Desquamative Inflammatory Vaginitis

Desquamative Inflammatory Vaginitis
Hope K. Haefner, MD
The University of Michigan Hospitals
Ann Arbor, Michigan
Disclosures
Hope K. Haefner, MD Nothing to disclose
Learning Objectives
At the end of this lecture, the participant will gain
knowledge on the:
– Diagnosis of desquamative inflammatory
vaginitis
– Differential diagnosis of conditions
associated with desquamative
inflammatory vaginitis
– Treatment strategies for patients
presenting with inflammatory cells on wet
prep
Conditions Associated with
Vulvovaginitis
• Atrophic vaginitis
• Traumatic
– Foreign body
• Allergic vaginitis
• Infection
– Streptococcal,
Amebic, Herpes
•
•
•
•
Erosive lichen planus
Pemphigus vulgaris
Behçet’s disease
Collagen vascular
diseases
• Degenerating
leiomyoma or
endometrial polyp
• Idiopathic
Desquamative Inflammatory
Vaginitis
Desquamative Inflammatory
Vaginitis (DIV)
D. Birenbaum MD collection
Desquamative Inflammatory
Vaginitis
D. Birenbaum MD collection
Desquamative Inflammatory Vaginitis
• Previous terms
– Exudative or membranous vaginitis
– Hydrorrhea vaginalis
– Serofibrinous allergic dysregulative
colpitis
Desquamative Inflammatory Vaginitis
Symptoms and Signs
• Dyspareunia
• Exudative chronic
vaginitis, purulent
discharge (yellowwatery; at times blood
tinged)
• Spotted rash
vagina/cervix
• Massive vaginal cell
exfoliation-see
parabasal cells
• (PMNs/epith > 1:1 in
at least 4 hpfs on wet
prep)
• Increased vaginal pH
Desquamative Inflammatory Vaginitis
History
• First described in 1950’s
– Franken H, Rotter W. Geburtsh u Frauenh
1954;14:154
– Scheffey LC, Rakoff AE, Lang WR. An
unusual case of exudative vaginitis
(hydrorrhea vaginalis) treated with local
hydrocortisone. Am J Obstet Gynecol
1956;72:208-211
Desquamative Inflammatory Vaginitis
History: Franken H, Rotter W.
• Chronic exudative vaginitis in 12 y.o.
• Fibrin, lymphocytes and squamous
debris
• Increased histiocytes
• Intravaginal estrogen
• Different from other DIV cases
Desquamative Inflammatory Vaginitis
History
• Gray LA, Barnes ML Vaginitis in women,
diagnosis and treatment. 1965
• Gardner HL. Desquamative inflammatory
vaginitis: A newly defined entity. 1968
Desquamative Inflammatory Vaginitis
History
• Sobel-retrospective of 51 cases DIV 1994
• Mean age was 41.8 years (range 21 to 66
years)
• 19 women were menopausal
Sobel JD. Desquamative inflammatory vaginitis:a new subgroup
of purulent vaginitis responsive to topical 2% clindamycin therapy
Am J Obstet Gynecol 1994;171:1215-30.
DIV- A New Subgroup
• Vaginal pH > 4.5
• Amine odor
• Vaginal PMNs
– 4+
– 3+
• Parabasal cells
51/51
0/51
100%
0%
46/51
5/51
90%
10%
51/51
100%
Sobel JD.
Am J Obstet
Gynecol
1994;171:1215-30.
? Vitamin D
Peacocke M. Djurkinak E. Tsou HC. ThysJacobs S. Desquamative inflammatory
vaginitis as a manifestation of vitamin
D deficiency associated with Crohn
disease: case reports and review of the
literature. Cutis. 86(1):39-46, 2010 Jul.
DIV Treatment
• 2% clindamycin cream (i applicator) per
vagina qhs x 14
versus
• 25 mg hydrocortisone suppository per
vagina qhs x 14
-Recurrent DIV or Resistant DIV
• Combine 2% clindamycin (i applicator) with one
hydrocortisone suppository (25 mg) per vagina
every other night (it is easier for patients to use
these agents together rather than alternate
days).
• -For difficult DIV: Hydrocortisone 100 mg/gram
in clindamycin 2% emollient cream base. Insert
5 gram (applicator full) q.o.d. ( at night time) x 14
doses. This needs to be made at a
compounding pharmacy.
Recurrence/Maintenance
• Repeat successful regimen after verifying
diagnosis
• May require long term hydrocortisone
suppository (25 mg)
• May need to add estrogen and/or
clindamycin
Desquamative Inflammatory Vaginitis
History
• Cytological changes identical to atrophic vaginitis
Oates JK, Rowen D. Desquamative inflammatory vaginitis .
A review Genitourin Med 1990;66:275-279.
Atrophic Vaginitis
Foreign Body
Desquamative Inflammatory Vaginitis
History: Edwards and Friedrich
Edwards L, Friedrich EG. Desquamative vaginitis: Lichen
planus in disguise. Obstet Gynecol 1988;71:832-836.
Pemphigus Vulgaris
Cicatricial Pemphigoid
Degenerating Endometrial Polyp or
Leiomyoma
Areas Associated with Vaginal
Discharge
Lacking Information
• Bacterial vaginITIS
• Lactobacillus
• Cytolytic vaginosis
LACTOBACILLUS
• Symptoms of yeast (itching)
• Cottage cheese discharge
• Produced by antifungal therapy
LACTOBACILLUS
• Wet mount
– Elongated lactobacilli (formerly
believed to represent leptothrix, a
marker for trichomonas)
– Noninflammatory
• Treat with Amox/clavulanate or
doxycycline or Ciprofloxacin
L Edwards, MD collection
L Edwards, MD collection
CYTOLYTIC VAGINOSIS
• Symptoms of yeast – itching
• Cottage-cheese discharge
• Most common cause of
vaginitis at Cibley/Cibley
vaginitis clinic
CYTOLYTIC VAGINOSIS
• Wet mount
– Cytolysis (naked nuclei of epithelial
cells, appear like lymphocytes unless
seen under phase microscopy).
– Noninflammatory
– Increased lactobacilli
• Treat with chronic, intermittent
baking soda douches
Sodium Bicarbonate
Sitz Bath: Mix 2-4 tablespoons of baking soda in 2
inches of bath water (any temperature). Sit in the tub
twice daily for 15 minutes each time. Take sitz bath
2-3 times in the first week of treatment, then 1-2
times weekly (as needed) to prevent recurrences.
Douche: Mix 1-2 teaspoons of baking soda in 1 pint
of warm water. Gently douche 1-2 times weekly as
needed.
Hutti MH. Hoffman C. Cytolytic vaginosis: an overlooked cause of cyclic
vaginal itching and burning. Journal of the American Academy of
Nurse Practitioners. 12(2):55-7, 2000 Feb.
Current Thoughts on the
Same vs. Different Conditions
• DIV is not a diagnosis in itself, and may be
the presentation of a range of disorders
• Therefore no one treatment will work for all
of these conditions