Going beyond steroid creams

There are many annoying and irritating conditions for which there is no satisfactory cure. People suffering from such conditions keep going from one doctor to another and try out different types of medications — allopathy, homeopathy, ayurveda — with little relief. Some may even try out remedies suggested by laymen or resort to self medication, only to derive temporary relief.

A white patch on the vulva is one such condition. Though vulval diseases are considered uncommon, it is not unusual for gynaecologists to come across women complaining of vulval itching who have been using steroid ointments for months or years with little relief.

Vulva, in simple words, is the skin that is covered by pubic hair. A white patch is usually noticed because of annoying itching or is incidentally discovered when a woman comes to a gynaecologist for the treatment of some other problem.

Rule out the risks

The possibility of cancer should always be ruled out in any new growth/ulcer, increase in size, colour change or bleeding from any pre-existing lesion in any part of the body.

Though antihistamines, soothing lotions, avoidance of synthetic undergarments and irritant cosmetics, and a mild sedative at bedtime help in reducing itching, a white patch on the vulva mandates a biopsy.

Certain conditions (hyperplastic keratosis and lichen sclerosis) are known to undergo a malignant change in a small percentage of women and should be observed for any change in symptoms and appearance for time to time. Any woman coming with the complaint for the first time should undergo a pap test (a compulsory investigation which should be done in all women at regular intervals). Precancer lesions and cancers of vulva, vagina and cervix frequently coexist with each other, and hence a pap smear followed by colposcopy (examination using a low power microscope to look for any abnormal area before it becomes visible to the naked eye) should be done.

What is colposcopy?

Colposcopy helps in deciding where to take the biopsy from. In case of a small white patch, the entire white patch can be removed and sent for biopsy. But in case of a large white patch extending up to the anus and involving the clitoris, biopsy following colposcopy (vulvoscopy) is essential. Obviously, the entire white patch cannot be removed for biopsy. The reason for this is that one part of the white patch may be benign, another part may be precancerous and yet another part may be frankly malignant. Therefore, the most suspicious part of the lesion should be taken for biopsy. A blindly taken or a random biopsy may show a benign lesion when malignant changes may be present at another site.

Pap test and colposcopy are simple tests consuming only a few minutes, not costing more than a few hundred rupees in most centres in India. Potent steroid ointments are of benefit and are prescribed after the white patch is biopsied and is proved benign. However, since itching can recur and may aggravate from time to time, high potency steroids are tapered and lower potency steroids are given for maintenance. The patient is instructed to come for regular follow-up so that a close watch can be kept of any change in character of the white patch. Most importantly, the woman should be counselled about the chronic nature of the condition and she does not indiscriminately use steroids.