Steroids, Estrogen & Other Bad Decisions

Welcome to season three of Terms on Drugs and Video Podcast brought to you by Scholars and Medicine, the best educational platform in dermatology and provided no cost to medical providers. Terms on Drugs is for cutting edge derm meets endermis comedy. I'm Dr. Matt Zyres from Dr. Dermatology and each week I'm joined by residency buddies with your Laura Ferris from the University of North Carolina. Dr. Tim Patton from the University of Pittsburgh and we use our 60 years of combined derm experience to discuss debate and dissect the topics in dermatology. It is everything you need to know to be on the cutting edge of derm and it actually has to fun listening. New episodes drop every Friday on Scholars and Medicine. I have a podcast, Spotify, another region podcast, platforms and I highly recommend that you download this college and medicine app to access the full podcast video archive, explore the best derm educational content out there, real farmy independent coverage of all of derms. It's called by an amazing AI clinical consult called Ask Simon. So this week we've got one of our patented deep dive episodes and I'm so excited to welcome Dr. Kelly Tyler to the show. So Dr. Tyler was formerly one of my residents at the Ohio State University and is currently the residency director at the Ohio State University and she is double-borted in both dermatology and OBGYN and we are going to be talking about vulvar diseases this week. Dr. Tyler great to have you on the show and tell us a little bit about how you ended up deciding to become a vulvar dermatosis expert. Well, first of all, thanks for having me. This is an honor to be on your podcast. So actually it sort of happened by accident and I think it's kind of your fault actually, Matt, but I was here in the. Many things. Many things. I was here in town practicing general gynecology and I kept getting these referrals for vulvar disease from dermatologists and I said, well, you know, we didn't really learn that much about vulvar disease in my OBGYN residency. We didn't have a vulvar disease expert and I said, well, gosh, if the skin doctors aren't seeing these people who are seeing these people. So I actually just wanted to come to Ohio State and spend some time learning about skin disease and topical treatments and how better to treat these patients. I met with Matt and he said, hey, bring all your stuff with you, like all your scores and all the stuff from medical school. So I had to dig all that out. You know, I graduated from medical school in 2003 and I think this happened around 2012. So in any case, he said, you know what? You can't learn enough about dermatology just coming and spending some time with us. You're going to need to do a residency. So that's kind of how it happened in a nutshell. It was an interesting journey trying to get an E-RAS token from Tulane. I met some folks, they didn't understand what I was doing. You know, because most people don't go back to residency. They don't go back and do residency eight years later. And the real story behind that when Dr. Tyler contacted me as like, because it was one of the other faculty in Ohio State and the OBGYN was like, hey, I've got this. So, you know, we meet with her. And so as the contact dermatitis person, which by the way, Dr. Tyler now does the patch testing at Ohio State as well, as the contact dermatitis person, you get sent a lot of the vulvar disease patients. And I did not want to take care of them. I did not want to see them. I did not want to have anything to do with them. So when Dr. Tyler contacted me, I was of course scheming like, I'm going to make her come and take over all these patients. It's going to be great. I'm going to get out of it. And it worked. Now she's there and she's all this famous national, you know, woman parts expert. That's the specialty in Derb. So let's go ahead and get into our first article. Let's start with Dr. Ferris. What do you got? All right. So I sort of pulled together because we each on these deep dives usually do one paper. So I just pulled together a couple high yield thing of like three papers. I'm not going to really like go crazy on them, but I just thought I'd highlight what's come out recently. So one is in the chat and these were quick papers. Estil at all. Acetrutin and Methatrexate in vulvar, Lycan sclerosis. So basically multi center, retrospective chart review of 38 women with vulvar L.S. treated at six centers over a 10 year period with either acetretin or Methatrexate. And you know, what they found was basically 75 and 77% of women improved in very few people. Like, people didn't really go into full remission. But most people had some improvement. It was like two people in acetretin and three on Methatrexate went into remission. So how do you judge improvement? There's no like Lycan sclerosis, Pazzy score. So it was really just clinical judgment. And you know, the both drugs had kind of similar rates of lab abnormalities. Although if you look at the side effect rate, it was higher for acetretin than it was for Methatrexate. So you know, I thought I'd just throw that in there as two things that can be treated. Dr. Tyler, do you use like either of these drugs when you have patients? I'm sure it's not like your first line treatment. But do you ever use these drugs when you start out? People who've got refractory Lycan sclerosis. Yeah, I have used Methatrexate more for people who have both genital and extra genital. So someone who might be progressing more, they have a lot of extra genital involvement. Methatrexate, I think, has been my go to for that. As a treten, I have used a few times. I do find like the study, you know, these are older patients with other comorbidities. And so a lot of times they will want to discontinue due to side effects. So yeah, it's not a lot of my patients, but to be honest, I'm able to control a lot of people mostly on topicals once I make sure they're using it correctly. Okay. How would you define using it correctly? So I'm sure you're going to say, "What does that mean?" Yeah. So a potent or super potent topical steroid. And I just tell people a pea size amount. And I tell them, so what we want them to do is we want them to apply it to the modified mucus membranes. All right. So we want to keep it off the hairbearing area. The areas that are going to be more prone to acrophysiastrae A. It wants, we want it to be a very small amount. So labia minora, entroidus, clitoris, clitoral hood, you know, a lot of them have perineal involvement. So we really want to try to keep it in that area. And we want to start, usually I start on it twice a day depending on how severe they're like in sclerosis, then I'll kind of go down to sometimes once a day for a few months. And then eventually what I want to do is get them down to maintenance treatment, which typically is two to three applications a week. So usually bedtime and day Wednesday, Friday. But sometimes what I find is people come in, they've been given this tube of cream or ointment and they don't know where to put it. So they're just kind of putting it everywhere. Okay. So that's been the medzirus regimen of like, here you go. Because you're surprisingly, we don't really get any side effects, whatever we use, clobatus out down there, although you would think that you do. I turned south, I did not know I was supposed to be telling them to really just put it on the non. So I like the idea that if you don't get hair there, it's okay to put it on. I probably have to, if they've had at least your hair removal, maybe, maybe qualify that a little. So you're really supposed to just be putting it on like not even the, the labia majora. Right. Like if, if they've got some spread beyond the mucus membrane parts, do you use it up beyond there? Or do you try to still keep them just use this in the mucus membrane parts? Right. So I should clarify that medial labia majora are okay, just not out on the hair bearing external labia majora. But yes, I do have a couple of patients who kind of get it out in the grain folds and I worry a little bit about that. So sometimes I will put them on a lower potency, you know, steroid ointment for those areas for flares. Okay. Do you, you, we'll get, go ahead, Ferris. Well, let's just say, do you also then add insulin like topical tachyrilitis, you know, particularly as you're stepping them down from twice a day or every day? And my issue with tachyrilitis in the genital area is the potential for a burning sensation on application. And I know not everybody does that. Unfortunately, I don't work in a place where I have the luxury of keeping samples and letting them try it. I think that's a really, if you're able to do that, let them put it on in the office and see if they tolerate it. And that would be, you know, I think a great tip for people who are able to, but it's really sort of, I want to say tachyrilitis is kind of my last resort. And I like it a little bit more for people who have likened simplex chronicus, who just, I can't get them to use things in the right area. And I'm like, tachyrilitis is fine. They can put it wherever they want. And it's not going to cost any atrophy or st. So if they can tolerate it and I feel like I just can't get them to put their, like, their steroid women in the right area, I will use tachyrilitis sometimes. for our listeners and more. to tell you my my pearl with tachyrilitis anytime you prescribe tachyrilitis. The way you describe it is you're going to put this on. If you're really lucky, it's going to burn really badly when you put it on. It's going to feel like your tongue feels when you eat a jalapeno because that is a sign that it's working really well. And there is actually there's mechanistically because the burning is caused by substance p release, same thing the capsaicin does and it's part of why the tachyrilitis works well for itch is substance p depletion just like we can use topical capsaicin for localized peritis. And so it the more it burns the better. And I'll say, but if you know some people just so bad you just can't stand it. But if it burns, that's a good thing. And I believe it. Okay, Pat, and I cut you off. What were you going to say? I was going to ask if you tell them to put it everywhere just because like, oh, it can spread or like are you bringing them into the office and say, okay, you know what? This area looks a lot better. Let's let's ease up there. Let's go to the maintenance on just this area. Or do you just kind of say like just put it everywhere? Yeah, so we just put it on all the areas that have a ligand sclerosis. Now if they do have an area that's particularly bad. So say someone comes in and I've been treating them, but they have a small area that's flared. Sometimes I will have them, you know, just treat that area twice a day for maybe like two to four weeks and do maintenance on everything else. So I think that was your question. I got one other question here before I let fairs get to our next article. The are people do it, so it seems obvious to me. Lots of things seem obvious to me that are wrong. But this seems obvious that you're in low grade, you're in exposure has to be what is causing like in sclerosis, right? You get it in little girls once they get to where they're not in an intensive go away and then it comes back once women get to the age where they start to have, you know, stress and condense whenever you laugh too hard or you're like whatever, it seems that way. I'm not saying it is, but it seems, it seems like it can't just be coincidence that the two ages whenever you get it are whenever you tend to be a little susceptible to stress and condense. Am I, am I told, do people actually think that or am I totally in left field? It is possible. I've never thought that. Somebody doesn't think about it all the time. I have never thought that. Okay, fair. Yeah. Dr. Tyler or anything? No, I mean, it's very complicated, although a urinary condense is something that I talk to people about a lot because you're getting irritant contact dermatitis from pads and urine on top of lichen sclerosis, which can make it really difficult to control. So I think that's the piece where urine comes into it and why dermatologists should send more people to the uroguinecologist and ask them about incontinence more often. But no, I really haven't heard that theory before. I think lichen sclerosis is a little complicated and we don't quite understand everything that plays into it. Just pee. The the urea in the pee, that's it. It's the whole thing. So if people stop peeing, they'll be okay. If they stop peeing, that's right. They'll be fine. Drink, drink less water. You're diverting your bladder, your bladder, your bladder. Yes. We'll do a study on that. That'll be great. Okay. That's good. Just home to drink less water. No more than eight ounces a day. If you have to pee more than once every three days, your lichen sclerosis is never going to go away. That's it. That's recommended by Dr. Kelly Tyler at the Ohio State University. No, please do not call me. All right, fairs. Good. Sorry. Next paper. Another quickie was just in Jad. Treatment of refractory L.S. and women with mycophonylate moffatil, Mayo retrospective study, New end at all. So 51 women, Aino-genital L.S. And so in about half of those, the the cell sept was our mycophonylate moffatil is actually prescribed for L.S. The end point of treatment again was just an improvement of at least one symptom. And so what did they find about 70% of women had improvement in one symptom? Time to response was about 2.2 months. And median duration of treatment was just over two years. Interestingly, among those responders, two of them did have a vulvar SCC before they then were put on mycophonylate. And they did sustain, they did continue it in out sustained treatment. So, you know, putting that out there is sort of another medication that could be used. You know, I don't think I've ever used this for Lycan sclerosis, but I don't have tons of these patients. Any thoughts on mycophonylate? Yeah, I mean, I've used it for refractory Lycan planis before, which just like L.S., you know, we don't have a lot of great studies for vulvar Lycan planis. And so it's hard to tell. I tell people, you know, I have no idea. There's not like one go to medication that I have for it, but I have to be honest, I haven't tried it for vulvar Lycan sclerosis. They may have actually also did a study on hydroxychloroquine for resistant Lycan sclerosis. And that actually, they had some good results with that too. So I like hydroxychloroquine, a lot. I use it. That's usually my first line systemic for vulvar Lycan planis. If I can't get them under control atop the cools or intermittent prednisone for flares. So I really like that. And so now I've started thinking more about using hydroxychloroquine for resistant Lycan sclerosis. Although I can't say, I have a few people for Lycan planis, but I don't have anybody on it right now for Lycan sclerosis. It's the main symptom of your treating itch. Would you say it seems like that's what patients can play is itch or pain or, you know, but itch seems to be number one. Yeah, almost everyone has itching with Lycan planis. It's more pain, you know, the painful erosions that they get. But yeah, if you have a patient with Lycan sclerosis who has pain and they don't have fishering or other reasons for it, sometimes they'll have secondary vulvidinia too. So something to think about, I'll get patients that are like, oh, this person has refractory Lycan sclerosis and I look at their skin and it looks okay. But sometimes these chronic inflammatory diseases can cause patients to get secondary vulvidinia too. Do you do a few years ago, there was a lot about PRP, like microneedling and PRP, or just PRP injections in general for Lycan sclerosis. I feel like I haven't heard as much about that in the last couple of years, but I just might not be looking. Is that, is there reasonable evidence to support it? Is it something that you ever send people for or that you do or is it, you know, if a patient asks about it, what do you tell them? Yeah, I haven't had any patients specifically to ask me about it, but there's still data out there and now there's actually some emerging data for genital urinary syndrome of menopause, as kind of where the PRP is coming on the horizon. You know what, and I haven't done it, but I think when I think about it, I'm thinking of plumping or revitalizing the tissue. So I would tell a patient, you know, it's not, we're not treating the underlying mechanism of the Lycan sclerosis. So the likelihood is I'm still going to have them on, you know, topical steroids or whatever treatment I have them on, but I would think of it as an adjunct treatment. Same for genital urinary syndrome of menopause, you know, that might help plump the tissue, make it healthier, but they're probably still going to need something like a vaginal estrogen for them. Okay, fair. All right, fairs, what's your next one? All right, final one. This was one that was published in JAMA dermatology, Lycan sclerosis prevalence and squamous cell carcinone development in female Medicare beneficiaries. And so this basically they looked at women 65 and older who were on Medicare. And so they had a sample from 2015 to 21 over 2.5 million women. And so one was like a prevalence measurement, which was 0.7% of women in that age group had Lycan sclerosis. And then they also looked at what percentage of women developed squamous cell carcinoma in the Volvar SCC and it was 1.2%. Interestingly, they looked at what percentage of women had some sort of topical steroid or TCI, it was 72.6%. So, you know, there was, they also could do like a competing hazard risk ratio to see, is there really a higher risk of SCC and women with Volvar LS? It was yes, the, um, compete, the hazard ratio was 11.8. So, can significantly higher risk of squamous cell carcinoma. Interestingly, most were managed by OB-GYNs. And, most was like almost never used for the genital SCC. So, you know, claims database, but a large sample. Thought I would ask you what you thought about this study. What do you think, what do you say to women about the risk of developing SCC? How important do you think treatment is? And like what's kind of your your spiel and monitoring for that? Yeah, it's really important. I actually was a little surprised on this study because their rates of SCC were a bit lower. Then we typically see I usually tell people about a two to three percent risk with either like in planis or like in sclerosis in the genital area. And my spiel is, you know, when I'm starting treatment, I tell them, you know, we have three reasons we want to treat them. Number one is we want to treat your symptoms. So we don't want you, you know, having itching and pain. You know, we want to get that under control. Number two is to prevent progression because we know that with like in sclerosis, they can get scarring, they can get narrowing of the introidas. And that in and of itself can cause other problems and some urinary symptoms, you know, perhaps. And then the third reason I tell them is we need to prevent skin cancer. So, you know, both our cancers, I think probably still the least common female genital cancer out there. So it's not a very high risk, or it's not a very common female cancer, but when you look at that, it's probably less than 1% of the population in general. But when you look at vulvar like in sclerosis, it's about two to three percent risk. So I tell people, you know, if we do your maintenance therapy, even if you think you're like in sclerosis is quote in remission, we still have studies that show us we think we can reduce your risk of SCC down to, you know, 0%. You know, if you're using your maintenance treatment, so there are some studies. So the mainstream and does help reduce the risk of cancer. Okay. Yeah, we don't even have great data of that for five flu or euro sale like for on your face, like we've got more now, we used to not have great data for that. But so that's interesting that we've got data that it does help to reduce it. Yeah, it's fairly new, but yeah, there are a lot of great quality studies, unfortunately, and like in the process, but you know, it's something that experts have kind of done for a long time, but we're starting to get some data to support what we're doing. Okay, very fair. All right, let's move on Dr. Patron. What do you got? My deep die paper from April 2026 edition of the journal of the German society of dermatology. It is titled evidence and consensus based guideline on Lycan sclerosis by Kurt Schig et al. So it's a condensed version of guidelines that were formulated by 26 experts from various specialties, first few pages go through symptoms and signs of Lycan sclerosis. Was there anything in the they have some images of male and female anything in the like any clinical pearls for diagnosing Lycan sclerosis. I'm curious if you get a lot of people that are like dermatologist or somebody told me I have Lycan sclerosis and you look and you're like, this is not like Lycan sclerosis. So does that happen a lot? Are there any tips you would give to any of our listeners of what you're looking for? Yes, so the biggest thing is texture change. So if there's not a texture change in the skin, it's most likely not Lycan sclerosis. One of the biggest things I see is people who are postmenopausal and they have itch or irritation and people say, well, if you itch, you know, and the tissue looks pale, it must be Lycan sclerosis. But we know that the vaginal atrophy for menopause can actually cause you know irritation, sometimes some mild itch, you know, pain on your nation sometimes and it can cause the tissue to look pale. But what you notice with those patients is that they don't have that texture change so it doesn't have that atrophic look. Sometimes there's a hypercarototic look or a waxy look that you can get with Lycan sclerosis. So that's that's kind of my tip and I don't do a ton of biopsies now to diagnose Lycan sclerosis just because I do it all the time and I feel pretty comfortable with what I see clinically. But if you're not sure, you know, biopsy, that's really going to be. I think that's really going to be the thing and the other thing is make sure you send it to your dermatopathologist because I'll get a lot of patients from gynecologist to a general pathologist is looked at the biopsy and they're just like, okay, well, no cancer. And so that doesn't really help me too much either, which is great that I have cancer, but it doesn't really help me with the diagnosis. So I think the biggest confusion I see is with the whole vaginal atrophy for menopause. Okay, they do recommend right diagnosis is often clinical. If you do want to do a biopsy, they mentioned stopping therapy for three weeks prior to obtaining a biopsy. That was longer than like what I think of with you know, CTCL. It's like take a week off a steroid, but they mentioned three weeks here. So I don't know how important that is moving on to the management, you know, skin care, general recommendations. How strongly do you feel they said, ointments are preferred over creams and gels. Do you feel strongly about that? Yeah, the Germans have this right. It's true. So yeah, definitely ointments because I feel like people get burning, especially if they have, you know, fishers or erosions or they've been scratching. You know, they have inflamed skin creams for a lot of my patients will tend to burn. And I feel like ointments are definitely more soothing. So I definitely prefer ointments. I'd say 99% of my patients are on ointments. And they do say ultra potent and topical and I'm just going to kind of brush over this other stuff because we talked about steroids and twice a day and then daily and then maintenance. Do you ever like stop maintenance? Is there a point at which you're like you've been doing three times a week for six months. There's been no recurrence. No, never. And the main reason is because of the risk of SEC. Even though you know, you say it's two to three percent that's still a lot higher than the general population. And I tell them they should see someone, you know, once a year. And so if you know, I feel like they're seeing someone who is comfortable with like insular system comfortable with continuing maintenance therapy. That's great. They don't necessarily need to see me. But some of the patients will continue to follow with me yearly. They mentioned some other topical therapies. We talked about the. And the topical retinoids and the topical hormones. I was surprised. I thought like there was decent data on like estrogens and things like that. But there were actually strong recommendations against, you know, outside of treating like G.U. syndrome in general. It doesn't seem like. I was surprised to see that too. Yeah, they doesn't seem like they're terribly enthusiastic about hormones being actually used to treat like insularosis. Yeah, no. Yeah, I don't I don't ever use hormones to treat like insularosis. This is why we have the experts come on the show. We're all three of us are like, yeah, is it they're pretty good? No, no, there is no. What are you doing? There is no. It's a good agenda. I think it's because mostly these patients are going to be postmenopausal. And you know, they're going to have volulvaginal atrophy. And so I think, you know, I do have a lot of patients on both estrogen and topical steroids. So the way I use it is, you know, you get them on daily vaginal estrogen, cream or pill or whatever you want to use. And then maintenance is twice a week on that. So what I'll have them do is that they're steroid Monday, Wednesday, Friday, bedtime. And then I'll have them do their estrogen Tuesday, Thursday. So I think it does have a role in making the patients more comfortable and helping the tissue be healthier, but it doesn't really do anything for the like insularosis. When you're on the maintenance therapy, are there like a mullions on the days off or you do say don't use anything? Yeah, you know, if they're comfortable, which is the goal, right? We want them to not have any symptoms, you know, once they're on maintenance, then I don't really have them use anything else. I tell them, you know, plain Vaseline is fine. Also, you know, just natural oils, coconut oil, almond oil, olive oil, you know, all those things are great. And if they feel like they need something else for moisture, but I don't tell them they need to use any amolians about like that highly you're I seem like highly erotic acid, you know, I don't know. So positories. Do you believe in that? Do you think that's witchcraft? Do you think it makes sense? Do they go to help here for symptoms? Yeah, I think it makes sense for the vaginal atrophy due to estrogen loss. So where that place of role is, you know, you have a patient, maybe they have breast cancer, maybe they're really worried about using estrogen. I do think hyaluronic acid is becoming more popular. And I do think it plays a role. It's definitely not as good as estrogen, because it doesn't really address the underlying reason that they're getting atrophy. But if they need a moisturizer, you know, I think I think that's reasonable. We talked about the PRP, but they also mentioned UV, photo dynamic therapy, cryotherapy lasers, not a lot of enthusiasm for any of those. Do you do any procedures like a lot or almost never? No, almost never. Yeah. And I don't we have a, you know, a group at Ohio State is doing a study on the laser. And I think it's a CO2 laser again, same, same thing that we talked about with PRP earlier, it doesn't really address the underlying reason for the Lycan sclerosis. But if they want to try it to kind of plump the tissue or make the tissue healthier. I would see it as sort of an adjunct, but the problem is, is it's being marketed as a treatment. So, okay, you know, if you're not better, let's just keep doing treatments with the Mona Lisa or whatever it is. And it's, you know, I just, I think it gets misconstrued a little bit. The only systemic therapies they talk about are methotrexate and acetretin. You had mentioned hydroxychloroquine because there was a study of male. What about the new stuff? I saw a case report at Tofa and Barisitnib, like Jack inhibitors seems like that would make sense to me. And then there were two cases of topical roflumalast. I don't know how many episodes, the germs on drugs that you listen to, but we love, love, love, oral roflumalast. With the newer medications, do any of those strike you as a lot of potential or you've had great experience? Or VTAMA, I'd throw in there too. So, like the TAMA's or re-- I can say we did the absururist, so absururra did a Lycan sclerosis study and it did something, but pretty much the patients were all like, and the clobatus always better. Like that was what I got across the board from them. Yeah. VTAMA, I've tried for both our psoriasis and I'm really unimpressed. So I would be hard pressed to try that for Lycan sclerosis. I haven't used any Jack inhibitors yet. I think I'm a little bit-- I don't know. I am a little bit limited just because I'm at an academic center, so I don't really have a lot of just samples at my disposal that I can give out to people. I do think the Jack inhibitors are promising. I would say if I had to pick, I would probably oral over topical, especially because a lot of the newer topicals are in a cream base, which can be another little bit of an issue for me using it. But yeah, I'll be interested to see if we had these little studies that we're doing through the Lovar Dermatosis Research Consortium. We have small groups of people looking at these things. So I think it's going to take a while for us to be able to say for sure, but I'm saying that Jack inhibitors are kind of working for everything. Yeah. That's-- it's actually more of a-- it's a more novel case report at this point. If somebody was like, I used a Jack inhibitor for X, and it didn't work. That'd be much more reportable than anything else anybody could report it for using for. Pat, you got anything else before move on? I didn't really dive into the procedural stuff. Is procedural gynecology? Is that play a big role in managing these patients? Is that something you do? No, not really. My partner in the clinic is a gynecologist. And so if someone needs to go to the OR, I'd say the main reason we do procedures is someone who say has Lycan Plannis or severe scarring, or they have a severe band of tissue that's scoured, and it's causing a lot of pain, releasing those adhesions or kind of releasing vaginal adhesions. People have really bad vaginal stenosis, but we're really not. We haven't really adopted any procedures on a routine basis. I would be interested in exploring PRP for some various things, but I guess I have to find one of my dermatology colleagues who wants to do a vaginal study. So overall a good sort of consent. You agree with the Germans, which that's a bad-- I don't-- I drive a BMW. You don't. You do not do that a good thing. But in this case, you're saying, OK, it's good. What do you tell people? So when we were doing the Lycan Sclerosis studies, so I was like 20 people in there, and it was by far the most Lycan Sclerosis I've ever dealt with, dysperunia was like-- so painful intercourse was like a big thing. And do you proactively-- if you get somebody who comes in and they've got the beginnings of Lycan Plannis or not Lycan Plannis, like any of it, I guess, Lycan Plannis, like Sclerosis, whatever, and intercourse is now painful, do you ever-- do you proactively tell them, like, don't stop because you're going to get stenosis and then it's going to-- what do you tell people about intercourse? If they're not scarred already, like, what do you tell people? Well, it kind of depends on what their goal is. Some people don't have the goal to be sexually active, or maybe they have a partner that, you know, for whatever reason, you know, they can't be sexually active. So I asked them that. Now I don't-- you know, I think my main thought when I have a new patient and is controlling the disease. So we get the disease under control first, and then we have a conversation about if your disease is controlled and you're still having dysperunia, you know, what is the issue? Is there a band of adhesions that's causing it? Is it, you know, something else? You know, some other reason you're having dysperunia. Maybe they have volubaginal etrophy, and you just need to go with some estrogen. I see that a lot, you know, that's something that we need to make sure that we're doing for these patients. But yes, regular intercourse, if they're able to, you know, we say that's nature's dilator, right? So if they're comfortable and they do have the goal of being sexually active and they have something like a planis which can cause scarring, you want to get it under control, but be, you know, regular intercourse is, you know, can really be helpful. Okay. Is the-- so let's move on to my article, which was one that you have been working on that has been published yet about vulvar contact dermatitis. And you know, my take from your article was completely consistent with my experience, which was that when I saw allergic contact dermatitis of the genitals, it was pretty obvious. And so like as a patch testing person, they rarely ever got to me because like anybody would have looked at it and be like, "What are you putting down there?" And then they'd be like, you know, benzocaine, Neomycin, you know, Neosporin, whatever. And you're just like, "Stop." And then if you don't get better, but I would still get lots of patients referred because basically people were looking for, you know, they had vulvar paritis and they were looking for a, "Oh, maybe there's a cryptic contact dermatitis." And reality, it was just like, "Get the hell out of my go see them. Let them deal with it." So would you reasonably agree with that that it's pretty rare to see vulvar contact dermatitis and pretty obvious? Like, you know, whenever I saw a couple of cases of like people allergic to the acrolates in the absorbent pads or benzocaine allergy, it wasn't like, it was pretty obvious. There was a, yes. Yeah, I see a lot of benzocaine. It's in vagicill and said like, "That's my worst enemy." But when they come in, it's acute or even unfortunately, acute on chronic, you know, they've been using it for a year every day. I had a lady who used to tube every day for a year of a vagicill and it was really just sore, horrible contact nerve. So that can be obvious. I think the things that aren't as obvious is, do they have like and simplex chronicus, you know, and maybe it started out as an acute contact dermatitis, but they might have a driver, you know, they might still be using something that we haven't identified that's making that. So what is your approach to, because vulvar paritis, right? So there's, there's, and for listeners, right, there's, there's vulvar pain. I think that pretty rarely comes to germs. And I, we probably come to you a lot, but not too normal. It does. Yeah. So for rightist though, I think comes to germs pretty regularly. What's your approach? Like, what do our listeners need to know? Like, do you empirically treat people for Canada just like as a just in case? Do you put them every, if they're over 65, they automatically get estrogen? Like, what do you, anything weird that you do? Not weird, but like the wouldn't be like, well, that's obvious. Like, yeah. Yeah. But, you know, I mean, I think you just have to know what the most common irritants and allergens are in the genital area, right? So for, for our vulvar patients, that's going to be, you know, incontinence urine pads. Make sure they're not using over-the-counter stuff like vagicillia. You have to ask what they're putting on, you know, are they wiping a lot with toilet paper because that rubbing can cause, you know, worsening paritis. So I think you just, you know, my main thing is asking them about the itch scratch cycle, because that tells me, you know, if they're like, yeah, you know, I itch, but then when I scratch, it, you know, feels good to scratch, but then it makes me itch more and they end up in this vicious cycle, you know, that's, that's pretty obvious, like, in simplex chronicus. And it can be really hard to say what started it. Sometimes it could have been a yeast infection a year or two ago that started the itch scratch cycle. I don't test everybody for yeast, although I don't think it's a bad idea to swab for yeast, is, you know, I have had a few patients that, you know, it looks like like in simplex chronicus, but then when I test them, you know, they're getting recurrent yeast. So that can definitely be an issue. Is there like, what kind of is that, is that like a special swab that you do just use, like a bacterial swab? and send it for yeast or like what do you do that? Yeah, well, we do have a like a special test called an actima that we use in our our vulvar clinic that's like a pretty quick like you send it out you swab you can send it to the lab for GC, Climidia, BV, you know, Candida, just in the regular Dermophage, just the swabs that I use for bacterial swabs, you know, you can send those for yeast too. So that's pretty simple to do. You can just or just send it off for a culture. So it's it's a yeast cut. It's not like because I know there's like a new clague acid amplification test or something. Yes. Or you could probably even do the PCR from like Vidcorp. So really there's not like one particular test for you're like, this is what you should be doing. And is do you ever see Candida as a like just it's like if you see Candida is it like we need to do something or is it like if you see Candida, yeah, probably just got supported at like what do you yeah, yeah, if it's Candida albicans, you know, and they're having it, you know, I'm treating that. Yeah, I'm usually not just randomly testing people for yeast, so that's usually a reason. There is something called Candida gliburata, which can be, you know, some people get irritation with it, but some people can be asymptomatic. So it's sort of like testing for gardenerola for BV, like some people just have it. If you test them, they're going to be positive, but if they're not having any of the symptoms of bacterial vaginosis, you don't have to treat it. So I would say by far and away though, if they have Candida albicans, you know, and especially if they have some other disease process on the bowl, though, I'm treating it. What's your normal? Do you just give one dose of fluconazole? Do you give them like weekly for a month? Like what's your standard treatment for both our Candidiasis? Yeah, so just, you know, if it's just simple, it's 150, one dose, like we do or do in the gynecology world. If it's more complicated, like the SGLT2 inhibitors, like Jardians, for Ziga, those patients, sometimes I'm actually treating them weekly, because I need to get them to their PCP, your endocrinologists, and I need to get them off of the medication. So sometimes I'll go ahead and give them a more prolonged treatment because A, they have more severe disease and then B, we're trying to get them off of the medication before we stop treating them. And for vulvar, like in simplex, is there what is your kind of go to there? Do you regularly end up going to oral drugs? Do you, you know, okay, so you try some tachyrolitis? Fine, if that doesn't work, you know, do you use dermal leave? Do you use, what do you use for them? If it's if it's parietist, like in simplex, but you're just not seeing much, but they're itchy. Okay, it depends on where the involvement is, right? Like in simplex, chronic is can be anywhere on the vulva. So if it's on the hairbearing area, I'm probably going to lean more towards like a low to medium potency, topical steroid, but I'm going to really monitor them very closely. So say I'd give them try and send a little appointment, I do it twice a day. I'm going to see them back pretty quickly, like six weeks and make sure they're doing well and trying to get them tapered off of that. Sometimes it's a prolonged taper, like six months, but sometimes if topicals really aren't working, I'll do interleagional catalogue, actually. So I just, you know, it's usually like a CC of K-10 and I'll do point one and kind of come down the say it's on the labia majora, I'll kind of come down and put point one in each spot down the bilateral labia majora and people get some pretty quick relief with that. I know there are people who do specialized in vulva or disease who are big proponents of just doing that off the bat. Give them some eye okay, shut down the itch crap cycle, and I don't think that's a bad idea. I think there are some patients who are like, "Oh, you want to give me a bunch of shots to my vulva." So sometimes you have to get over that or I'll pre-medicate them with topical light-according or something before they come in. As you say that I'm thinking about it, if we were trying to do that to our men with red scrotum syndrome. Okay, so I'm going to give you 20 shots into your scrotum and then that will probably make it feel better. At least you know they're not going to come back. If that was your therapeutic goal, it was then they're good. You're they're gone. Okay. Right. Could you ever see a role for like do Pixant or something like that? Yes. You know to help with that because LSC is pyroganodularis and adjacent. Yes, absolutely. I have a couple of patients on it actually. I couldn't get them better and you know a lot of times I can kind of squeeze a little bit more BSA out of it. You know, they might have something going on in their scalp, a couple of porigo nodules up there. Maybe they've got a little bit on the arms or the groin and you know I'll get them on to Pixant. It's it's awesome. They do great. If I could put everybody on it, that's great, but you know with a limited BSA in the genital area sometimes that's hard, but yeah, I find a lot of extra involvement when I'm trying to get these. It's getting reasonable to count anywhere that they are itchy as countering towards BSA. That is a reasonable thing to do. The all right, so before we go to trivia, last thing, this Volvo something of menopause, like I keep hearing about this. Like what's the, it's basically like atrophy and so it makes people susceptible to irritant derm. Is that like for a simple dermatologist? Is that what's it called again? Okay, so it's a genital urinary syndrome of menopause and they replaced Volvo vaginal atrophy with that term because you know people atrophy sounds kind of like a derogatory term, right? Like you're a trophic, you're losing your tissue, but also it encompasses more symptoms, right? It's not just loss of estrogen. It's women who have lower urinary tract symptoms so they might have frequency, urgency, you know burning on your nation, but they also have maybe irritation or itching or stinging from loss of estrogen to the vagina, to the entroidis and the vulva. So you know that is definitely, you know it's not just that they lost the estrogen and the tissue looks pale. It's that they're having other symptoms along with it so it makes it a syndrome. And is that something that? So will you give women? Good, there's that. Well, you give women, like, transdermal estrogen if pridus is one of their main complaints and their postmenopausal. If you think you know we know that this is a symptom of, you know, we've talked about, and we had a functional medicine episode when we talked about, you know, sort of not functional medicine, but generally the sense of what it was. Said that in a very demeaning way. Like we had a functional medicine. It was like, no, no, it was a good generative. But yes, well, I use a lot of topical estrogen because if it's really the GSM or the, you know, atrophy that they're dealing with, then that's really going to target that tissue, right? It would be, I would liken it to someone coming in and I put them on prednisone because they have over like insularosis as opposed to topical basal, right? So if I put them on oral estrogen or transdermal estrogen for genital urinary syndrome of menopause that's just localized, then, you know, maybe they don't really need that. Now some women may have other menopausal symptoms, you know, they're having a lot of hot flashes, other things, mood swings, you know, then I'm going to get them to, you know, one of their, either their general gynecologist or menopause specialist to talk about systemic hormone therapy. But I would say the majority of what I do is just, just topical, topical estrogen. And that I think for probably 90% of patients, that's enough if, you know, it's their main symptoms are in the genital area. For our, that's helpful. For our dermatology listeners, is there any reason to be afraid of or contraindications to giving topical estrogen to women? Like if this is something that you can do because they're having discomfort, is there history of breast cancer, history of blood clots? Do you need to think twice or can you safely do topical estrogen? So there have been studies. I think the main thing people worry about is do you have to add progesterone, right? If they still have a uterus, is there a unique cause, you know, endometrial hyperplasia or cancer? So studies have said, no, you don't need to do any, you know, any progesterone. So you don't need to worry about that. So that's one thing off your list as a dermatologist. The second thing is breast cancer. Now, you need to be aware that the package inserts the same for oral estrogen as it is for topical estrogen. So it's going to have that contraindication, you know, any history of blood clots, a history of breast cancer. I will say there haven't been any studies to prove that it increases the risk of breast cancer recurrence if you're just using vaginal estrogen. So my approach is if they have a history and they have really bad, you know, atrophy, and they're having a lot of symptoms. And I feel like we need to treat them and nothing else has worked as far as like the non-hormonal options. I just reach out to their oncologist and you know we have a conversation like, you know, this is safe, ACOG, the American College of Cetrics and thenicologists actually has a statement about this with breast cancer that it's safe. So you have that to back you up. But yeah, I just, you know, just to cover my bases, you know, if they're worried about it, you know, I will reach out, but we have a lot of patients. I guess you would call it off label on vaginal estrogen who have had breast cancer, but it really is the best treatment out there. And it's easy to use. It's, you know, one gram twice a week after you get them through the first two week loading dose. And does it, does genito urinary syndrome of metapause? Is it fairly reasonable that it could present just skin symptoms, just like Michi. And so they might, you know, because I, my understanding is if a woman's like past the age of new pap smears a lot don't follow up with a guy anymore. And so they might be coming to you. And like, is this something terms need to have like a working knowledge that it exists? And if so, is it reasonable to say, you know, you know, these kind of things look a little mat to be down there. And here's some estrogen, or should you send them to a guy if there's like other stuff you should be doing that we wouldn't know to do? - No, I mean, I think that's reasonable. I think the biggest thing is if someone comes to you with genital itching is to have that on your differential, you know, it might be atrophy. And so if you look and the tissue looks pale and they're having kind of stinging or burning and you don't see that texture change, yeah. I mean, go ahead and go ahead and treat. Yeah, if you don't feel comfortable, you know, a general gynecologist would be an easy consult. - Yeah, but if you're not like, oh my God, no, they need to work up for this and that. And they need to, you know, do a urinary voiding study or like whatever. It's just like you can symptomatically give some estrogen and if they're, you know, if the itching gets better or better, okay. So you said loading dose for the first two weeks is that like every day for the first two weeks and then twice a week after that, or what do you do? - Correct, yeah. Yeah, anywhere from 0.5 to 1 gram and that comes with an applicator if you do the cream and you do that nightly for two weeks and then you go to twice a week. I usually do just like Tuesday, Thursday. Yeah, and that's it. And then if you do vagifim, it's the little pills they can use in the vagina. If they're like the cream is messy or it causes burning, I have a few patients who can't use it. It's like a little pill and it's an applicator and they, it's the same way. You just do like a pill every night for two weeks and then it's twice a week. So that can be an eye-s option too. - Okay, all right, that's you have answered all of my lady parts questions. I think we're now ready to move on. And I only have to get to be age 52 to have them all in. So now we're ready to revult to trivia. Dr. Patton, what's our topic this week? - It's lady part of the vagina. - Oh gosh, I was afraid of that. - I know, it made my Google searches for the week very dicey, very dicey. - Hopefully it didn't do those at work. Yeah, yeah. - No, no. - No way. All right, number one, what feminist 1996 play written by Eve Endster is a series of stories based on interviews with hundreds of women. - The vagina monologues. - I'm giving that a tie. - No surprise from that has zero point. Half a point each for fairs and time. What was the name of the femme fatale in the James Bond movie Goldfinger? - Dr. Booty. - Near real cool. - Goal or what was that? - It's (beep) goal or. - It was goal or. - The way it is. - Not something I wanted to say I'm packed on the podcast. You may have to take that out. - It was great. It was in 1964, that movie. I'm like, how did they get a war? - I know. - Yeah. - How did they get away with that? I remember hearing about that when I was a kid. I was like, yeah. - Yeah. - I heard where. - All right, there. - They might have got one out. - Third and final. What Arnold Schwarzenegger movie had the iconic line spoken by a young child, boys have a penis, girls have a vagina. - Hint or garden pot. - Yep. - Oh. - That's it. Tyler walks away. Oh no, it was. - It was a big tie. - I had one point. - That was a tie. I was 10. - Several only cut my mouth. Then I'll take the L on that. - I didn't get the P. - It was amazing. - The P word of the podcast. - We didn't make up that name. That's what the girl called me. - I know. - You put it on a loop. - But all my residents. - It was on a loop. - And someday if I ever come to lecture in UNC Grand Rounds, I'm just gonna have that in the background. - You could sub in. - I put it just for time. Because I didn't know the answer by my views. - She's like, I don't wanna say this, but I also don't wanna lose. - You could sub in pocketbook. That is an acceptable, urban dictionary term for the vulva. It's one of my favorites. - Oh, pocketbook. - Yeah. - That's right. - I know. I do love the patient. I have a pocketbook. Lady Bits is another big one that I hear. - She has a hat. - Never seen men is just growing. That's it. Growing. That's all we have. - I don't know. - I think she has two growing. - Growing galore. - That's the left growing and the right growing. It just went growing. You have one growing and it has two parts. You don't have two growings. - Well, you could have a rash on one side. And the guy would be like, you're looking at the wrong side of my growing. Well, I guess it's side of the growing. - Right. You're not looking at the wrong growing. - There, huh? - That's great. - Right, I think it's time for that. - Thank you for joining us. Right, this was so much fun. For our listeners, I hope you learned a few things. I hope you laughed once or twice, but mostly hoping you're planning to join us next week. And until then, I'm Matt Zyrus. I'm Tim Patton. - And I'm Laura Ferris and we are Derms on Drugs. [BLANK_AUDIO]