GYN

CMECNE

Desquamative Vaginitis—How to Recognize and Treat It

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe the typical symptoms of desquamative inflammatory vaginitis
2. List the typical treatment options and duration of therapy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from April 10 2018 through April 10 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Desquamative inflammatory vaginitis is a form of vaginitis occurring primarily in perimenopausal white women. The etiology is unknown. The syndrome includes vaginal inflammation, rash and purulent discharge along with dyspareunia.

Consider desquamative vaginitis in women presenting with
- Chronic vaginal symptoms, specifically
  - Discharge | pruritis |burning| irritation
- Dyspareunia
Exam findings may include
- Vaginal inflammation (‘fiery red’)
- Purulent discharge
- Spotted vaginal rash
- Areas of a white reticulated pattern
- Erosions in a spotted or linear pattern
- Areas of hemorrhage or ecchymosis
- Lack of Lactobacillus predominance
Vaginal pH is typically ≥5
Microscopy shows increased parabasal cells and inflammatory cells (neutrophils)
- Inflammatory to squamous cell ratio is 1:1
Rule out trichomoniasis
- WBCs my be present with similar pH
- However, parabasal cells less likely to be present and motile T. vaginalis organisms can be seen on microscopy
Look for oral, cutaneous or vulvovaginal lesions that may be suggestive of lichen planus

SYNOPSIS:

Desquamative inflammatory vaginitis should be in the differential diagnosis for all menopausal and perimenopausal women presenting with complaints of chronic vaginitis. It is important to rule out other entities such as BV, trichomonas, and STDs prior to beginning treatment. Treatment is generally of longer duration than for other causes of vaginitis. Cause is unknown, with disproved theories including estrogen deficiency, bacterial infection, or vitamin D deficiency. Possible underlying mechanisms include a noninfectious disease with a genetic predisposition for an abnormal immune attack on elements in the vaginal mucosa.

KEY POINTS:

Treatment is topical and can be either antibiotic or steroid based (official guidance on treatment not yet developed)
- Clindamycin 2% cream: Intravaginally once daily (bedtime) for 1-3 weeks; Consider maintenance once or twice a week for 2 to 6 months or
- 10% hydrocortisone cream 300-500 mg: Intravaginally daily (bedtime) for 3 weeks; Consider maintenance once or twice a week for 2 to 6 months or
- Cortisone acetate 25 mg suppository: Twice daily for 4-6 weeks or
- Clobetasol propionate: Intravaginally daily (bedtime) for 1 week; Maintenance duration not evidence-based
- Consider addition of Fluconazole 150 mg orally once a week as maintenance therapy or topical vaginal estrogen twice a week in addition to clindamycin or glucocorticoid
Reevaluate 4 weeks after treatment is concluded and if residual symptoms persist and clinical findings are only partially controlled, offer additional treatment such as
- Reverse treatment—if initially on clindamycin, switch to hydrocortisone and vice versa
- Combine treatment—use both clindamycin and hydrocortisone together
- Increase hydrocortisone to 15% strength cream
Cure rates are low
- 26% cure at 1 year
- 58% will be controlled (require maintenance therapy)
Diagnosis code: N76.1

Learn More – Primary Sources:

Prognosis and Treatment of Desquamative Inflammatory Vaginitis

Bacterial Vaginosis and Desquamative Inflammatory Vaginitis

Vaginitis: Beyond the Basics

Management of Persistent Vaginitis

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