Subacute atopic dermatitis of the vulva has been described for the first time by Dr. Albert Altchek, clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, New York, according to the physician.
Atopic dermatitis is a clinical diagnosis, according to Dr. Altchek. "There’s no corresponding biopsy."
His findings are based on his observations of a large number of the same girls over a long period of time at three separate clinics as well as his continuing private office consultation, which he presented at the 15th Annual Postgraduate CME Course on Pediatric, Adolescent, and Young Adult Gynecology held at New York’s Mount Sinai Hospital. He also has written a chapter on the topic in "Pediatric, Adolescent, & Young Adult Gynecology" (Oxford: Wiley-Blackwell, 2009), edited by Dr. Altchek and Dr. Liane Deligdisch.
The symptoms include recurrent itching, redness, fissures, and vulva dysuria. Diagnosis of vulvar atopic dermatitis includes gathering a family history of allergies, asthma, hay fever; looking at the past history of the patient; and conducting a physical examination starting from the head, said Dr. Altchek.
Atopic dermatitis fissures are symmetrical and narrow, and look as if they were "made with an artist with a scalpel," he said. The hymen is intact. In early stages, vulvar atopic dermatitis’ most pronounced part is bilateral symmetrical fissures between labia minora and majora. Sometimes the fissures are deep and may cause bleeding. In addition, there is a midline sagittal perineal fourchette to the anterior anus at 12 o’clock, where there is usually a papule. The latter is the result of an anterior anal fissure with red inflamed edges. When red and present for a long time, there is severe permanent swelling simulating a hemorrhoid. In more severe cases there is a fissure anterior to clitoris.
In younger girls, the fissures may cause a sudden jump up from sitting because of pain, which is at times misdiagnosed as a neurologic condition.
The condition is sometimes confused with sexual molestation or lichen sclerosis. In sexual molestation cases there may be general signs of trauma and any vulvar fissures are irregular, with lacerations in addition to the history. "Lichen sclerosis of the vulva has coarse, wide irregular fissures in the same areas. With slight trauma the labia and vulva have transient dark blue subcutaneous blood boils," said Dr. Altchek, also an attending ob.gyn. at Lenox Hill Hospital in New York. Lichen sclerosis has a specific biopsy finding, which vulvar atopic dermatitis does not.
Patients with vulvar atopic dermatitis also have the condition on other parts of their body, including behind the ears, in axilla, elbows, or behind the knees, highlighting the importance of whole body exam.
The condition is managed by avoiding things that could irritate the vulva, including wet bathing suits, hot water, perfume, and certain clothing such as leotards and tights. Otherwise, treatment is individualized to reduce irritation and symptoms, Dr. Altchek said.
The condition is most common among prepubertal and young pubertal girls, it may or may not disappear at puberty, and it is less common in adults, said Dr. Altchek.
"Basically, my message is ‘wake up, world.’ This is how you diagnose [vulvar atopic dermatitis], which has never been described before," said Dr. Altchek.
Dr. Altchek said he had no relevant financial disclosures.