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Introduction: Sodium-glucose co-transporter 2 (SGLT2) inhibitors, or gliflozins, are used as mono or combined therapy in the management of diabetes. Genital infections are the most common reported adverse effect, as a result of induced glycosuria. Cutaneous features of patients experiencing vulval symptoms while on SGLT2 inhibitor therapy have not been clearly described in published literature. We have observed a specific inflammatory vulvitis with psoriasiform features in patients taking SGLT2 inhibitors, related to candidiasis in most cases., Methods and Results: Demographic and treatment outcomes of 11 patients with characteristic inflammatory changes after starting SGLT2 inhibitors were extracted from electronic records. Ninety-one percent (n = 10) had candidiasis, treated with fluconazole. Six (54.5%) were able to continue SGLT-2 inhibitors through the addition of topical treatments, but five patients had to discontinue the drug., Conclusions: SGLT2 inhibitors can result in characteristic inflammatory vulvitis. Treatment with topical agents and single-dose antifungals may allow patients to continue their therapy to achieve improved glycemic control. In resistant cases, discontinuation of the drug is necessary. We highlight this effect so that early treatment can be initiated to alleviate symptoms and recognition of underlying cause., (© 2022 the International Society of Dermatology.)

Plasma cell vulvitis is a rare inflammatory disorder of the vulva with an unknown aetiology, characterised by mucosal inflammation. It commonly manifests as pain, itching, dyspareunia, and dysuria and clinically presents as erythematous plaque and macules on the vulva. This condition is refractory to available treatment modalities in the literature. We present a case of a 70-year-old female with histopathologically proven plasma cell vulvitis treated by platelet-rich plasma therapy after multiple failed treatment attempts with topical steroids and immunomodulators. The patient improved both symptomatically and clinically on follow-up with platelet-rich plasma therapy. Platelet-rich plasma which is a new novel treatment can be a therapeutic option for recalcitrant cases of plasma cell vulvitis., Keywords: case report; immunosuppressant; platelet-rich plasma; vulvitis.

The most problematic vulvovaginal conditions are familiar to dermatologists but may exhibit distinct clinical features or medication management because of the anatomic location. The second article in this continuing medical education series focuses on management pearls for treating vulvar diseases. We highlight key conditions, such as lichen sclerosus, erosive lichen planus, and vulvodynia. In addition, we review conditions that dermatologists may be less familiar with, such as plasma cell vulvitis, desquamative inflammatory vaginitis, vulvar aphthae, and low estrogen states. Nearly 1 in 6 women experience undiagnosed and untreated vulvovaginal discomfort at some point in their lives. Physicians who treat vulvar disorders will improve the quality of life of countless women., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Treatment options for advanced cervical cancer are limited and patients experiencing recurrence after first-line cisplatin-based chemotherapy and bevacizumab have a poor prognosis. A recent phase II study in advanced cervical cancer has demonstrated a disease control rate of 68.4% with the immune checkpoint inhibitor nivolumab. By blocking immune checkpoints, immunotherapy puts the immune system into a state of hyper-activation that can cause immune-related adverse events. We present the clinical, pathological and molecular data of a patient with metastatic cervical cancer and progressive disease after second-line therapy. We report on the therapeutic response under third-line immunotherapy with nivolumab, the immune-related adverse events (IRAE), and their successful management., Case Presentation: We report the case of a 62-year-old woman who was diagnosed with advanced squamous cell carcinoma of the cervix with paraaortic lymph node metastases. After an initial combined radio-chemotherapy with cisplatin, she developed local and nodal (supraclavicular) recurrence. Second-line chemotherapy with 6 cycles of carboplatin, paclitaxel, and bevacizumab resulted in a partial response for 6 months. Checkpoint inhibition with nivolumab was started due to progression, leading to persistent complete remission. Immunotherapy was well tolerated for 8 months until the patient presented with an immune-related isolated vulvitis, which was successfully managed with topical corticosteroids., Conclusions: The persistent complete response after third-line treatment for relapsed chemotherapy-resistant cervical cancer presented in this case highlights the potential of immunotherapy for patients with advanced cervical cancer impressively. To our knowledge, this is the first report of an isolated immune-related vulvitis under nivolumab. This adverse event might be underdiagnosed and mistreated, however, it is of importance due to its impact on quality of life, sexual wellbeing and compliance of patients. Successful IRAE management may enable prolonged immune checkpoint inhibitor therapy. In the future, routine molecular tumour profiling is likely to aid in the stratification of cervical cancer patients for immunotherapy. Here, we provide the methylome data of a case with complete response.

Objectives: Acute Bartholinitis is a common pathology affecting nearly 2% of women in their lifetime. Many treatments are used, although their effectiveness is not demonstrated in the literature. The main objective was to evaluate the success rate of first-line antibiotic therapy. The secondary objective was to identify factors associated with successful treatment., Methods: We conducted a retrospective unicentric study between January 2014 and June 2018 at the University Hospital Center of Nancy. Inclusion criteria were the presence of acute bartholinitis treated with first-line antibiotic therapy. Exclusion criteria were patients lost to follow-up after initiation of treatment. The primary endpoint was the absence of surgical treatment within 30 days of initiation of antibiotic therapy. Factors associated with successful medical treatment were sought., Results: Thirty-three patients were included. The success rate of medical treatment was 48.5% at 30 days. In the case of symptoms that had been evolving for less than 3 days, the success of medical treatment was more frequent (75% vs. 35.3%, P=0.02). Medical treatment was more effective in lesions of less than 2cm (68.7% vs. 23.5%, P=0.01). After adjustment, the only factor associated with successful medical treatment was lesion size≤2cm [ORa=5.31 (1.05-26.81)]., Conclusion: First-line antibiotic therapy for acute bartholinitis seems effective but should be targeted according to certain eligibility criteria., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background: Evidence on the treatment of plasma cell vulvitis (PCV) is scarce and comparative studies are lacking., Objective: To assess and compare the effectiveness and safety, on a long-term basis, of three topical interventions for the treatment of PCV., Methods: Retrospectively collected efficacy and safety data of a cohort of PCV patients treated with fusidic acid 2% and betamethasone valerate 0.1% cream fixed combination (FA/BM, 14 patients), clobetasol propionate 0.05% ointment (CP, six patients) and tacrolimus 0.1% ointment (TC, four patients) at different regimens between January 2000 and June 2013 were analysed. Treatment outcome was assessed according to Investigator Global Assessment (i) symptoms and (ii) signs, at 12, 24 and 52 weeks., Results: After 12 weeks, 85% of all patients achieved satisfactory improvement in PCV-related symptoms and maintained the improvement across a 52-week observation period. About 45% achieved a satisfactory result in clinical signs after 12 weeks, without further improvement during the following 9 months. No statistical differences in response were found among treatment groups at 12, 24 and 52 weeks. All study treatments were significantly more effective in improving PCV symptoms rather than clinical signs. With regard to treatment tolerability, one patient (7.1%) in FA/BM group and one (25%) in TC group discontinued the treatment due to local side-effects., Conclusions: CP, FA/BM and TC are effective and safe in treating PCV, inducing both a rapid improvement of the disease, notably of symptoms, and stabilizing its control., (© 2014 European Academy of Dermatology and Venereology.)

Infections of the vulva and vagina are one of the most common gynecological diseases. They can be determined by a variety of physical, chemical and biological factors. The main risk factors contributing to vaginitis are aerobic and anaerobic bacterias, fungal and viral infections, and irritants. Subjective complaints are pruritus, vulvar and/or perivulvar erytema and different in volume and characterization discharge. Excepting etiological treatment in most cases it is necessary to use additional agents, for example Saforelle.

Background: Studies assessing symptoms of plasma cell vulvitis (PCV) are lacking., Objectives: To assess the prevalence and severity of PCV-related symptoms and identify possible associations between patient characteristics, clinical features of PCV and treatments administered before a definitive diagnosis., Methods: Thirty-six patients affected with PCV were included. Data were collected by direct interview and clinical examination., Results: Thirty patients (83.3%) complained of symptoms: burning was the most frequent (80.6%) while dyspareunia was the severest. Of the symptomatic patients, 73.3% experienced severe symptoms. Severity of symptoms was not associated with age at onset and duration of PCV. Almost 70% of the patients had previously undergone treatments., Conclusions: Symptoms in PCV are frequent and more than often severe. Neither age at onset nor duration of the disease nor the extent of vulvar involvement were associated with symptom severity. Both the delay in diagnosis and the inappropriate previous treatments seem to indicate frequent misdiagnosis., (© 2015 S. Karger AG, Basel.)

A 52-year-old female with dyspareunia presented with red-brown maculae at the vulva.Biopsy revealed an inflammatory cell infiltrate mostly consisting of plasma cells, and the diagnosis 'vulvitis circumscripta plasmacellularis' was established.A biopsy is mandatory to confirm this rare benign inflammatory disorder of the vulva.

Interferons deficiency has a negative influence on the development of infection and inflammation in general. The use in the complex of anti-inflammatory therapy of interferon inducers (Meglumine acridоnacetate, Tilorone), combining antiviral, immunomodulatory, interferon correction effects with etiopathogenic action leads to the correction of the interferon system defects and eliminate etiological infectious agents, that is confirmed by laboratory data and clinical efficacy.

Inflammatory mucosal disorders are treated conventionally with potent or superpotent topical corticosteroids. For more than 20 years, topical cyclosporine has been used in the management of oral mucous membrane affections. Recently other topically applied calcineurin inhibitors, namely tacrolimus and pimecrolimus, expanded the armamentarium for the treatment of inflammatory mucosal diseases. This chapter places its main emphasis on the efficacy and safety of topical calcineurin inhibitors in the management of different oral and genital conditions, including anogenital lichen sclerosus (LS), oral and genital lichen planus, plasma cell balanitis and vulvitis, mucous membrane pemphigoid and pemphigus vulgaris, all conditions having usually a protracted course, requiring long-lasting treatment. There is current evidence for the effectiveness of both pimecrolimus and tacrolimus in the topical treatment of inflammatory oral mucosal diseases and genital dermatoses, especially oral lichen planus and genital LS., (Copyright © 2011 S. Karger AG, Basel.)

Contact dermatitis of the vulva is common, with irritant contact dermatitis occurring more frequently than allergic contact dermatitis. Patients with chronic vulvar dermatoses are at greater risk and should continually be reassessed for possible contact dermatitis. Comprehensive and specific questioning about hygiene practices and product use is necessary to elicit a history of contactant use. Patch testing is required to identify relevant contact allergens, the most common of which include medicaments, preservatives, and fragrances. Patient education and follow-up are essential in optimizing treatment and preventing recurrence of vulvar contact dermatitis., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Pre-pubertal girls with inflammatory chronic vulval disease excluding lichen sclerosus are often described as having 'non-specific vulvovaginitis'. The aim of this retrospective case series was to determine the aetiology of chronic vulvovaginitis in pre-pubertal (Tanner Stage 1) girls, with particular reference to candidiasis. A chart review recorded and compared the characteristics of 38 girls and 68 post-menarchal adolescents and pre-menopausal women with chronic vulvitis. Nineteen (50%) of the pre-pubertal children had been previously diagnosed with candidiasis and 21 (55%) had been treated unsuccessfully with topical antifungal agents. Candida albicans was isolated in two (5%) of the children and 37 (54%) of the adults (P < 0.001). A positive Candida culture was causally associated with chronic vulvovaginitis in 50% of the adults but in none of the children (P < 0.001). In 28 (74%) of the children and 28 (41%) of the adults, no pathogens were isolated on microbiological testing. General skin examination of the girls revealed signs of psoriasis in 27 (71%) and atopic dermatitis in nine (24%). Symptoms were controlled with topical anti-inflammatory treatment and environmental modification, including cessation of topical antifungals. Pre-pubertal girls with chronic vulvitis are likely to have either psoriasis or atopic dermatitis. Chronic vulvovaginal candidiasis is not seen in Tanner Stage 1 girls.

Vulvovaginal-gingival syndrome is a distinct variant of classic lichen planus frequently associated with mucocutaneous scarring and vaginal stricture formation, therefore early diagnosis and treatment through a multidisciplinary approach is essential. Management is challenging and is characterised by wide variation in treatments and lack of evidence-based therapeutic approaches. Literature review with particular regard to therapeutic approaches is performed with a view towards a cooperative treatment study.

A 31-year-old woman presented in the 23rd week of her third pregnancy with extremely painful pustular vulvitis, unresponsive to antibiotics. Although the histological findings were was consistent with a diagnosis of hidradenitis suppurativa (HS), bridged comedones, the hallmark of this disease, were absent and there were no dermal sinuses. Incision and drainage of the pustules provided only temporary improvement, which was briefly maintained with oral clindamycin and topical steroids. After the birth, a course of isotretinoin produced almost total clearance, a response not typically found in HS. This patient's condition may represent a variant of HS, and if so, it would be the first case report of de novo HS in pregnancy, but its clinical features and evolution differed so much from those in HS that the possibility of a previously unrecognised condition cannot be excluded.

We present a case of a 10-year-old girl with a diagnosis of vulvar pyoderma gangrenosum. Intravenous methylprednisolone was started and on tapering the steroid regimen, the lesion showed significant enlargement and purulent discharge without any remission of fever and inflammatory activity, so she was treated with oral cyclosporin A in combination with low-dose steroid. A response to treatment was achieved after 2 weeks and clinical and laboratory follow-up at 12 months did not show any disease relapse or inflammation.

Background: Metastatic vulval Crohn's disease is uncommon, and diagnosis is frequently delayed. Topical therapy is often ineffective, and systemic immunosuppressive agents are required., Case: A 32-year-old Caucasian female with known gastrointestinal Crohn's disease presented with a 7-year history of vulvitis. Perianal biopsy demonstrated typical granulomas. Her disease was resistant to treatment with prednisone and azathioprine; however, infliximab effected good control, and she remains well on 8 weekly infusions 1 year later., Conclusion: Biopsy should be performed in patients with vulvitis who have Crohn's disease to rule out metastatic involvement. Infliximab was successfully used in this case to control Crohn's vulvitis.

Vulval adhesion is a rare but recognized local complication following genital herpes infection. We believe this is only the second reported case of successful resolution of vulval herpetic adhesion using topical potent corticosteroid as the primary early treatment.

Background: Plasma cell vulvitis is a clinically and histologically well-characterized chronic disease that usually relapses after various topical therapies. Considering the inflammatory nature of the disease, the new topical calcineurin inhibitors have been also employed successfully in few cases of Zoon's balanitis, the corresponding male condition., Objective: The aim of our study is to evaluate the effectiveness of tacrolimus ointment in a small group of plasma cell vulvitis sufferers., Methods: 4 women affected by biopsy-proved plasma cell vulvitis were enrolled, after informed consent. The topical drug was applied twice daily for 6 weeks, then tapered on the basis of the clinical results. Symptoms and objective parameters were obtained periodically at the beginning, after 6 weeks and up to the end of the topical treatment. A final biopsy was performed in 3 out of our 4 patients. The follow-up is still ongoing., Results: The comparative analysis of subjective, objective and histopathological data has shown discordant and less encouraging results than those reported for the corresponding male condition., Conclusion: At the moment, topical tacrolimus could be considered an alternative treatment for plasma cell vulvitis only in cases resistant to conventional therapies.

A 36-year-old woman presented with chronic recurring dermatitis of the vulva, perineum, and lips. The genital lesions had a 3-year history and were associated with slight pruritus and occasional pain. The lesions of the upper lip had a history of 6 months. The patient had been treated with cycles of antimycotics and topical steroids which only partially controlled the symptoms during treatment. Dermatologic examination showed erythematous, infiltrative dermatitis with edema of the labia majora and persistent edema of the upper lip (Fig. 1a,b). Routine blood chemistry, urine analysis, and chest X-ray were normal. Microscopic examination and cultures of vaginal swabs did not reveal any pathogenic bacteria or fungi. Histologic examination of a biopsy of vulval lesional skin showed lichenoid lymphocytic infiltration of the papillary dermis and small, nonnecrotic epithelioid granulomas in the deep dermis (Fig. 1c,d). No microorganisms, including acid-fast bacilli or fungi, were identified. Culture was negative for fungi. Polymerase chain reaction was negative for the mycobacterial genome. Histologic examination of a biopsy from the upper lip showed similar results. The pathology reports of both regions were compatible with a diagnosis of granulomatous cheilitis and vulvitis. To investigate concomitant asymptomatic inflammatory bowel disease, the patient underwent colonoscopy with retrograde ileoscopy and gastroscopy, which were both negative. The patient refused radiographic examination of the small intestine with a barium meal. The patient was treated with systemic metronidazole (500 mg/day). After 6 months of therapy, the upper lip showed significant improvement and erythema and desquamation in the genital area showed slight improvement, but genital edema was unaffected.

Objective: To evaluate symptomatic response and recurrence rates of graduated topical fluorinated corticosteroid in patients with vulvar squamous cell hyperplasia., Methods: Nine hundred seventy-six patients with biopsy-proven vulvar squamous cell hyperplasia from 1990 to 2003 were reviewed in this retrospective study. All patients were treated with graduated topical fluorinated corticosteroid. Data were obtained from hospital records. Symptomatic remission and recurrence rates were noted following six months local therapy., Results: The mean age was 42.55+/-10.93 (15-85). The remission rate was 93.8% in six months. The remission rate was non-significantly higher in postmenopausal patients than that in their premenopausal counterpart (94.9% vs 93.0%, p=0.15). The disease recurred in 6.9% of patients. Of the patients that suffered recurrence 47.5% had persistent disease initially. The patients with following factors older ages (>40 years), postmenopausal period had significantly higher recurrence rates. Four patients with recurrent disease and six patients with persistent disease in the form of vulvar intraepithelial neoplasia I-II or atypical squamous hyperplasia, were treated with skinning vulvectomy., Conclusion: Corticosteroid in the treatment of vulvar squamous cell hyperplasia yielded excellent response rates. In the evaluation of patients without symptomatic relief, the first step should be a vulvar biopsy to exclude the presence of atypical components.

Rosacea fulminans (also known as pyoderma faciale) has been reported to occur in association with Crohn's disease. It is still unclear whether the papulopustules and confluent nodules of rosacea fulminans represent a manifestation of mucocutaneous Crohn's disease or whether this association is a mere coincidence. A 46-year-old woman presented with the spontaneous outbreak of rosacea fulminans and pyostomatitis/pyovulvitis. Complete remission of the mucocutaneous symptoms was achieved with 2 months combination therapy with methylprednisolone, isotretinoin and dapsone. The patient's Crohn's disease, already diagnosed for 3 years, did not flare during this period.

Zoon's vulvitis is a rare, chronic condition of the vulva that presents with burning, pruritus, and dysuria with characteristic lesions and histopathology. Several treatment options have been reported with limited success. A 63-year-old woman with Zoon's vulvitis diagnosed on histopathology was treated with clobetasol propionate 0.05%. Complete resolution of her symptoms and lesions occurred in less than 1 week. No recurrence of her symptoms has occurred after 9 months. Zoon's vulvitis may be successfully and expeditiously treated with high potency topical steroids.

The in vitro activities of enrofloxacin, florfenicol, oxytetracycline and spiramycin were determined against field isolates of Mycoplasma mycoides mycoides large colony (MmmLC) by means of the broth microdilution technique. The minimum inhibitory concentrations (MICs) of these antimicrobial drugs were determined for a representative number of 10 isolates and 1 type strain. The susceptibility of Arcanobacterium pyogenes to enrofloxacin, oxytetracycline and tilmicosin was determined by means of an agar disk diffusion test. The MICs of enrofloxacin, florfenicol, oxytetracycline and spiramycin were within the ranges of 0.125-0.5, 1.0-2.0, 2.0-4.0 and 4.0-8.0 microg/ml, respectively. This study has shown that resistance of MmmLC against enrofloxacin, florfenicol, oxytetracycline and spiramycin was negligible. All the field strains of A. pyogenes that were tested were susceptible to enrofloxacin, oxytetracycline and tilmicosin with mean inhibition zones of 30.6, 42.3 and 35.8 mm, respectively. Although there is lack of data on in vivo efficacy and in vitro MIC or inhibition zone diameter breakpoints of these antimicrobial drugs for MmmLC, the MIC results indicate that these 4 classes of antimicrobial drugs should be effective in the treatment of ulcerative balanitis and vulvitis in sheep in South Africa.

Merkersson-Rosenthal syndrome (MRS) is characterized by cheilitis or pareitis granulomatosa, facial palsy, and fissured tongue. Sometimes the forehead, eyelids and chin are involved, and occasionally genital lesions are present. A vulval lesion of MRS is named vulvitis granulomatosa. Tranilast has been described as an effective treatment for cases of MRS, granulomatous cheilitis, and granulomatous blepharitis. Herein we report a successful treatment with tranilast of an adult female patient with vulvitis granulomatosa.

Objective: To present the first reported case series of plasma cell vulvitis successfully treated with topical misoprostol., Materials and Methods: Three women with vulvar pain and lesions secondary to plasma cell vulvitis refractory to conventional therapy were treated with topical misoprostol compounded in white petrolatum., Results: All three patients had resolution of pain and lesions within 6 weeks of starting topical misoprostol. All patients tolerated the 0.01% concentration; however, local side effects were seen with the higher 0.02% concentration., Conclusions: Plasma cell vulvitis is a rare and painful vulvar disorder that is often refractory to therapy. All three patients in this case series were successfully treated with topical misoprostol. The immunosuppressive effects of misoprostol are hypothesized to be the mechanisms of action of this novel therapy for plasma cell vulvitis.

Objective: The purpose of this study was to evaluate the use of local capsaicin cream as an effective treatment for patients with documented vulvar vestibulitis syndrome., Study Design: A retrospective chart review was performed for patients who received a diagnosis of vulvar vestibulitis syndrome that was treated with capsaicin. Patients performed local application of capsaicin 0.025% cream for 20 minutes daily for 12 weeks. A comparison was made between the pre- and posttreatment Kaufman touch test to evaluate discomfort. The Marinoff dyspareunia scale was also used to assess pre- and posttreatment., Results: The sum of the Kaufman touch test scores before the treatment (13.2 +/- 4.9) compared with the scores after treatment (4.8 +/- 3.8) was statistically improved (P < .001). A significant improvement was also observed at each individual site (P < .001). The Marinoff dyspareunia scale also showed a significant improvement (P < .001)., Conclusion: Vulvar vestibulitis syndrome that is treated with capsaicin significantly decreases discomfort and allows for more frequent sexual relations.

Objective: To assess the efficacy of topical capsaicin in the treatment of vulvar vestibulitis syndrome., Study Design: Thirty-three consecutive women referred for vulvar vestibulitis syndrome were treated with topical capsaicin 0.05 %. The capsaicin cream was applied twice a day for 30 days, then once a Day for 30 days, and finally 2 times a week for 4 months., Results: In 19 patients (59%), improvement of symptoms was recorded, but no complete remission was observed. Symptoms recurred in all patients after the use of capsaicin cream was discontinued. A return to a twice-weekly topical application of the cream resulted in the improvement of symptoms. Severe burning was reported as the only side effect by all the patients., Conclusion: Response to treatment was only partial, possibly due to the concentration of the compound being too low, or to the need for more frequent than daily applications. The therapeutic role of capsaicin should hence be confined to a last-choice medical approach.

A 20-year-old woman initially presented with clinical evidence of an acute vulval inflammatory disorder incorrectly diagnosed as a Bartholin's abscess. Prolonged healing associated with infection followed attempts to incise and biopsy the area. Over a decade the condition has followed a chronic course with exacerbations and remissions and the vulva has become progressively more swollen and distorted. Lymphangiomas have developed. Histology showed non-necrotizing granulomas. Investigations for Crohn's disease and sarcoidosis were negative. Prednisone resulted in improvement during acute inflammatory episodes.

Vulvitis circumscripta plasmacellularis (VCP) is a rare but well-described entity. It is notorious for its recalcitrant nature to various modalities of treatment. Intralesional interferon-alpha showed some promise, with complete resolution, but is coupled with the side-effect of myelosuppression. Topical imiquimod is a novel immune response modifier with the ability to induce the production of interferon-alpha. In this paper, we report two cases of VCP whose lesions were resistant to antibiotics, topical and oral corticosteroids, but resolved after a treatment trial with imiquimod.