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#1
15.03.2010, 21:31
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Крауроз вульвы, тактика?
Здравствуйте, уважаемые коллеги, помогите определиться с тактикой ведения пациентки.
Женщине 62 года, постменопауза 9 лет. Обратилась с жалобами на водянистые выделения из влагалища. В анамнезе - последние три года постоянные жалобы на зуд вульвы, к врачу обращалась редко. Со слов, ставили диагноз лейкоплакия вульвы, вагинит. Проводились санации влагалища, затем Овестин по схеме. Самостоятельно применяла Овестин-крем почти постоянно 1 раз в неделю, облегчение зуда после овестина на 1-2 дня. При осмотре выставлен диагноз Лейкоплакия, крауроз вульвы, вагинит. На УЗИ - Серозоцервикс (матка 38/30/43, эндометрий 2 мм, линейный, однородный, яичники 18/12 мм, фолликулярный аппарат не визулизируется). Осмотр проктолога: Нейродермит перианальной области, rrs на 20 см - слизистая без патологии. Сахар крови - 5.9. После санации влагалища направлена на консультацию к онкогинекологу. Закл: Серозоцервикс. Крауроз вульвы (о/цит с вульвы - гиперкератоз). Назначено раздельное диагностическое выскабливание и контрольный осмотр с результатом гистологии. Вопрос: насколько в данной ситуации показано диагностическое выскабливание? Заранее спасибо за помощь. 
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#3
28.03.2010, 19:08
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У меня была такая пациентка, несколько моложе , 54 года, учительница, только превалирующей жалобой был зуд. Она страдала около 5ти лет, выставляли крауроз, консультировалась где только можно, ничего не помогало, была суицидальная попытка. В школе не могла работать , понятно, учитель . Ушла с работы (перед пенсией).Невропатологи делали проводниковые блокады новокаином.
Я тогда увлекался гомеопатией, ходил на лекции к Поповой в Киеве. И что интересно нашел я препарат для нее. Это была Ambra Grisea в 200 потенции 1 раз в день по 7 крупинок каждый третий день. Через две недели , как потом рассказывала больная, у нее началась сильнейшая головная боль , которую снять ничем не удавалось. К четвертому дню головная боль начала уменьшаться. К 7му дню головная боль ушла, а зуда нет по сей день. Пациентка восстановилась на работу. Если онкологии у Вашей пациентки нет можете попробовать. С уважением Alex.
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#4
29.03.2010, 22:01
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Гомеопатия
Боюсь, что с гомеопатией вас на этом форуме не поддержат. Это форум по продвижению доказательной медицины (со всеми ее преимуществами и недостатками). Во всяком случае 2 - 3 года назад гомеопат пытался порассуждать на эту тему. Его забанили на второй день.
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#5
03.04.2010, 17:14
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Попробуйте курс физиотерапии -красный лазерь на пораженную область,при условии отсутствия противопоказаний.
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#6
03.04.2010, 17:52
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Published 15 February 2010, doi:10.1136/bmj.c731
Cite this as: BMJ 2010;340:c731 Practice Easily Missed? ....... Lichen sclerosus is a chronic inflammatory skin disease usually involving the anogenital skin. It is most common in postmenopausal women but occurs in both sexes at all ages.1 The cause is unknown, but lichen sclerosus is strongly associated with autoimmune disorders, particularly thyroid disease, in almost 30% of patients.2 How common is lichen sclerosus? No good prevalence data exist for lichen sclerosus in either sex Lichen sclerosus is one of the most frequently seen conditions in vulval clinics.1 It is the commonest underlying skin disease in elderly women presenting with squamous carcinoma of the vulva3 ...... Why is it missed? Lack of familiarity with the condition and failure to examine the genital skin properly can lead to long delays in diagnosis. Reticence and embarrassment on the part of patient and doctor may hinder the taking of a full history and examination. Common mistaken diagnoses in women are candida infection and postmenopausal vulval atrophy. Candida vulvovaginitis is usually confined to women of childbearing years5 and is unusual in older women unless there are additional risk factors such as diabetes. The delay to diagnosis in one case series of 327 female patients was 2.2 years in children and 5.3 years in adults.6 Lack of familiarity with the condition probably explains why lichen sclerosus is rarely diagnosed as a cause of severe constipation in girls.7 Terminology has been confusing in the past, when terms such as vulval dystrophy and balanitis xerotica obliterans have been used instead of lichen sclerosus. The introduction of internationally agreed terminology8 and the advent of multidisciplinary vulval clinics have improved the recognition of lichen sclerosus and the use of correct nomenclature. Why does this matter? Lichen sclerosus is highly symptomatic. Vulval, penile, and perianal disease can cause severe intractable itching and soreness. Scarring may follow, leading to loss of vulval anatomy (fig 1), clitoral phimosis, and vulval stenosis in women.1 Sexual function may be severely impaired.9 Phimosis and anterior urethral obstruction can occur in men and boys. The development of squamous cell carcinoma on genital lichen sclerosus is a well recognised complication in both sexes and is estimated to occur in about 5% of women. Sexual abuse is sometimes suspected in children with lichen sclerosus and, although the condition does not exclude abuse, which must always be considered, this has led to mistaken diagnosis. ..... Why does this matter? Lichen sclerosus is highly symptomatic. Vulval, penile, and perianal disease can cause severe intractable itching and soreness. Scarring may follow, leading to loss of vulval anatomy (fig 1), clitoral phimosis, and vulval stenosis in women.1 Sexual function may be severely impaired.9 Phimosis and anterior urethral obstruction can occur in men and boys. The development of squamous cell carcinoma on genital lichen sclerosus is a well recognised complication in both sexes and is estimated to occur in about 5% of women. Sexual abuse is sometimes suspected in children with lichen sclerosus and, although the condition does not exclude abuse, which must always be considered, this has led to mistaken diagnosis ...... How is it diagnosed? Clinical features Adult women The commonest presenting symptom of lichen sclerosus is severe vulval itching, and many patients will already have self medicated with over the counter anticandidal or anti-itch creams. Typical changes of lichen sclerosus include areas of white skin that may be small and numerous or confluent over larger areas affecting the labia minora, labia majora, and adjacent skin of the perineum and groin creases. Perianal disease is common, giving a "figure of eight" pattern of affected skin around the vulva and perianal region. The white skin often looks thin, wrinkled and fragile, with red or purple areas of bleeding into the skin. Excoriations are common. Sometimes there are thickened plaques or even warty areas. In a series of 253 women with lichen sclerosus, 177 had atrophic change and 94 had hyperkeratotic (warty) areas.6 In the patients with scarring (about 70% of women)6 symptoms can include difficulty in passing urine, especially in men, and in women, dyspareunia, apareunia and splitting of the skin on attempted intercourse. Women may notice the change in their vulva with loss of the labia minora (fig 1) and fusion of the labia over the clitoris. Occasionally the first presentation of lichen sclerosus will be when squamous carcinoma develops: a plaque, ulcer or nodule can arise and enlarge very quickly, sometimes in a matter of weeks. ...... Investigations No diagnostic biochemical or immunological investigations exist, but a skin biopsy will often provide the diagnosis. The histology of lichen sclerosus is distinctive, and biopsy will help to differentiate it from other skin diseases that cause anogenital itching and scarring. However, use of a very potent topical steroid (such as clobetasol propionate) may completely correct the clinical and histological changes, so such a steroid must not be used before a definitive diagnosis is made. Accurate diagnosis is important because patients with lichen sclerosus will need follow-up and education about ongoing treatment and the risk of cancer development. Check thyroid function in all adult patients with lichen sclerosus, given the association with autoimmune thyroid disease. How is it managed? Evidence based guidelines for the management of lichen sclerosus state that if clinical doubt exists then a biopsy should be performed to confirm the diagnosis.11 The general practitioner may wish to refer the patient to a specialist with an interest in vulval disease or to an established vulval clinic (based in dermatology, genitourinary medicine, or gynaecology departments). Pending the definitive diagnosis, emollients can be used as soap substitutes and to help repair the skin barrier, and a moderate potency topical steroid such as clobetasol butyrate ointment can be used sparingly. After diagnosis, the accepted treatment is with the very potent topical steroid clobetasol propionate ointment.11 No controlled trials have been published to establish the best regime, but the guidelines suggest a single application at night for four weeks followed by alternate nights for four weeks and then twice a week for four weeks. Once symptoms are well controlled, the steroid ointment is used as required. Some patients will achieve complete remission; others will require ongoing treatment. In women, surgery is reserved for correcting the effects of scarring and for removal of cancer. Surgery is not otherwise appropriate for benign disease as it is mutilating and there is rapid relapse of the lichen sclerosus. .....
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#7
19.04.2010, 19:59
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Большое спасибо за консультации. После прекращения использования Овестина на контрольном УЗИ через 2 недели серозоцеле не было, поэтому РДВ решили пока не делать: женщина очень негативно отнеслась к этой рекомендации. А основной и постоянной жалобой на протяжении последних 3 лет является зуд, который несколько облегчается при применении Овестина. Лазер делали - зуд, со слов, значительно уменьшался, но ненадолго. Сейчас планирую сделать пациентке биопсию вульвы и в последующем назначить кортикостероидную мазь. Вот только какую? Здесь на форуме нашла в рекомендациях клобетазола пропионат. Но у Дермовейта, в частности, в инструкции зуд аногенитальной области является противопоказанием. Как быть?
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Линейный вид
