MUCOSAL DISEASE: ORAL AND GENITAL

Dec
2015
Vol. 34. No. 4

Introduction

There is a wide range of inflammatory and neoplastic disorders that affect mucosa of the oral cavity. Many of these conditions manifest in the oral cavity and the anogenital region, some affect the oral cavity and skin only, and others are unique to the mouth. Clearly the conditions that occur on the skin and mouth will be familiar to most dermatologists, but others occur specifically on mucosa without cutaneous involvement and may be new and unfamiliar. Even for those conditions that affect the skin and mucosa, the clinical presentation in the mouth frequently differs from their cutaneous manifestation. Awareness of the similarities and differences will help the clinician achieve the diagnosis and select the correct therapy.

White lesions are common in the oral cavity and despite often similar clinical appearances, include a range from variants of normal (leukoedema) to mucocutaneous immunological disorders (oral lichen planus) to premalignancy and cancer. Drs Jones and Jordan discuss many of these conditions focusing on the clinical presentation, methods to establish the diagnosis, and practical solutions to manage the disorders. Ulcers are also common in the oral cavity and like white lesions encompass a range of immunologic and neoplastic disorders. Importantly for the clinician, oral squamous cell carcinoma is common with biopsy invariably required to both establish the diagnosis and exclude other similar-appearing, traumatic, immune-mediated, and fungal disorders. The vesiculobullous disease mucous membrane pemphigoid and pemphigus vulgaris frequently present as ulceration without bullae and these disorders are discussed in this context.

HPV infection produces many benign papillary growths; but increasingly, oncogenic strains, mostly HPV 16, are the cause of a rising incidence of carcinomas in the tongue and oropharynx. Dr Yom discusses the rising incidence of this disorder, how to establish the diagnosis, adjuvant testing, and the role of radiation therapy in its management. The clinical profile of patients with HPV-associated oropharyngeal cancer (OPC) differs quite notably from that of traditional head and neck cancer patients, and the prognosis for HPV-associated OPC is significantly better. We hope that this issue will assist clinicians as they see patients with oral lesions and those with conditions of the anogenital mucosa.

It can be fun, surprising, and discouraging to practice a new and often unrecognized subspecialty. Genital dermatology is actually a multidisciplinary area including: dermatology, gynecology, physiatry, neurology, and psychiatry, in addition to the well-recognized and studied diseases that fall into the fields of infectious disease and oncology. Chronic genital symptoms are usually multifactorial
in nature, with skin diseases complicated by infection, irritant contact dermatitis, estrogen deficiency, and psychological factors. Many practitioners are uncomfortable treating these patients. Skin diseases present atypically in skin-fold areas, pain syndromes are very common, and discomfort of using potent topical corticosteroids and chronic therapy all make a provider unsure and unassertive. Fortunately, careful and caring management of these patients is appreciated enormously and usually very effective, and patients are forgiving of trial and error therapy. Even without a specific proven diagnosis, attention to detail, vigilant follow-up, empiric therapy after careful elimination of infections and malignancy usually provide patients with significant relief.

The articles in this issue target common, unrecognized problems such as the pain syndrome vulvodynia, skin diseases such as lichen planus, and the distinctive but rarely discussed problem of noninfectious ulcers. Hopefully, these discussions will pique the interest of the clinician, who will then teach theirself, with the help of the patients.

The information on vulvodynia is arguably the most useful in this issue for the average provider. Nearly 20% of women experience this pain syndrome at some point in their life, and 7%-8% of women have unexplained sensations of burning and irritation on any given day. Therefore, these women are seen very often, but usually treated repeatedly and ineffectively with antifungal and antibiotic
therapies without culture proof of infection. The dialogue in this issue provides the clinician with effective tools for managing the patient with symptoms but no objective abnormalities.

Much less well-recognized than vulvodynia are penodynia, scrotodynia, and anodynia; but Dr Edwards and other providers have extrapolated information on vulvodynia for successful management of many of these unfortunate men.

Another article in this issue that can be used daily by many providers is an explanation and update on the terminology for genital tumors produced by human papillomavirus (HPV) infections. For years, the terminology was dependent on the specialty. Dermatologists called atypia from HPV infection squamous cell carcinoma in situ, later renamed bowenoid papulosis. Gynecologists talked about vulvar intraepithelial neoplasia (VIN); but this terminology did not differentiate between HPV-related neoplasia and that associated with the chronic underlying diseases of lichen sclerosus and lichen planus, a condition with a much higher risk of invasion and metastasis. Over the past few years, multidisciplinary groups have revised this terminology. The information in this article helps the clinician to understand and interpret the biopsy reports.

The article on erosive lichen planus helps the clinician to recognize the atypical and nonspecific appearance of lichen planus on the genitalia. Importantly, this article contains information regarding the management of other inflammatory chronic skin diseases on the genitalia and in the vagina. Nonspecific local care, estrogen replacement, and the administration of corticosteroids in the vagina
are all discussed and are important aspects of treating many conditions on the genital mucous membranes and modified mucous membranes. These issues are less relevant—and sometimes totally irrelevant—when the diseases occur on extragenital skin.

The risks of severe scarring and secondary squamous cell carcinoma are also discussed.

Finally, the manuscript on noninfectious ulcers addresses a group of diseases that is generally not discussed. The average practitioner begins an evaluation with the erroneous assumption that most genital ulcers are sexually transmitted, either herpes simplex virus (HSV) or syphilis. In reality, HSV in an immunocompetent patient is an erosive, not ulcerative disease. Second, chancres are extremely uncommon in the United States compared to noninfectious causes of genital ulcers. This article gives the reader a manageable differential diagnosis.

In the end, the patient is the best teacher of genital disease for the observant and careful provider. Hopefully, this issue will help to direct and fill in the gaps.

Vulvodynia

Libby Edwards, MD, FAAD | Zahi Ben-Aroya, MD

Vulvodynia is a pain syndrome affecting the vulva. It occurs in about 16% of women at some time of their lives. The etiology of vulvodynia is still enigmatic and is probably multifactorial—including physiological concerns (eg, pelvic floor muscle dysfunction, neuropathic pain, and psychosocial) and sexual issues (eg, anxiety and sexual dysfunction). Although it is a common syndrome, most patients are neither correctly diagnosed nor treated. A diagnosis of vulvodynia is based upon patient history and lack of physical findings upon careful examination. No clinical or histological findings are present to aid in diagnosis. Most treatment options for vulvodynia are neither well studied nor have an evidence base, relying instead upon expert opinion, care provider experience, and use of data from other pain syndromes. However, many patients show marked improvement after physical therapy for the pelvic floor, medications for neuropathic pain, and psychosexual therapy.
Semin Cutan Med Surg 34:192-198 © 2015 Frontline Medical Communications

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Epithelial vulvar neoplasms and their changing classification

Jason Reutter, MD | Katherine M. Ball, BS | Russell Ball, MD

In recent years, there have been many changes in the classification scheme for squamous lesions of the vulva; this is primarily due to the assimilation of new scientific information into the diagnostic terminology. For example, over the past 75 years we have realized that precancerous and cancerous lesions of the vulva may be induced by a variety of preconditions, which are typically divided into human papillomavirus (HPV) and non-HPV precursor lesions. The latter include several dermatoses, especially lichen sclerosus and lichen planus. Additionally, we have learned that HPV on extramucosal and nongenital sites does not have the same malignant potential as on mucosal or genital sites. Because of the frequent changes in nomenclature due to these discoveries, both old and new terms continue to be used in clinical practice; a summary of these terms is provided to help prevent a misunderstanding of their scope and significance. Important points for clinicians and pathologists who are involved in the care of these patients are provided.
Semin Cutan Med Surg 34:199-205 © 2015 Frontline Medical Communications

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