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Guidelines for Management of Vulvodynia Issued

Clinical Context

Vulvodynia has been defined by the ISSVD as vulval discomfort, described as a burning pain occurring in the absence of visible findings or a neurologic disorder. Classification has been by anatomic site and whether pain is provoked or unprovoked.

This is a report from the BSSVD that presents evidence-based guidelines for the diagnosis and management of vulvodynia, but the authors noted many limitations in published research, including poor patient selection, limited follow-up, and a paucity of randomized trials.

Study Highlights

  • The BSSVD group consists of gynecologists, dermatologists, genitourinary specialists, and patients who conducted a search of the literature to identify evidence for the guidelines.
  • 12 recommendations emerged with evidence levels after literature review:
  • Recommendation 1:
    • An adequate pain history should be taken to assess pain severity and impact on the woman’s life and to categorize the subgroup of vulvodynia involved.
    • The ISSVD classification divides types of vulvodynia into generalized vs localized and provoked vs unprovoked.
    • Localized vulvodynia includes vestibulodynia, cliterodynia, and hemivulvodynia.
    • Provoked vulvodynia can be sexual, nonsexual, or both.
    • Mixed vulvodynia can be provoked or unprovoked.
  • Recommendation 2:
    • Patients with dyspareunia should have a sexual history taken to identify psychosexual morbidity and dysfunction, with a focus on provoked pain that reduces arousal and interest in sex.
    • High degrees of anxiety, depression, somatization disorders, and hypochondriacal symptoms have been associated with vulvodynia.
  • Recommendation 3:
    • The diagnosis of vulvodynia is clinical; therefore, biopsies, patch testing, and magnetic resonance imaging are not necessary for diagnosis.
  • Recommendation 4:
    • A team approach may be necessary with a lead clinician to refer patients to physiotherapy, psychosexual medicine, and pain management. o Recommendation 5:
    • Combining treatments (eg, medical, psychological, physiotherapy, and dietary advice) should be encouraged to address different facets of pain.
    • Surgical vestibulectomy has a better outcome when psychosexual dysfunction is present.
  • Recommendation 6:
    • Patients should receive an adequate explanation of symptoms and medication instructions.
  • Recommendation 7:
    • Topical agents may cause irritation and should be prescribed with caution.
    • Topical lidocaine gel may aid penetration for intercourse, but potential effects on the partner should be addressed.
    • Other topical agents such as capsaicin, nifedipine, and ketoconazole cream have unproven effects and mixed results.
  • Recommendation 8:
    • Tricyclic antidepressants are an initial treatment option for unprovoked vulvodynia, and other agents such as gabapentin and pregabalin may be considered as additional agents.
    • Gabapentin can be started at 300 mg daily increasing every 3 days to a maximum of 3600 mg daily, but the optimal medication is still unclear.
  • Recommendation 9:
    • Surgical excision of the vestibule can be considered for local provoked vulvodynia if other measures have failed, but only a minority of patients will benefit.
    • Compared with behavioral measures, 1 study found similar results with patients preferring the behavioral approach (pain management, sex education, partner education).
    • Laser vaporization of the vestibule is not recommended.
  • Recommendation 10:
    • Pelvic floor muscle dysfunction should be addressed in women with sex-related pain, and self-help exercises and physical therapy may be of benefit, with self-massage, biofeedback, and trigger point pressure being alternative strategies.
  • Recommendation 11:
    • Acupuncture may be considered for treatment of provoked pain, but the long-term outcomes and mechanism are still unclear.
  • Recommendation 12:
    • Intralesional injections of methylprednisolone and lidocaine may be of help in those with provoked vulvodynia; a 32% remission rate has been reported.
  • In conclusion, these guidelines act as a starting point to help clinicians increase their education and awareness of vulvodynia.

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd


Evidence-based guidelines for management of vulvodynia were issued by the British Society for the Study of Vulval Diseases Guideline Group and reported online in the March 16 issue of the British Journal of Dermatology.


27 abril, 2010 Posted by | Noticias dermatología y dermatopatología | 6 comentarios

Combined approach to pregnancy-related conditions

Wailea, Hawaii — In the absence of incontrovertible data regarding best treatments for many skin issues associated with pregnancy, therapy often involves combination treatments, an expert says.

Physiologic skin changes associated with pregnancy include pigmentation changes, vascular ectasia and striae distensae, along with the appearance of “glowing” skin and faster-growing hair (often followed by hair loss) and nails, says Theodore Rosen, M.D., professor, department of dermatology, Baylor College of Medicine, Houston. Dr. Rosen spoke about this issue at MauiDerm 2010: Advances in Cosmetic and Medical Dermatology in January.

Melasma woes

Melasma affects an estimated 50 percent to 70 percent of pregnant women, although it also impacts women on hormone replacement therapy or birth control pills. Because cases differ in terms of pigment levels, depth and extent and skin types, “Nobody has an absolute answer for how to treat melasma. We try to mix and match. It’s all individualized therapy,” Dr. Rosen says.

Dr. Rosen says he prefers to use Tri-Luma (fluocinolone acetonide, hydroquinone, tretinoin; Galderma). However, “We must be circumspect about its use because of the potency of the steroid,” he adds.

Other useful agents include Solagé (mequinol, tretinoin; Stiefel) and Glyquin (hydroquinone, glycolic acid; Valeant). “There’s no substitute for broad-spectrum sunscreen for protecting against additional sun damage. I prefer Anthelios (La Roche-Posay),” Dr. Rosen says.

Struggling with striae

Striae impact an estimated 50 percent to 90 percent of pregnant women, Dr. Rosen says. “It appears that people who have stretch marks during their growth phase, and those whose mothers have stretch marks, face the highest risk (Chang AL, Agredano YZ, Kimball AB. J Am Acad Dermatol. 2004 Dec;51(6):881-885).” To prevent striae, “Some experts believe that regular moisturization — with shea butter, cocoa butter or gotu kola — is important,” and that low-concentration alpha hydroxy acids (AHAs) are helpful, he adds.

“Combining moisturizers and AHAs seems to provide some protection for patients prone to developing stretch marks,” he says, although randomized, controlled trials have shown no benefit for either of these approaches (Osman H, Usta IM, Rubeiz N, et al. BJOG. 2008 Aug;115(9):1138-1142).

Several recent reports tout fractional laser resurfacing (Fraxel, Solta Medical), even for tough-to-treat white stretch marks and skin of color (Katz TM, Goldberg LH, Friedman PM.Dermatol Surg. 2009 Sep;35(9):1430-1433. Epub 2009 Jun 22), although such treatments are costly, Dr. Rosen says.

Genital warts, HSV

For external genital warts, Dr. Rosen says imiquimod shows higher cure rates in nongravid women than in men. Based on a few small series, he says, “Imiquimod appears safe in pregnancy. The highest cure rate for the drug as approved, three times a week for up to 16 weeks, is just under 80 percent (Audisio T, Roca FC, Piatti C. Int J Gynaecol Obstet. 2008 Mar;100(3):275-276. Epub 2007 Nov 26).”

He adds that reducing the amount of affected tissue with CO2 laser and then treating the remaining field or residual tissue with imiquimod is an effective combination in nongravid women. But in pregnancy, he adds, “We have no data to totally verify the effectiveness of this combination.”

As for herpes simplex virus (HSV) in pregnancy, “The closer to the pregnancy the disease state was acquired, the higher the risk to the neonate, because less immunity can be transplacentally passed,” Dr. Rosen says.

However, he adds that in a meta-analysis of six randomized, controlled trials, researchers concluded that the impact on the neonate of antiviral prophylaxis (with acyclovir or valacyclovir) in the third trimester could not be estimated. Nevertheless, Dr. Rosen recommends this approach partly because it is associated with a lower likelihood of cesarean section and positive culture at delivery (Hollier LM, Wendel DG. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004946).

By: John Jesitus


18 abril, 2010 Posted by | Noticias dermatología y dermatopatología | 2 comentarios

Genetic test for androgenetic alopecia

Bologna, Italy — A novel genetic testing technique allows for patients who experience hair loss of any severity to know whether their condition is likely due to androgenetic alopecia. The genetic testing method, known as HairDx, is not used for diagnosis; instead, it is used to predict the risk of developing hair loss in patients at a young age, and, according to one expert, it can prove to be extremely useful in the clinical setting when treating and managing patients stricken with androgenetic alopecia.

Alopecia unveiled

Male and female pattern hair loss, or androgenetic alopecia, is the most common type of hair loss and can be a source of great psychological stress for the patient. It is thought that up to 50 percent of females will develop this condition over their lifetime, with up to 80 percent of males being affected, depending on their age. Patients who experience excessive hair loss can take this novel test to see whether they have a genetic predisposition for developing androgenetic alopecia.

“A negative test will surely placate those unfortunate individuals who experience hair loss, as the treatment of androgenetic alopecia can be challenging,” says Antonella Tosti, M.D., professor, department of dermatology, University of Bologna, Bologna, Italy. “However, a positive test will make patients take their therapeutic regimens more seriously and increase their compliance to treatment.”

Testing details

The genetic sample is collected using a cheek swab. All cells have an androgen receptor, and the test works by assessing whether there is a polymorphism in the androgen receptor gene. If a polymorphism is found, the test is positive, indicating a 70 percent risk of the individual developing androgenetic alopecia at a young age. Though it is not 100 percent, the probability of developing androgenetic alopecia with a positive test is very high.

“If the polymorphism is not found, it does not rule out that a patient may develop androgenetic alopecia in the future. However, a negative test is even more specific than a positive result of the test, as a negative test indicates that the chances of developing androgenetic alopecia are very low,” Dr. Tosti says.

The HairDx genetic test is currently available on the market in the United States to physicians. It must be performed in an office setting. In Europe, the test is available to the general public.

Current therapies

Currently, the only therapies for androgenetic alopecia approved by the Food and Drug Administration include oral finasteride (Propecia, Merck) and topical minoxidil (Rogaine, McNeil-PPC) for men, and topical minoxidil for women. According to Dr. Tosti, both of these approaches work well. It is thought that topical minoxidil works by opening the potassium channels in the cells and thereby increasing the duration of the anagen growth phase of the follicle.

“I think that this genetic test is very useful for doctors, because we often have patients who are very distressed because of their hair loss, and therefore the testing may give them an opportunity to start the treatment earlier or simply serve to placate them, should the test be negative,” Dr. Tosti says. “If treatment with Propecia or minoxidil is started earlier, the final hair regrowth result is undoubtedly better, as all of the current literature indicates.”

Finasteride for women

To date, finasteride is indicated for use only by men. However, results of a recent six-month pilot study of HairDX in post-menopausal women suffering from androgenetic alopecia have shown that this therapy could soon also be used by women.

Researchers have found genetic evidence that can help identify females who could equally benefit from finasteride treatment. The study findings indicate that females with post-menopausal androgenetic alopecia have a female corollary to the androgenetic alopecia in men, opening the door for a new treatment for women with this type of hair loss.

On average, the therapeutic benefits of oral finasteride can be seen after approximately six months of treatment. The sooner the test is done, the sooner the patient knows his or her risk.

Response to finasteride

Dr. Tosti says that HairDx is developing a genetic test that may predict whether a patient will respond to oral finasteride. This new test will facilitate and clarify treatment options for patients with androgenetic alopecia.

“When a patient complains of hair loss, physicians should not be so quick to blame it on stress. It is always very important to rule out androgenetic alopecia, even in younger patients, and to have a definitive diagnosis,” Dr. Tosti says.

Disclosures: Dr. Tosti is an adviser for HairDx, but she reports no financial compensation from the company.

By:  Ilya Petrou, M.D.


17 abril, 2010 Posted by | Noticias dermatología y dermatopatología | 1 comentario

Effectiveness of vitamins in sun-damaged skin

While everyone knows that getting an adequate daily dose of vitamins and minerals is important in maintaining one’s overall health, many question whether or not the vitamins touted in skin care products work in reducing the signs of sun-damaged skin. Now, a new study reviews the currently published scientific literature to determine what evidence exists to support the use of vitamins in skin care products to slow or reverse the effects of sun damage.

In the report entitled, “Vitamins and photoaging: Do scientific data support their use?”, published online in the Journal of the American Academy of Dermatology, dermatologist Jenny Kim, M.D., Ph.D., FAAD, associate professor in the division of dermatology, department of medicine, at the University of California, Los Angeles (UCLA), David Geffen School of Medicine in Los Angeles, presented results of a study that may support the use of certain vitamins in oral or topical formulations.

“It is well documented that ultraviolet (UV) radiation contributes to premature skin aging through the process of photoaging, and there is increasing evidence that the antioxidant properties of vitamins may contribute to the prevention and treatment of photoaging,” said Dr. Kim. “In fact, numerous companies developing cosmeceuticals base their effectiveness claims on the fact that their formulations contain vitamins proven in laboratories to modify cellular processes thought to contribute to the appearance of photoaged skin. As dermatologists, we can help our patients navigate this maze of marketing claims by sharing scientific data on the known efficacy of vitamins in skin care products.”

Based on a comprehensive review of the available published data on the role of vitamins in skin care products, Dr. Kim and her colleagues, Jamie Zussman, M.D., FAAD, and Jennifer Ahdout, M.D., found there is evidence to support the potential role of vitamins A, C, E, and B3 in modifying the photoaging process.

“While it’s evident that these vitamins can play a role in fighting sun damage, the question still remains whether these properties are effective when delivered in skin care products,” notes Dr Kim.

Vitamin A: Effective in treating a variety of skin conditions

The two most common forms of vitamin A studied for their role in protecting the skin from UV-induced damage are retinols and carotenoids. Retinol is found in foods such as liver, milk and eggs, and is the most biologically active form of the vitamin. Carotenoids are found in many fruits and vegetables, and have strong antioxidant capabilities.

While carotenoids are not shown to be beneficial in the treatment of photoaging, research suggests that they may play a role in photoprotection by preventing UV-induced collagen breakdown.

“Although the evidence available at this time is not strong enough to offer definitive support for the use of dietary carotenoids for photoprotection, a role for carotenoids as a supplement to photoprotective agents should not be discounted yet,” said Dr. Kim. “We hope to see larger-scale clinical trials conducted to further explore the photoprotective effects of carotenoids.”

Unlike carotenoids, there is vast evidence supporting the role of topical retinoids (the class of substances formed by retinol and its natural and synthetic derivatives) in treating photoaged skin. For example, prescription retinoid formulations have the most scientific data to support their use in this area.

Dr. Kim noted that both tretinoin cream (0.025% and 0.05%) and tazarotene cream (0.1%) are already FDA-approved for the treatment of fine wrinkles, skin roughness and mottled hyperpigmentation caused by aging and sun exposure. In addition, she added that studies of other retinoids have shown that a once-daily application of 0.1% isotretinoin cream for 36 weeks was effective in reducing fine wrinkles.

Retinoids also are found in over-the-counter cosmeceuticals, but there is less clinical evidence supporting their effectiveness in improving photoaged skin. “An important point to remember with retinoids is that we cannot assume that all retinoids are equal in their ability to fight photoaging,” said Dr. Kim. “In over-the-counter products, retinol appears to be the most effective retinoid based on clinical studies completed to date. However, patients should consult their dermatologist before using any topical retinoid, as side effects can occur when used with other topical products. When properly instructed by a dermatologist, most patients can tolerate topical retinoids and benefit from their effect.”

Dr. Kim added that unlike topical retinoids, there is minimal evidence supporting the use of oral retinoids in the treatment of photoaging.

Vitamin C: Possible skin care product value

Vitamin C, a water-soluble vitamin also known as ascorbic acid that is found in citrus fruits and dark green leafy vegetables, plays an essential role in the production of collagen and elastin. Because of its antioxidant properties, vitamin C may reverse the negative effects of UV radiation in the skin, but there are few clinically controlled studies to confirm this theory.

“An animal study examining the role of vitamin C in reversing sun damage found that when 5% ascorbate was applied two hours before UVB and UVA exposure, UVB-induced skin wrinkling was reduced,” said Dr. Kim. “Some of the human clinical trials have shown similar favorable results when applying a daily dose of L-ascorbic acid treatment, but all of these studies involved small sample sizes.”

In addition, Dr. Kim pointed out that one concern of adding vitamin C to cosmeceuticals is that vitamin C is unstable when used in formulations, and it is not known how much, if any, intact molecule remains when applied to the skin.

“This problem has been partially overcome by chemically modifying ascorbic acid,” said Dr. Kim. “However, for the body to use the supplied ascorbic acid, it must convert it to L-ascorbic acid, and many of the stabilized, commercially available forms have not been examined to determine whether this conversion is possible. For that reason, the average consumer will not be able to determine if a cosmeceutical containing vitamin C will be effective.”

Vitamin E: A primary antioxidant

Vitamin E, or tocopherol, is a fat-soluble vitamin, and its synthetic form is found in many over-the-counter products. Working as an antioxidant, vitamin E protects cell membranes and is thought to play an important role in skin aging because of its antioxidant properties. While topical vitamin E is available in a variety of products, there is no data which support claims that it improves skin wrinkling, discoloration and texture.

“Topical vitamin E has been studied in humans, as in mice, more as a protectant to be used before sun exposure than as an agent to be included in cosmeceuticals to reduce the signs of skin aging,” said Dr. Kim. “Through research we have learned that UV exposure significantly decreases levels of cutaneous vitamin E, and vitamin C should be included in any formulation containing vitamin E because of the important role it plays in maintaining active vitamin E levels.”

Research also has explored combining vitamins E and C as an oral supplement to provide sun protection. Multiple studies suggest that this combination therapy is beneficial for photoprotection. However, Dr. Kim noted that overzealous oral vitamin E supplements may be harmful, and two new studies also suggest that a high intake of vitamin E may be associated with an increased risk of basal cell carcinoma.

Vitamin B3: A possible treatment for photoaging

The B vitamins consist of eight different water-soluble vitamins that are found in a variety of foods. Vitamin B3 has been shown to reduce blood cholesterol and atherosclerosis (a condition in which fatty materials collect along artery walls), but now new insights are examining its role as an effective treatment for several skin conditions from acne to photoaging.

Specifically, Dr. Kim noted that vitamin B3 has been found to increase collagen production in in vitro studies and to reduce skin hyperpigmentation (dark spots) in clinical studies.

“There has been one clinical trial conducted in Caucasian women in which 50 women applied 5% niacinamide (topical vitamin B3) to one side of their faces twice per day for 12 weeks, and these women experienced significant reductions in the appearance of hyperpigmented spots, redness, wrinkles, and yellowing, as well as improved skin elasticity,” said Dr. Kim. “While initial studies show promise that topical vitamin B3 may prevent UV-induced skin aging, larger clinical trials are needed to confirm its role as a definitive treatment of photoaging.”

Bottom Line: Maintain healthy lifestyle, healthy diet, practice sun protection

Dr. Kim added that it is important for everyone to get an adequate daily supply of vitamins to maintain a healthy lifestyle, and any insufficiencies may negatively impact the skin’s overall appearance.

“Research has shown a potential role for various vitamins in reducing the damaging effects of sun exposure on the skin. Whether topical or oral formulations containing these vitamins have a protective effect is uncertain. Given the number, type and variability of preparations available, consumers should understand from our study that skin care products with vitamins may not provide clinically meaningful improvement,” said Dr. Kim. “What is known is that proper sun protection is key to the prevention of photoaging and should be top of mind at all times.”

Headquartered in Schaumburg, Ill., the American Academy of Dermatology (Academy), founded in 1938, is the largest, most influential, and most representative of all dermatologic associations. With a membership of more than 16,000 physicians worldwide, the Academy is committed to: advancing the diagnosis and medical, surgical and cosmetic treatment of the skin, hair and nails; advocating high standards in clinical practice, education, and research in dermatology; and supporting and enhancing patient care for a lifetime of healthier skin, hair and nails.

Source: American Academy of Dermatology


17 abril, 2010 Posted by | Noticias dermatología y dermatopatología | , , , | 2 comentarios