okay, and how would you define using it correctly? So I'm sure.

A (6:31)

There we go.

C (6:32)

You're going to say clobatazole, but. Yeah. What does that mean?

B (6:36)

Yeah, so a potent or super potent topical steroid. And I just tell people a pea size amount and I tell them. So what we want them to do is we want them to apply it to the modified mucous membranes. All right, so we want to keep it off the hair bearing area, the areas that are going to be more prone to atrophy, striae. We want it to be a very small amount. So labia minora introitus clinic clitoris, clitoral hood. You know, a lot of them have perineal involvement, so we really want to try to keep it in that area. And we want to start. Usually I start them at twice a day, depending on how severe they're lichen sclerosis is. Then I'll kind of go down to sometimes once a day for a few months. And then eventually what I want to do is get them down to Maintenance treatment, which typically is two to three applications a week. So usually bedtime Monday, Wednesday, Friday. Um, but sometimes what I find is people come in, they've been given this tube of cream or ointment, and they don't know where to put it, so they're just kind of putting it everywhere.

A (7:37)

Okay, so. So that's been the Matt Zyrus regimen of, like, here, here you go. This year, surprisingly, we don't really get any side effects whenever we use clobazole down there. Although you would think that you do. It turns out I did not know I was supposed to be telling them to really just put it on the non. So I like the idea that if you don't get hair there, it's okay to put it on. I probably have to, if they've had laser hair removal, maybe, maybe qualify that a little. But so you're really supposed to just be putting it on, like, not even the labia majora.

B (8:13)

Right.

A (8:14)

Like, if they've got some spread beyond the mucous membrane parts, do you use it up beyond there, or do you try to still keep them. Just use this in the mucous membrane parts.

B (8:28)

Right. So I should clarify that medial labia majora are okay, just not out on the hair bearing external labia majora. But yes, I do have a couple patients who kind of get it out in the groin folds, and I worry a little bit about that. So sometimes I will put them on a lower potency, you know, steroid ointment for those areas for. For flares.

A (8:50)

Okay, do you. And we'll get. Go ahead. Faris.

C (8:54)

Well, I was to say, do you also then add insulin, like topical tacrolimus, you know, particularly as you're stepping them down from twice a day or every day

B (9:04)

sometimes. My issue with tacrolimus in the genital area is the potential for a burning sensation on application. And I know not everybody does that. Unfortunately, I don't work at a place where I have the luxury of keeping samples and letting them try it. I think that's a really. If you're able to do that, let them put it on in the office and see if they tolerate it. And that would be, you know, I think, a great tip for people who are able to. But it's really sort of. I want to say tacrolimus is kind of my last resort. And I like it a little bit more for people who have lichen simplex chronicus who just. I can't get them to use things in the right area. And I'm like, tacrolimus is fine. They can put it wherever they want and it's not going to cause any atrophy or striae. So if they can tolerate it, and I feel like I just can't get them to put their, their steroid ointment in the right area, I will use Tacrolimus sometimes.

A (9:58)

So for, for our listeners, I'm going to tell you my, my pearl with Tacrolimus. Anytime you prescribe Tacrolimus. The way you describe it is you're going to put this on. If you're really lucky, it's going to burn really badly when you put it on. It's going to, you're, it's going to feel like your tongue feels when you eat a jalapeno because that is a sign that it's working really well. And there is actually there's mechanistically because the burning is caused by substance P release, same thing the capsaicin does. And it's part of why the tacrolimus works well for itch is substance P depletion. Just like we can use topical capsaicin for localized pruritus. And so the more it burns, the better. And I'll say, but if, you know, some people, it's just so bad you just can't stand it. Some people, but if it burns, that's a good thing. And, and I, I believe it. Okay, Pat, I cut you off. What were you going to say?

D (10:53)

I was going to ask if you tell them to put it everywhere just because like, oh, it can spread or like, are you bringing them into the office and say, okay, you know what, this area looks a lot better. Let's, let's ease up there. Let's go to the maintenance on just this area or do you just kind of say like just put it everywhere?

B (11:13)

Yeah, so we just put it on all the areas that have a lichen sclerosis. Now if they do have an area that's particularly bad, so say someone comes in and I've been treating them, but they have a small area that's flared. Sometimes I will have them, you know, just treat that area twice a day for maybe like two to four weeks and do maintenance on everything else. So I think that was your question.

A (11:35)

I got one other question here before I let Ferris get to her next article. The are people do. So it seems obvious to me, lots of things seems obvious to me that are wrong, but this seems obvious that that urine, low grade urine exposure has to be what is causing lichen sclerosis. Right? You get it in little girls, once they get to where they're not, and it tends to go away, and then it comes back once women get to the age where they start to have, you know, stress incontinence, whenever you laugh too hard or you're like, whatever. It seems that way. I'm not saying it is, but it seems. It seems like it can't just be coincidence that the two ages, whenever you get it, are whenever you tend to be a little susceptible to stress incontinence. Am I. Am I told? Do people actually think that? Or am I totally in left field, just possible?

C (12:31)

I've never thought that somebody who doesn't think about it all the time. I've never thought that.

A (12:36)

Okay. Fair.

C (12:38)

Yeah.

A (12:38)

Dr. Tyler, anything?

B (12:40)

No. I mean, it's very complicated. Although urinary incontinence is something that I talk to people about a lot because you're getting irritant contact dermatitis from pads and urine on top of lichen sclerosis, which can make it really difficult to control. So I think that's the piece where urine comes into it and why dermatologists should send more people to the urogynecologist and ask them about incontinence more often. But no, I really haven't heard that theory before. I think lichen sclerosis is a little complicated and we don't quite understand everything that plays into it.

A (13:15)

Just pee. The ur. The. The urea and the pee. That's it. It's the whole thing.

B (13:21)

So if people stop peeing, they'll be okay?

A (13:23)

If they stop peeing, they'll be. That's right. They'll be fine. Drink. Drink less water.

D (13:28)

Diverting your. Your bladderos. Cystos.

A (13:32)

Yeah, what do they call it?

B (13:35)

Yes, we'll do a study on that. That'll be great.

A (13:38)

Okay, that's good. I'm just home to drink less water. No more than 8 ounces a day. If you have to pee more than once every three days, your lichen sclerosis is never going to go away. That's it. That's recommended by Dr. Kelly Tyler at the Ohio State University.

B (13:57)

No, please do not quote me.

A (13:59)

All right, Fairs. Guns. All right, next paper.

C (14:03)

Another quickie was just in. Jad treatment of refractory LS in women with mycophenolate mofetil Mayo Retrospective study. Nguyen et al. So 51 women anal genital LS. And so in about half of those, the. The cellcept was. Or mycophenolate mofatil was actually prescribed for LS the endpoint of treatment again was just an improvement of at least one symptom. And so what did they find? About 70% of women had improvement in one symptom. Time to response was about 2.2 months and median duration of treatment was just over 2 years. Interestingly, among those responders, two of them did have vulvar SCC before. They then were put on my phenylate and they did sustain, you know, they did continue it and add sustained treatment. So, you know, putting that out there as sort of another medication that could be used. You know, I don't think I've ever used this for lichen sclerosis, but I don't have tons of these patients. Any thoughts on mycophenolate?

B (15:16)

Yeah, I mean I've used it for refractory lichen planus before, which, you know, just. Yeah, just like ls, you know, we don't have a lot of great studies for vulvar like in planus and so it's hard to tell. I tell people, you know, I have no idea. There's not like one go to medication that I have for it. But I have to be honest, I haven't tried it for vulvar like in sclerosis. They may actually also did a study on hydroxychloroquine for resistant like in sclerosis and that actually they had some good results with that too. So I like hydroxychloroquine a lot. I use it, that's usually my first line systemic for vulvar like implantus if I can't get them under control with topicals or intermittent prednisone for flares. So I really like that. And so now I've started thinking more about using hydroxychloroquine for resistant lichen sclerosis. Although I can't say I have a few people for lichen planus, but I don't have anybody on it right now for lichen sclerosis.

C (16:18)

And is the main symptom you're treating itch, would you say? It seems like that's what patients complain is itch or pain or, you know, but itch seems to be number one.

B (16:27)

Yeah, almost everyone has itching with lichen planus it's more pain, you know, the painful erosions that they get. But yeah, if you have a, a patient with lichen sclerosis who has pain and they don't have fissuring or, or other reasons for it, sometimes they'll have secondary vulvodynia too. So something to think about. I'll get Patients that like, oh, this person has refractory lichen sclerosis, and I look at their skin and it looks okay. But sometimes these chronic inflammatory diseases can cause patients to get secondary vulvodynia, too.

A (17:03)

Do you do. A few years ago, there was a lot about prp, like microneedling and prp, or just PRP injections in general for lichen sclerosis. I feel like I haven't heard as much about that in the last couple of years, but I just might not be looking. Is that. Is there reasonable evidence to support it? Is it something that you ever send people for or that you do, or is it, you know, if a patient asks about it, what do you tell them?

B (17:33)

Yeah, I haven't had any patients specifically ask me about it, but there is. There's still data out there. And now there's actually some emerging data for genitourinary syndrome of menopause as kind of where the PRP is coming on the horizon. You know what? I. And I haven't done it, but I think, when I think about it, I'm thinking of plumping or revitalizing the tissue. So I would tell a patient, you know, it's not. We're not treating the underlying mechanism of the lichen sclerosis. So the likelihood is I'm still going to have them on, you know, topical steroids or whatever treatment I have them on, but I would think of it as an adjunct treatment. Same for genital urinary syndrome of menopause. You know, that. That might help plump the tissue, make it healthier, but they're probably still going to need something like a vaginal estrogen for that.

A (18:22)

Okay, fair. All right, Ferris, what's your next one?

C (18:26)

All right, final one. This was one that was published in JAMA Dermatology. Lichen sclerosis prevalence and squamous cell carcinoma development in female Medicare beneficiaries. And so this basically, they looked at women 65 and older who were on Medicare. And so they had a sample from 2015-21, over 2.5 million women. And so one was like a prevalence measurement, which was.7% of women in that age group had lichen sclerosis. And then they also looked at what percentage of women developed squamous cell carcinoma in the Evolvar SCC, and it was 1.2%. Interestingly, they looked at what percentage of women had some sort of topical steroid or TCI. It was 72.6%. So, you know, there was. They also could do like a competing hazard risk ratio to see is there really a higher risk of SCC in Women with vulvar ls? It was, yes. The compute the hazard ratio was 11.8. So significantly higher risk of squamous cell carcinoma. Interestingly, most were managed by OB GYNs and Mohs was like almost never used for the genital scc. So, you know, claims database. But a large sample thought I would ask you what you thought about this study. What do you think, what do you say to women about the risk of developing scc? How important do you think treatment is and like what's kind of your, your spiel and monitoring for that?

B (20:21)

Yeah, it's really important. I actually was a little surprised on this study because their rates of SCC were a bit lower than we typically see. I usually tell people about a 2 to 3% risk with either lichen planus or lichen sclerosis in the genital area. And my spiel is, you know, when I'm starting treatment, I tell them, you know, we have three reasons we want to treat them. Number one is we want to treat your symptoms. So we don't want you, you know, having itching and pain. You know, we want to get that under control. Number two is to prevent progression because we know that with like in sclerosis they can get scarring, they can get narrowing of the introitus, and that in and of itself can cause other problems, some urinary symptoms, you know, perhaps. And then the third reason I tell them is we need to prevent skin cancer. So, you know, vulvar cancer is, I think, probably still the least common female genital cancer out there. So it's not a very high risk or it's not a very common female cancer. But when you look at that, it's probably less than 1% of the population in general. But when you look at vulvar lichen sclerosis, it's about 2 to 3% risk. So I tell people, you know, if we do your maintenance therapy, even if you think your lichen sclerosis is, quote, in remission, we still have studies that show us, we think we can reduce your risk of SCC down to, you know, 0%, you know, if you're using your maintenance treatment. So there are some studies.

A (21:51)

So the mainstreaming does help reduce the risk of cancer. Okay, yeah, we, we don't even have great data of that. Four or five fluorouracil, like for on your face, like we've got more now. We used to not have great data for that, but so that's interesting that we've got data that it does help to reduce it.

B (22:09)

Yeah, that's fairly new, but, yeah, there aren't a lot of great quality studies, unfortunately. And like, but, you know, it's, it's something that experts have kind of done for a long time, but we're starting to get some data to support what we're doing.

A (22:23)

Okay, all right, fair. All right, let's move on. Dr. Patton, what do you got?

D (22:28)

All right, my deep dive paper from April 2026 edition of the Journal of the German Society of Dermatology. It is titled Evidence and Consensus Based Guideline on Lichen Sclerosis by Kurt et al. So it's a condensed version of guidelines that were formulated by 26 experts from various specialties. First few pages, go through symptoms and signs of lichen sclerosis. Was there anything in the. They have some images of male and female. Anything in the. Like, any clinical pearls for diagnosing lichen sclerosis? I'm, I'm curious if you get a lot of people that are like, dermatologist or somebody told me I have lichen sclerosis. And you look and you're like, this is not like lichen sclerosis. So does that happen a lot? Are there any tips you would give to any of our listeners of, you know, what you're looking for?

B (23:18)

Yes, yes. So the biggest thing is texture change. So if there's not a texture change in the skin, it's most likely not lichen sclerosis. One of the biggest things I see is people who are postmenopausal and they have itch or irritation. And people say, well, if you itch, you know, and the tissue looks pale, it must be like in sclerosis. But we know that vulvovaginal atrophy from menopause can actually cause, you know, irritation sometimes some mild itch, you know, pain on urination sometimes, and it can cause the tissue to look pale. But you're. What you notice with those patients is that they don't have that texture change. So it doesn't have that atrophic look. Sometimes there's a hyperkeratotic look or a waxy look that you can get with lichen sclerosis. So that's, that's kind of my tip. And I don't do a ton of biopsies now to diagnose lichen sclerosis just because I do it all the time and I feel pretty comfortable with what I see clinically. But if you're not sure, you know, biopsy that's really going to be. I think that's really going to be the thing. And the other thing is make sure you send it to your dermatopathologist. Because I'll get a lot of patients from gynecologists who, a general pathologist has looked at the biopsy and they're just like, okay, well, no cancer. And so that doesn't really help me too much either, which, I mean, it's great that you have cancer, but it doesn't really help me with the diagnosis. So I think the biggest confusion I see is with vulval vaginal atrophy from menopause.

A (24:47)

Okay.

D (24:47)

They, they do recommend. Right. Diagnosis is often clinical. If you do want to do a biopsy, they mentioned stopping therapy for three weeks prior to obtaining a biopsy. That was longer than like what I think of with, you know, ctcl. It's like, take a week off a steroid. But they mentioned three weeks here. So I don't know how important that. Moving on to the management, you know, skin care, general recommendations. How strongly do you feel they said ointments are preferred over creams and gels. Do you feel strongly about that?

B (25:18)

Yeah, the Germans have this, right? It's true. So, yeah, definitely ointments. Because I feel like people get burning, especially if they have, you know, fissures or erosions or they've been scratching, you know, they have inflamed skin creams for a lot of my patients will tend to burn and I feel like ointments are definitely more soothing. So I, I definitely prefer ointments. I'd say 99 of my patients are

D (25:44)

on ointments and they do say ultra potent and topical. And I'm just going to kind of brush over this other stuff because we talked about steroids and twice a day and then daily and then maintenance. Do you ever, like, stop maintenance? Is there a point at which you're like, you've been doing three times a week for six months. There's been no recurrence?

B (26:03)

No, never. And the main reason is because of the risk of SCC. Even though, you know, you say it's 2 to 3%, that's still a lot higher than the general population. And I tell them they should see someone, you know, once a year. And so if, you know, I feel like they're seeing someone who is comfortable with lichen sclerosis and comfortable with continuing maintenance therapy, that's great. They don't necessarily need to see me, but some of the patients will continue to follow with me yearly.

D (26:32)

They mentioned some Other topical therapies. We talked about the calciner and inhibitors, topical retinoids and the topical hormones. I. I was surprised. I thought, like, there was decent data on, like, estrogens and things like that, but there were actually strong recommendations against, you know, outside of treating, like, GU syndrome in general. It doesn't seem like I was surprised

C (26:56)

to see that too.

D (26:57)

Yeah, it doesn't seem like they're terribly enthusiastic about hormones being actually used to treat lichen sclerosis.

B (27:04)

Yeah, no, yeah, I don't. I don't ever use hormones to treat lichen.

A (27:09)

This is why. This is why we have the experts come on the show when all three of us are like, yeah, they're pretty good. No, no, there is not.

D (27:16)

What are you doing?

A (27:17)

There is not.

B (27:17)

Yeah, it's a good adjunct, though. I think it's because most of these patients are going to be postmenopausal and, you know, they're going to have vulval vaginal atrophy. And so I think, you know, I do have a lot of patients on both estrogen and topical steroids. So the way I use it is, you know, you get them on daily vaginal estrogen cream or pill or whatever you want to use, and then maintenance is twice a week on that. So what I'll have them do is their steroid Monday, Wednesday, Friday at bedtime, and then I'll have them do their estrogen Tuesday, Thursday. So I think it does have a role and making the patients more comfortable and helping the tissue be healthier. But it doesn't really do anything for the leg and sclerosis.

D (28:00)

When you're on the maintenance therapy, are there like emollients on the days off or you do say don't use anything?

B (28:07)

Yeah, you know, if they're comfortable, which is the goal. Right. We want them to not have any symptoms. You know, once they're on maintenance, then I don't really have them use anything else. I tell them, you know, plain Vaseline is fine also, you know, just natural oils, coconut oil, almond oil, olive oil, you know, all those things are great if they feel like they need something else for moisture. But I don't tell them they need to use any emollients.

C (28:33)

How about like, that? Highly urine. I've seen, like hyaluronic acid, you know, I don't know suppositories. Do you believe in that? Do you think that's witchcraft? Do you think it makes sense? Do you think it would help here for symptoms?

B (28:46)

Yeah, I think it makes sense. Sense for vulvovaginal atrophy due to estrogen loss. So where that plays a role is, you know, you have a patient, maybe they had breast cancer. Maybe they're really worried about using estrogen. I do think hyaluronic acid is becoming more popular, and I do think it plays a role. It's definitely not as good as estrogen because it doesn't really address the underlying reason that they're getting atrophy. But if they need a moisturizer, you know, I think. I think that's reasonable.

D (29:21)

We talked about prp, but they also mentioned uv, photodynamic therapy, cryotherapy, lasers. Not a lot of enthusiasm for any of those. Do you do any procedures, like, a lot or almost never?

B (29:34)

Nope, almost never. Yeah. And I don't. We have a, you know, a group at Ohio State who's doing a study on the laser. Like, I think it's a CO2 laser. Again, same same thing that we talked about with PRP earlier. It doesn't really address the underlying reason for the lichen sclerosis, but if they want to try it to kind of plump the tissue or make the tissue healthier, I would see it as sort of an adjunct. But the problem is, is it's being marketed as a treatment. So, okay, you know, if you're not better, let's just keep doing treatments with the Mona Lisa or whatever it is. And it's, you know, I. I just. I think it gets misconstrued a little bit.

D (30:18)

The only systemic therapies they talk about are methotrexate and acetretin. You had mentioned hydroxychloroquine because there was a study of mayo. What about the new stuff? I saw a case report of Tofa and baricitinib. Like Jack inhibitors. Seems like that would make sense to me. And then there were two cases of topical reflumelast. I don't know how many episodes of germs on drugs that you listen to, but we love, love, love oral roflumilast with the newer medications. Do any of those strike you as a lot of potential or you've had

C (30:49)

great experience or V. Tama. I throw in there too.

A (30:53)

So, like the Tamazori, we did the Abzelura study. So Opzolura did a lichen sclerosis study, and it did something. But pretty much the patients were all like, the clobat is always better. Like, that was what I got across the board from them.

B (31:12)

Yeah. Vitamin. I've tried for vulvar psoriasis, and I'm really unimpressed. So I would be hard pressed to try that for lichen sclerosis. I, you know, I haven't used any JAK inhibitors yet. I think I'm a little bit, I don't know, I am a little bit limited just because I'm at an academic center. So I don't really have a lot of just samples at my disposal that I can give out to people. I do think the JAK inhibitors are promising. I would say if I had to pick, I would, you know, probably oral over topical especially because a lot of the newer topicals are in a cream base, which can be another, a little bit of an issue for me using it. But yeah, I'll be interested to see, you know, if we, we have these little studies that we're doing through the Vulvar Dermatoses Research Consortium. You know, we have small groups of people looking at these things. So I think it's going to take a while for us to be able to, to say for sure. But I'm, I'm seeing that JAK inhibitors are kind of working for everything.

A (32:21)

Yeah, that's, yeah, that's, it's, it's actually more of a, it's a be a more novel case report at this point. If somebody was like, I used a JAK inhibitor for X and it didn't work, that'd be much more reportable than anything else anybody could report it for using for. All right, Pat, you got anything? You got anything else before move on?

D (32:40)

No, I didn't really like dive into the procedural stuff. I, is, is procedural gynecology, does that play a big role in managing these patients? Is that something you do?

B (32:51)

No, not really. My partner in the clinic is a, is a gynecologist and so if someone needs to go to the or. I'd say the main reason we do procedures is someone who say has lichen planus or severe scarring or they have like a severe band, you know, of tissue that's scarred and it's causing a lot of pain, you know, releasing those adhesions or kind of releasing vaginal adhesions and people have really bad vaginal stenosis. But we're, we're really not, we haven't really adopted any procedures on a routine basis. I would be interested in exploring PRP for some various things, but, you know, I guess I have to find one of my dermatology colleagues who wants to, wants to do a vaginal study.

D (33:37)

So, so overall a good sort of consent. You agree with the Germans, which, that's a bad.

B (33:44)

Don't I drive A BMW.

A (33:46)

Generally speaking, that's not a good thing.

D (33:48)

But in this case, you're saying, okay, good.

A (33:52)

What do you tell people? So it was when we were doing the lichen sclerosis study. So. Right. I like 20 people in there and it was by far the most lichen sclerosis I've ever dealt with. Dyspareunia was like so painful. Intercourse was like a big thing. And do you proactively, you know, if you get somebody who comes in and they've got the beginnings of lichen planus or not like in planets, like any of it, I guess lichen, planus, lichens, sclerosis, whatever. And intercourse is now painful. Do you ever, you know, do you proactively tell them, like, don't stop because you're going to get stenosis. And then it's going to like, what, what do you tell people about intercourse if, if they're not, if they're not scarred already? Like, what do you. Yeah. What do you tell people?

B (34:46)

Well, it kind of depends on what their goal is. Some people don't have the goal to be sexually active or maybe they have a partner that, you know, for whatever reason, you know, they, they can't be sexually active. So I, I asked them that. Now I don't, you know, I think my main thought when I have a new patient and is controlling the disease. So we, we get the disease under control first and then we have a conversation about if your disease is controlled and you're still, still having dyspareunia, you know, what is the issue? Is there a band of adhesions that's causing it? Is it, you know, something else, you know, some other reason you're having dyspareunia. Maybe they have vulvovaginal atrophy and you just need to give them some estrogen. I see that a lot. You know, that's something that we need to make sure that we're, we're doing for these patients. But yes, regular intercourse, if they're able to, you know, we say that's nature's dilator. Right. So if they're comfortable and they do have the goal of being sexually active and they have something like lichen planus, which can cause scarring. A, you want to get it under control, but B, you know, regular intercourse is, you know, can really be helpful.

A (35:54)

Okay, is the. So let's, let's move on to my article, which was one that you have been working on that hasn't been published yet about vulvar contact dermatitis. And, you know, My take from your article was completely consistent with my experience, which was that when I saw allergic contact dermatitis of the genitals, it was pretty obvious. And so like, as a patch testing person, they rarely ever got to me because, like, anybody would have looked at it and been like, what are you putting down there? And then it'd be like, you know, benzocaine, neomycin, Neosporin, whatever, and you're just like, stop. And then if you don't get better. But I would still get lots of patients referred because basically people were looking for, you know, they had vulvar pruritus and they were looking for a, oh, maybe there's a cryptic contactor. Whereas in reality it was just like, get the hell out of my, go see them, let them deal with it. Is that so? Did you. Would you reasonably agree with that? That it's pretty rare to see vulvar contact derm when it isn't pretty obvious? Like, ooh, you know, whenever I saw a couple of cases of like people allergic to the acrylates in the absorbent pads or a benzocaine allergy, it wasn't like, oh, I think it was pretty obvious there was a yes.

B (37:21)

Yeah, I see a lot of benzocaine, it's in Vagisil and so like, that's my worst enemy. But when they come in, it's acute or even unfortunately acute on chronic, you know, they've been using it for a year every day. I had a lady who used a tube every day for a year of Vagisil and it was really just sore, horrible contact derm. So that, that can be obvious. I think the things that aren't as obvious is do they have lichen simplex chronicus? You know, and maybe it started out as an acute contact dermatitis, but they might have a driver, you know, they might still be using something that we haven't identified that's making that.

A (37:58)

So what is your approach to. Because vulvar pruritus, right, so there's, there's. And for our listeners, right, there's. There's vulvar pain. I think that pretty rarely comes to derms and I probably comes to you a lot, but not to like normal derm.

D (38:16)

Yeah.

A (38:18)

Vulvar pruritus, though, I think comes to terms pretty regularly. What's your approach? Like, what do our listeners need to know? Like, do you empirically treat people for candida? Just like as a. Just in case. Do you put them. Everybody, if they're over 65, they automatically get estrogen. Like, what do you what do you. Anything weird that you do? Not weird, but like, that wouldn't be, like, that's obvious. Duh. Like.

B (38:47)

Yeah, yeah. No, I mean, I think you just have to know what the most common irritants and allergens are in the genital area. Right. So for, for our vulvar patients, that's going to be, you know, incontinence. Urine pads, make sure they're not using over the counter stuff like Vagisil. You have to ask what they're putting on. You know, are they wiping a lot with toilet paper? Because that rubbing can cause, you know, worsening pruritus. So I think you just, you know, my main thing is asking them about the itch scratch cycle because that tells me, you know, if they're like, yeah, you know, I itch, but then when I scratch it, you know, feels good to scratch, but then it makes me itch more and they end up in this vicious cycle. You know, that's, that's pretty obvious, like in simplex chronicus. And it can be really hard to say what started it. Sometimes it could have been a yeast infection a year or two ago that started the itch scratch cycle. I don't test everybody for yeast, although I don't think it's a bad idea to swab for yeast because, you know, I have had a few patients that, you know, it looks like lichen simplex chronicus. But then when I test them, you know, they're getting recurrent yeast. So that can definitely be an issue.

A (39:53)

Is there like, what kind of is that? Like a special swab that you just use, like a bacterial swab and send it for yeast or like, how do you do that?

B (40:04)

Yeah, well, we do have a, like a special test called an aptima that we use in our vulvar clinic. That's like a pretty quick, like you send it out, you swab, you can send it to the lab for gc, chlamydia, bv, you know, Candida. Just in the regular derm office. Just the swabs that I use for bacterial swabs, you know, you can send those for yeast too. So that's pretty simple to do. You can just, or just send it off for culture.

A (40:31)

So it's, it's a yeast. It's not like. Because I know there's like a nucleic acid amplification test or something.

B (40:36)

Yes.

A (40:37)

Or you could probably even do the PCR from like Vicor. So really there's not like one particular test where you're like, this is what you should be doing. And Is do you ever see Candida as a. Like just. It's not like if you see Candida, is it like we need to do something or is it like if you see Canada, probably just got some candidate out, like, like what do you. Yeah, positive test.

B (41:04)

Yeah. If it's Candida albicans, you know, and they're having itching, you know, I'm treating that. Yeah. I'm usually not just randomly testing people for yeast so that there's usually a reason. There is something called Candida glabrata, which can be, you know, some people get irritation with it, but some people can be asymptomatic. So it's sort of like testing for Gardnerella for bv. Like some people just have it. If you test them, they're going to be positive, but if they're not having any of the symptoms of bacterial vaginosis, you don't need to treat it. So I would say by far and away though, if they have Candida albicans, you know, and especially if they have some, some other disease process on the vulva, I'm treating it.

A (41:45)

What's your normal. Do you just give them one dose of fluconazole? Do you give them like weekly for a month? Like what's your, what's your standard treatment for vulvar candidiasis?

B (41:56)

Yeah, so just, you know, if it's just simple, it's 151 dose like you, we do or do in the gynecology world if it's more complicated like the SGLT2 inhibitors, like Jardians for Zika, those patients, sometimes I'm actually treating them weekly because I need to get them to their PCP or endocrinologist and I need to get them off of the medication. So sometimes I'll go ahead and give them a more prolonged treatment because A, they have more severe disease and then B, we're trying to get them off of the medication before we, we stop treating them.

A (42:33)

And for vulvar lichen simplex, is there, what is your kind of go to there? Do you regularly end up going to oral drugs? Do you, you know, okay, so you try some tacrolimus. Fine. If that doesn't work, you know, do you use dermaleve? Do you use, what do you use for them? If it's, if it's pruritus, lichen simplex, but you're just not seeing much. But they're itchy. Okay.

B (43:03)

It depends on where the involvement is. Right. Lichen simplex chronicus can be anywhere on the vulva. So if it's on the hair bearing area. I'm probably going to lean more towards like a low to medium potency topical steroid. But I'm going to really monitor them very closely. So say I give them trimecinolone ointment. I do it twice a day. I'm going to see them back pretty quickly, like six weeks and make sure they're doing well and trying to get them tapered off of that. Sometimes it's a prolonged taper like six months. But sometimes I've been. Topicals really aren't working. I'll do interlegional catalog actually. So I just, you know, it's usually like a CC of K10 and I'll do 0.1 and kind of come down the. Say it's on the labia majora. I'll kind of come down and put 0.1 in each spot down the bilateral labia majora and people get some pretty quick relief with that. I know there are people who do specialize in vulvar disease who are big proponents of just, just doing that off the bat. Give them some iok, shut down the itch scratch cycle. And I don't think that's a bad idea. I think there are some patients who are like, oh, you want to give me a bunch of shots my vulva. So sometimes you have to get over that. Or I'll help premedicate them with topical lidocaine or something before they come in.

A (44:20)

As you say that I'm thinking about if we were tried to do that to our men with red scrotum syndrome. Okay. So I'm going to give you 20 shots into your scrotum and then that will probably make it feel better at least you know they're not going to come back.

B (44:36)

That's what I was going to say.

A (44:37)

Or not. You were not going to see them again as a patient. You, you, if that was your, your therapeutic goal was then they're good, you're. They're gone. Okay.

C (44:47)

Right. Could you ever see a role for like dupixent or something like that, you know, to help with that? Because LSC is prurigo nodularis and.

A (44:59)

Yeah, adjacent, you know.

B (45:00)

Yes, absolutely. I have a couple patients on it actually. I couldn't get them better. And you know, a lot of times I can kind of squeeze a little bit more BSA out of it. You know, they might have something going on in their scalp, a couple prurigo nodules up there. Maybe they've got a little bit on the arms or the groin and you know, I'll get them on Dupixent. It's. It's awesome. And they do great. If I could put everybody on it, that's great. But, you know, with a limited BSA in the genital area, sometimes that's hard. But yeah, yeah, I find a lot of extra involvement when I'm trying to get the.

A (45:33)

It's reasonable to count anywhere that they are itchy as counting towards bsa. That is a reasonable thing to do. The. All right, so before we go to trivia, last thing, this Volvo something of menopause. Like, I keep hearing about this. Like, what's this? It's, it's. Is it basically like atrophy? And so it makes people susceptible to irritant derm. Is that like, for a simple dermatologist? Is that. And what's it called again?

B (46:08)

Okay, so it's a genital urinary syndrome of menopause, and they replaced vulvovaginal atrophy with that term because, you know, people. Atrophy sounds kind of like a derogatory term, right? Like you're, you're atrophic. You're, you know, you're losing your tissue. But also it encompasses more symptoms, right? It's not just loss of estrogen. It's women who have lower, lower urinary tract symptoms. So they might have frequency, urgency, you know, burning on urination, but they also have maybe irritation or itching or stinging from loss of estrogen to the, to the vagina and to the introitus and the vulva. So, you know, that is definitely, you know, it's not just that they lost the estrogen and the tissue looks pale. It's that they're having other symptoms along with it. So it makes it a syndrome.

A (46:59)

And is that something that.

C (47:01)

So will you give women, will you give women systemic, like, transdermal estrogen if pruritus is one of their main complaints and they're postmenopausal, if you think, you know, we know that this is a symptom of, you know, we've talked about. We had a functional medicine episode and we talked about, you know, sort of not functional medicine, regenerative medicine.

A (47:28)

Said that in a very demeaning way. He's like, we had a functional medicine.

C (47:34)

No, no, it was regenerative.

B (47:36)

But yes, well, I use a lot of topical estrogen. Because if it's really the GSM or the, you know, atrophy that they're dealing with, then that's really going to target that tissue, right? It would be. I would liken it to someone coming in and I put them on prednisone because they have vulvar like in sclerosis as opposed to topical betazole. Right. So if I put them on oral estrogen or transdermal estrogen for genital urinary syndrome and menopause that's just localized, then you know, maybe they don't really need that. Now some women may have, have other menopausal symptoms. You know, they're having a lot of hot flashes, other things, mood swings, you know, then I'm going to get them to, you know, one of their, either their general gynecologist or our menopause specialist to, to talk about systemic hormone therapy. But I would say the majority of what I do is just, just topical, topical estrogen. And that I think for probably 90% of patients that's, that's enough. If you know, it's, their main symptoms are in the, the genital area.

C (48:38)

For, for our, that's helpful for our dermatology listeners. Is there any reason to be afraid of or contraindications to giving topical estrogen to women? Like if this is something that you can do because they're having discomfort, is there history of breast cancer, history of blood clots? Do you need to think twice or can you safely do topical estrogen?

B (49:02)

So there have been studies. I think the main thing people will worry about is do you have to add progesterone? Right. If they still have a uterus, is there going to cause, you know, endometrial hyperplasia or cancer? So studies have said no, you don't need to do any, you know, any progesterone, so you don't need to worry about that. So that's one thing off your list as a dermatologist. The second thing is breast cancer. Now you need to be aware that the package inserts the same for oral estrogen as it is for topical estrogen. So it's going to have that contraindication. You know, any, any history of blood clots, history of breast cancer? I will say there haven't been any studies to prove that it increases the risk of breast cancer recurrence if you're just using vaginal estrogen. So my approach is if they have a history and they have really bad, you know, atrophy and they're having a lot of symptoms and I feel like we need to treat them and nothing else has worked as far as like the non hormonal options. I just reach out to their oncologist and you know, we have a conversation like, you know, this is safe acog, the American College of Obstetrics and gynecologists actually has a statement about this with breast cancer that it's safe. So you have that to back you up. But yeah, I just, you know, just to cover my bases, you know if they're worried about it, you know I will reach out. But we have a lot of patients, I guess you would call it off label on vaginal estrogen who have had breast cancer. But it really is the best treatment out there and it's easy to use. It's you know, one gram twice a week after you get them through the first two week loading dose.

A (50:43)

And does it does genitourinary syndrome of menopause. Is it fairly reasonable that it could present with just skin symptoms just like Mitchie? And so they might, you know because I, my understanding is if a woman's like past the age of pap smears a lot, don't follow up with a gyne anymore and so they might be coming to you and like is this something derms need to have like a working knowledge that it exists and if so is it reasonable to say hey, you know, this kind of things look a little atrophy down there, here's some estrogen or should you send them to a gyne? Is there like other stuff you should be doing that we wouldn't know to do?

B (51:33)

No, I mean I think that's reasonable. I think the biggest thing is if someone comes to you with genital itching is to have that on your differential it might be atrophy. And so if you look and the tissue looks pale and they're having kind of stinging or burning and you don't see that texture change. Yeah, I mean go ahead and treat now if you don't feel comfortable, you know, a general gynecologist would be be an easy consult but it's not like

A (52:01)

oh my God, no, they need a workup for this and that and they need to need to you know, do a urinary voiding study. Like whatever. It's just like you can symptomatically give them some estrogen and if they're feel if the itching gets better, they're okay. So you said loading dose for the first two weeks. Is that like every day for the first two weeks and then twice a week after that or what do you do? How?

B (52:24)

Yeah, yeah, anywhere from 0.5 to 1 gram and that comes with an applicator. If you do the cream and you do that nightly for two weeks and then you go to twice a week, I usually do just, like, Tuesday, Thursday. Yeah. And that's it. And then if you do vagifim, that's the little pills they can use in the vagina. If they're like, the cream is messy or it causes burning, I have a few patients who can't use it. It's like a little pill, and it's an applicator, and they. It's the same way. You just do like, a pill every night for two weeks, and then it's twice a week. So that can be a nice option too.

A (52:55)

Okay. All right, that's. You have answered all of my lady parts questions. I think we're now ready to move on. I only had to get to be age 52 to have them all in. So now we're ready to move on to trivia. Dr. Patton, what's our topic this week?

C (53:16)

Week, it's.

D (53:18)

It's lady parts. The vagina.

C (53:20)

Oh, gosh.

D (53:21)

Made.

C (53:21)

I was afraid of that.

D (53:22)

I know. It made my Google searches for the week very dicey. Very nice.

C (53:27)

Hopefully you didn't do those at work.

D (53:29)

Yeah, no way. All right, number one, what? Feminist 1996 play written by Eve Enster is a series of stories based on interviews with hundreds of women.

B (53:43)

The Vagina Monologues.

C (53:44)

Vagina Monologues.

D (53:45)

I'm giving that a tie. No surprise. Matt. You guys. 0 point half a point each for fares and time.

A (53:53)

Okay.

D (53:56)

What was the name of the femme fatale in the James Bond movie? Goldfinger.

A (54:03)

Octopussy. What was that?

C (54:10)

It's Galore.

D (54:11)

It was Galore.

C (54:15)

Not something I wanted to say. Unpack on the podcast. You may have to take that out.

A (54:19)

That was crazy.

D (54:19)

That was in 1964, that movie. I'm like, how did they get away?

C (54:23)

I know.

A (54:24)

Yeah.

C (54:24)

How did they get away with that? I remember, like, re hearing about that when I was a kid. I was like, yeah, yeah.

B (54:30)

I've heard worse.

C (54:31)

All right, maybe I put that one out final. What?

D (54:34)

Arnold Schwarzenegger movie had the iconic line spoken by a young child. Boys have a penis, girls have a vagina.

B (54:42)

Kindergarten Cop.

A (54:44)

Yep.

B (54:44)

Whoa.

A (54:46)

That's it.

D (54:47)

Tyler walks away. Oh, no.

A (54:49)

It was. That was a tie.

C (54:54)

Except when we cut mine out, then I'll lose. I'll take the L on that.

B (54:58)

I didn't get the P, so I'm

C (54:59)

not saying the P word. It's not like podcast.

D (55:02)

We didn't make up that name. That's what the girl's name was.

A (55:05)

Put it on a loop.

C (55:07)

Put all my residents.

A (55:08)

And someday, if I ever come and lecture at UNC Grand Rounds I'm just gonna have that in the background.

B (55:15)

You could sub in.

C (55:16)

I could have just pretended like I didn't know the answer, but, like, my.

D (55:21)

She's like. I don't want to say this, but I also don't want to lose.

B (55:24)

Yes, you can sub in Pocketbook. That is an acceptable, you know, urban dictionary term for. For the vulva. It's one of my favorites.

C (55:34)

Oh, yeah, that's right.

A (55:36)

Okay, okay.

C (55:37)

I know. I do love the patient. I have heard Pocketbook Lady Bits is another big one that I heard that, see, in men.

A (55:48)

It's just groin. That's it. Groin. That's all we have. Patton thinks we have two groins.

C (55:54)

Groin galore.

A (55:56)

That's the. The left groin and the right groin. It's just one groin. It has. You have one groin, and it has two parts. You don't have two groins.

D (56:05)

Well, you could have a rash on one side, and the guy would be like, you're looking at the wrong side of my groin. Well, I guess it's side of the groin, right?

A (56:12)

You're not looking at the wrong groin.

B (56:16)

It's very confusing.

C (56:18)

All right, I think it's time to wrap it up.

A (56:20)

Thank you for joining us tonight. This was so much fun for our listeners. I hope you learned a few things if you laughed once or twice, but mostly hoping you're planning to join us next week. And until then, I'm Matt Zyrus.

D (56:33)

I'm Tim Patton.

C (56:35)

And I'm Laura Farris. And we are Derms on Drugs.