2.3 Viral STIs & Chronic Vulvar Dermatoses (HSV, HPV, Lichen Sclerosus & Lichen Planus)

Viral STIs & Chronic Vulvar Dermatoses

Evaluating vulvar pathology requires distinguishing infectious ulcerative and verrucous entities from chronic inflammatory dermatoses and glandular disorders. While these conditions often share symptoms of pruritus, burning, and dyspareunia, their etiologies, malignant potentials, and therapeutic regimens differ profoundly. Women's Health Nurse Practitioners must master point-of-care differentiation, biopsy indications, and evidence-based pharmacotherapy for viral STIs, chronic dermatoses, and vestibular conditions.

Herpes Simplex Virus (HSV-1 & HSV-2)

Genital herpes is a lifelong viral infection caused by HSV-1 or HSV-2. Following mucosal inoculation, the virus ascends sensory peripheral nerves to establish latency within lumbosacral dorsal root ganglia (S2–S4).

Clinical Manifestations

• Primary Episode: Severe systemic symptoms (fever, malaise, tender bilateral inguinal lymphadenopathy) and extensive, exquisitely painful bilateral vesicles that ulcerate and crust over 2 to 3 weeks. Dysuria and urinary retention are common.
• Recurrent Outbreaks: Milder, unilateral, and self-limiting (healing in 5–10 days), typically preceded by a sensory prodrome (tingling, burning paresthesias in the perineum or buttocks 12–24 hours prior).

Diagnostics & Pharmacotherapy

• Diagnostics: Viral swab of an unroofed vesicular base for HSV Polymerase Chain Reaction (PCR) is the gold standard, offering superior sensitivity over viral culture. Type-specific glycoprotein G serology differentiates HSV-1 from HSV-2 when lesions are absent.
• Primary Outbreak: Oral valacyclovir 1 g twice daily for 7–10 days, or oral acyclovir 400 mg three times daily for 7–10 days.
• Episodic Therapy: Initiated during prodrome or within 24 hours of onset (valacyclovir 500 mg twice daily for 3 days or famciclovir).
• Daily Suppressive Therapy: Recommended for frequent recurrences (>=6 episodes per year) or to reduce partner transmission (valacyclovir 500 mg or 1,000 mg daily).
• Antepartum Management: Daily oral suppressive therapy (acyclovir 400 mg three times daily or valacyclovir 500 mg twice daily) is initiated at 36 weeks of gestation until delivery for women with genital herpes. This suppresses viral shedding and recurrences at term, avoiding cesarean delivery. If active lesions or prodrome exist at labor, cesarean delivery is mandatory.

Human Papillomavirus (HPV) & Condyloma Acuminata

Condyloma acuminata (anogenital warts) are benign proliferative lesions caused predominantly by non-oncogenic low-risk HPV types 6 and 11 (>90% of cases), whereas high-risk oncogenic types (HPV 16, 18, 31, 33, 45) cause intraepithelial neoplasia and cervical/vulvar carcinomas.

Clinical Presentation & Treatments

Warts appear as flesh-colored, exophytic, verrucous, cauliflower-like, sessile, or pedunculated papules.

• Patient-Applied (Home):
  • Imiquimod 5% cream: Applied at bedtime 3 times weekly for up to 16 weeks; washed off after 6–10 hours. Immune response modifier. (Avoid in pregnancy; CDC notes low apparent risk but insufficient data.)
  • Podofilox 0.5% solution/gel: Applied twice daily for 3 consecutive days, then 4 days off, up to 4 cycles. Antimitotic. (Contraindicated in pregnancy).
• Provider-Applied (Clinical):
  • Liquid Nitrogen Cryotherapy: Applied until lesions freeze with a 1–2 mm halo, repeated every 1–2 weeks. Safe in pregnancy.
  • Trichloroacetic Acid (TCA) 80–90%: Applied chemically until white frosting occurs. Safe in pregnancy.

Chronic Vulvar Dermatoses

Lichen Sclerosus (LS)

LS is a chronic inflammatory dermatosis common in postmenopausal women, characterized by porcelain-white plaques with a wrinkled "cigarette paper" texture and a "figure-of-eight" perianal distribution. Severe architectural loss occurs: labia minora resorb, the clitoral prepuce fuses (phimosis), and the introitus constricts. The vaginal mucosa is never involved. Diagnosis requires a 3 to 4 mm Keyes punch biopsy. First-line therapy is an ultra-potent topical corticosteroid (clobetasol propionate 0.05% ointment) applied nightly for 4 weeks, alternate nights for 4 weeks, then twice weekly for maintenance, with lifetime surveillance.

Lichen Planus (LP)

Lichen planus presents as erosive, papular, or hypertrophic forms. Unlike lichen sclerosus, erosive lichen planus regularly affects the vagina, causing desquamative inflammatory vaginitis, friability, serosanguinous discharge, and synechiae that obliterate vaginal fornices. Oral Wickham striae (lacy white streaks) are common. Management requires topical clobetasol 0.05% ointment for vulvar lesions and intravaginal hydrocortisone suppositories (25 mg BID) for vaginal disease.

Bartholin Gland Cyst and Abscess

The paired Bartholin glands lie at the 4 and 8 o'clock positions of the posterolateral vestibule. Duct obstruction produces a painless retention cyst; secondary polymicrobial superinfection generates an acute Bartholin abscess—an exquisitely tender, fluctuant labial mass.

Clinical Management

• Incision & Drainage with Word Catheter: Simple I&D without catheterization yields recurrence in >50% of cases. Clinicians perform incision and insert a Word catheter, inflating the balloon with 2 to 3 mL of sterile saline for 4 to 6 weeks to ensure epithelialization of a permanent tract. Marsupialization is reserved for recurrent cysts.
• Biopsy in Women Over 40: Any newly developing or persistent Bartholin mass in a woman older than 40 years requires biopsy of the cyst wall to rule out Bartholin gland adenocarcinoma, a rare but aggressive malignancy.