Lower reproductive tract comprised of vulva, vagina and cervix. This area can be affected by a wide spectrum of conditions from physiological, benign, premalignant and cancer (dealt with previously).

Squamous cell hyperplasia (thickening):

Chronic or on going trauma, like rubbing or scratching, can elicit a protective thickening of the effected skin. This thickening can affect the superficial layers and even the deep layers of the skin, causing a palpable thickening that may affect both sides of the vulva and even extend into the thigh areas. The main treatment modality is to prevent the rubbing, scrubbing and chronic itch-scratch cycle. This is often caused by the chemicals contained in cleaning solutions and topical solutions. Topical and even systemic steroids may be needed to decrease the inflammation, while lubricants and sitz baths restore the skin barrier.

Lichen sclerosis:

It is defined as a chronic inflammatory condition that predominantly affects the anogenital region. It is classically found in postmenopausal women, but can present in women in the premenopausal group and can even affect children. Many causes have been described like infection, genetics, hormonal and autoimmune conditions. In autoimmune conditions there seem to be a link between lichen sclerosis and thyroid disease and diabetes. Despite the many proposed causes it seems to rather be a multifactorial condition leading to difficulty in treatment.

Despite the fact that it is a benign skin condition, there seems to be a link between it and cancer of the vulva. This then requires close monitoring and regular assessments to prevent malignant transformation. In many cases it may be completely without symptoms, but the most common symptom is itching, resulting in scratching starting a cycle causing redness, breaking in the skin and thickening. This in turn may result in dyspareunia (pain during intercourse), painful urination and anorgasmia (inability to climax). As a result of discolouration of the skin it can be misdiagnosed as vitiligo and the only way to be sure is to have biopsy taken for histological assessment. Hormonal deficiency may respond to topical hormonal cream, but in the long term it may not treat the symptoms. Treatment include symptom relieve, prevention of anatomic changes and early detection of malignant transformation, this include education, vulvar hygiene, and pharmacological treatment. First line will include topical steroids, usually starting with lowest concentrations and increasing depending on response. Estrogen cream can be used to treat the itching, thinning skin, and prevent labial fusion, but is not the long-term solution. Surgery is reserved for the severe cases and in women where there is concern about possible malignancy. Understanding the condition will go a long way in setting realistic treatment goals.

Other conditions include:

Inflammatory causes like contact dermatitis, which is as a result of contact with an offending substance like soap, creams, powders, certain types of material, perfumes and lubrication. The treatment will be to identify and avoid the causative agent often by trial and error. Symptoms are treated as needed.

Atopic eczema is essentially nappy rash and can present with severe itching resulting in scaly patches and fissures/small tears. Treatment includes steroids and emollients and bath oils can offer relieve.

Psoriasis is an immunological condition resulting in thickened red areas of skin covered by silvery scales. Immune regulators in the form of creams and topical steroids form the basis of treatment, while other additional options include vitamin D ointment, and phototherapy.

Lichen planus is uncommon and can present with chronic vaginal discharge, intense pruritus, dyspareunia and bleeding after intercourse. Women with vaginal Lichen planus often have other areas involved and vice versa, so lesions in the mouth are also common. Treatment will include ultra-potent corticosteroids, often in combination with antifungal and antibiotic preparations.

Ulcerative lesions (sores) on the vulva and vagina are most likely infective in cause. Common infections include syphilis, herpes, chlamydia, gonorrhoea but cancer needs to be borne in mind. Treatment is often education and a course of antibiotics or antivirals in the case of herpes. Symptom relieve is also needed like pain medication, secondary infection treatment and partner involvement/treatment.

Vitiligo is de-pigmented skin as a result of loss in epidermal melanocytes. There is no greater propensity to race, ethnicity or socioeconomic circumstances, but it is more obvious in darker pigmented women. There seem to be a genetic component to its development and possible autoimmune link. It develops slowly and may often involve other areas of the body in a symmetrical fashion like the neck and face. Advances in its treatment have included narrow-band UV phototherapy, targeted light therapy and immune modulators.

The focus is on Lichen sclerosis, which can become malignant and the other infections and lesions that can be treated especially if treatment is sought early. In essence lesions of the vulva and vagina require further investigation or at least a look at by a doctor before it is written off as normal.