Desquamative Inflammatory Vaginitis Hope K. Haefner, MD The University of Michigan Hospitals
Desquamative Inflammatory Vaginitis Hope K. Haefner, MD The University of Michigan Hospitals Ann Arbor, Michigan Disclosures Hope K. Haefner, MD Nothing to disclose Learning Objectives At the end of this lecture, the participant will gain knowledge on the: – Diagnosis of desquamative inflammatory vaginitis – Differential diagnosis of conditions associated with desquamative inflammatory vaginitis – Treatment strategies for patients presenting with inflammatory cells on wet prep Conditions Associated with Vulvovaginitis • Atrophic vaginitis • Traumatic – Foreign body • Allergic vaginitis • Infection – Streptococcal, Amebic, Herpes • • • • Erosive lichen planus Pemphigus vulgaris Behçet’s disease Collagen vascular diseases • Degenerating leiomyoma or endometrial polyp • Idiopathic Desquamative Inflammatory Vaginitis Desquamative Inflammatory Vaginitis (DIV) D. Birenbaum MD collection Desquamative Inflammatory Vaginitis D. Birenbaum MD collection Desquamative Inflammatory Vaginitis • Previous terms – Exudative or membranous vaginitis – Hydrorrhea vaginalis – Serofibrinous allergic dysregulative colpitis Desquamative Inflammatory Vaginitis Symptoms and Signs • Dyspareunia • Exudative chronic vaginitis, purulent discharge (yellowwatery; at times blood tinged) • Spotted rash vagina/cervix • Massive vaginal cell exfoliation-see parabasal cells • (PMNs/epith > 1:1 in at least 4 hpfs on wet prep) • Increased vaginal pH Desquamative Inflammatory Vaginitis History • First described in 1950’s – Franken H, Rotter W. Geburtsh u Frauenh 1954;14:154 – Scheffey LC, Rakoff AE, Lang WR. An unusual case of exudative vaginitis (hydrorrhea vaginalis) treated with local hydrocortisone. Am J Obstet Gynecol 1956;72:208-211 Desquamative Inflammatory Vaginitis History: Franken H, Rotter W. • Chronic exudative vaginitis in 12 y.o. • Fibrin, lymphocytes and squamous debris • Increased histiocytes • Intravaginal estrogen • Different from other DIV cases Desquamative Inflammatory Vaginitis History • Gray LA, Barnes ML Vaginitis in women, diagnosis and treatment. 1965 • Gardner HL. Desquamative inflammatory vaginitis: A newly defined entity. 1968 Desquamative Inflammatory Vaginitis History • Sobel-retrospective of 51 cases DIV 1994 • Mean age was 41.8 years (range 21 to 66 years) • 19 women were menopausal Sobel JD. Desquamative inflammatory vaginitis:a new subgroup of purulent vaginitis responsive to topical 2% clindamycin therapy Am J Obstet Gynecol 1994;171:1215-30. DIV- A New Subgroup • Vaginal pH > 4.5 • Amine odor • Vaginal PMNs – 4+ – 3+ • Parabasal cells 51/51 0/51 100% 0% 46/51 5/51 90% 10% 51/51 100% Sobel JD. Am J Obstet Gynecol 1994;171:1215-30. ? Vitamin D Peacocke M. Djurkinak E. Tsou HC. ThysJacobs S. Desquamative inflammatory vaginitis as a manifestation of vitamin D deficiency associated with Crohn disease: case reports and review of the literature. Cutis. 86(1):39-46, 2010 Jul. DIV Treatment • 2% clindamycin cream (i applicator) per vagina qhs x 14 versus • 25 mg hydrocortisone suppository per vagina qhs x 14 -Recurrent DIV or Resistant DIV • Combine 2% clindamycin (i applicator) with one hydrocortisone suppository (25 mg) per vagina every other night (it is easier for patients to use these agents together rather than alternate days). • -For difficult DIV: Hydrocortisone 100 mg/gram in clindamycin 2% emollient cream base. Insert 5 gram (applicator full) q.o.d. ( at night time) x 14 doses. This needs to be made at a compounding pharmacy. Recurrence/Maintenance • Repeat successful regimen after verifying diagnosis • May require long term hydrocortisone suppository (25 mg) • May need to add estrogen and/or clindamycin Desquamative Inflammatory Vaginitis History • Cytological changes identical to atrophic vaginitis Oates JK, Rowen D. Desquamative inflammatory vaginitis . A review Genitourin Med 1990;66:275-279. Atrophic Vaginitis Foreign Body Desquamative Inflammatory Vaginitis History: Edwards and Friedrich Edwards L, Friedrich EG. Desquamative vaginitis: Lichen planus in disguise. Obstet Gynecol 1988;71:832-836. Pemphigus Vulgaris Cicatricial Pemphigoid Degenerating Endometrial Polyp or Leiomyoma Areas Associated with Vaginal Discharge Lacking Information • Bacterial vaginITIS • Lactobacillus • Cytolytic vaginosis LACTOBACILLUS • Symptoms of yeast (itching) • Cottage cheese discharge • Produced by antifungal therapy LACTOBACILLUS • Wet mount – Elongated lactobacilli (formerly believed to represent leptothrix, a marker for trichomonas) – Noninflammatory • Treat with Amox/clavulanate or doxycycline or Ciprofloxacin L Edwards, MD collection L Edwards, MD collection CYTOLYTIC VAGINOSIS • Symptoms of yeast – itching • Cottage-cheese discharge • Most common cause of vaginitis at Cibley/Cibley vaginitis clinic CYTOLYTIC VAGINOSIS • Wet mount – Cytolysis (naked nuclei of epithelial cells, appear like lymphocytes unless seen under phase microscopy). – Noninflammatory – Increased lactobacilli • Treat with chronic, intermittent baking soda douches Sodium Bicarbonate Sitz Bath: Mix 2-4 tablespoons of baking soda in 2 inches of bath water (any temperature). Sit in the tub twice daily for 15 minutes each time. Take sitz bath 2-3 times in the first week of treatment, then 1-2 times weekly (as needed) to prevent recurrences. Douche: Mix 1-2 teaspoons of baking soda in 1 pint of warm water. Gently douche 1-2 times weekly as needed. Hutti MH. Hoffman C. Cytolytic vaginosis: an overlooked cause of cyclic vaginal itching and burning. Journal of the American Academy of Nurse Practitioners. 12(2):55-7, 2000 Feb. Current Thoughts on the Same vs. Different Conditions • DIV is not a diagnosis in itself, and may be the presentation of a range of disorders • Therefore no one treatment will work for all of these conditions
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