Vulvar white lesions before and after the perimenopausal period

　　First, Causes of Disease

　　The occurrence of senile skin diseases may be due to physiological changes of aging, pathological changes, or unique or easily occurring lesions in the elderly period. Generally, they are caused by the interaction of multiple factors. In addition to the same points as general skin diseases, there are also several special aspects:

　　5. The signs of skin aging are mainly physiological, due to the aging and atrophy of the skin and its accessory organs, causing skin dryness, increased wrinkles, sparse hair, hair loss, whitening, brittle nails, skin itching, and spots, white spots, senile warts, hemangiomas, capillary dilatation, and other lesions, which become more severe with age.

　　4. The effect of physical and chemical factors Various stimuli can cause skin damage. If the collagen fibers and elastic fibers in the dermis become denatured and damaged, it can cause skin atrophy, keratosis, and even cancer.

　　3. The influence of systemic diseases Some elderly people with hypertension, arteriosclerosis, diabetes, and other diseases can cause skin diseases. For example, skin itching in diabetics is a good example. Diabetics can also cause large bullous purulent bacterial and fungal infections, skin malnutrition caused by arteriosclerosis, lower limb ulcers, necrosis, and other symptoms.

　　Second, Pathogenesis

　　The exact etiology of vulvar white lesions is unknown. There have been cases where the skin of vulvar lesions was exchanged and transplanted with normal skin on the patient's thigh. After a period of time, it was found that the transplanted lesions turned normal, while the normal skin transplanted to the vulva became diseased. Therefore, it is inferred that it may be due to a disorder of neural and vascular nutrition in the deep connective tissue of the vulva, leading to the occurrence of lesions on the skin covering it. In recent years, it has been found that there is a stimulant in the dermis that causes local connective tissue proliferation and promotes epidermal metabolism at that site. In the epidermis, there is a suppressor (chalon) that can inhibit the division and growth of epidermal cells. This hormone is a tissue-specific protein hormone that acts locally on the epidermis. Under normal circumstances, both are in a state of balance. Once the balance is destroyed, lesions occur. When the stimulant in the dermis is active and the suppressor in the epidermis decreases, there is a large amount of cell division and growth, resulting in thickening of the epidermis. When there is an excessive production of suppressor in the epidermis, the growth of the epidermis is inhibited, resulting in thinning of the epidermis.

　　Atrophic types often occur in women during or after menopause, and sometimes also occur in middle-aged women who undergo artificial menopause after radiotherapy or bilateral oophorectomy. Therefore, the decline or disappearance of ovarian function, and the lack of estrogen may be the cause of the disease. However, there are also some cases where the occurrence of the disease seems to have no relation to the lack of estrogen, so some people have proposed that the disease may be caused by some unknown factors that cause the vulvar tissue to lose its response to estrogen. It seems to be unrelated to marital status and the number of deliveries, and there is no obvious connection with systemic or local diseases.

　　In recent years, a large number of studies have confirmed that patients with lichen sclerosis (hard lichen) have immune diseases, and there are varying degrees of changes in CD3, CD4, CD5, and HLA-DR in their serum. 10% of lichen sclerosis patients have autoimmune diseases, such as hyperthyroidism, hypothyroidism, diabetes, and so on. Some studies have found that malnutrition, such as female estrogen receptor (ER), progesterone receptor (PR), and androgen receptor (AR), are all reduced to varying degrees, with lichen sclerosis being the lowest. The level of dihydrotestosterone in the serum of patients with vulvar dystrophy is significantly lower than that of normal people, suggesting that testosterone deficiency may be one of the causes of the disease. Some studies have shown that the content of human epidermal growth factor (EGF) in the skin tissue of vulvar dystrophy is significantly higher than that of the surrounding normal skin, which is again significantly higher than that of normal vulvar skin, suggesting that the occurrence of vulvar dystrophy is related to the increase in EGF content and dysfunction. In recent years, some authors believe that the occurrence, development, and changes of vulvar dystrophy are closely related to the action of free radicals. When the content of superoxide dismutase (SOD) and glutathione (GSH) in the local skin tissue and whole blood is significantly reduced, free radicals are continuously produced and accumulated. The increased production of free radicals causes strong oxidative damage to the collagen fibers, reticular fibers, elastic fibers, and tissue cells in the skin tissue, as well as biological macromolecules such as proteins, nucleic acids, and fats in blood vessels and nerves. This leads to the destruction of the physiological structure of the skin tissue, the occurrence of metabolic disorders, the obstruction of nutritional metabolism, and ultimately results in vulvar dystrophy. Reports have shown that the positive rate of HLA-B40 is relatively high in patients with lichen sclerosis. Clinical cases with family history are also common. In recent years, some people have found that the HLA-DQT of lichen sclerosis patients is positive.

　　For those with hyperplasia, the etiology is still unclear. However, according to some scholars' analysis and research findings, certain nutritional deficiencies (such as hydrochloric acid, iron, vitamin B2, folic acid, vitamin A, D, B12, etc.), local vascular changes, estrogen deficiency, chronic irritation, scratching, nervous and mental factors, and certain external stimuli may all be pathogenic factors for the disease.

　　Xue Xiang et al. used the monoclonal antibody against the apoptosis inhibitory gene BCL-2 and the immunohistochemical LSAB method to find that the BCL-2 protein has a weakly positive expression in the normal vulvar skin basement membrane. In hyperplastic dystrophy, atypical hyperplasia, and vulvar cancer tissues, the expression rate is increased to varying degrees, which is significantly different from lichen sclerosis and mixed type. There is no significant difference in the expression of BCL-2 gene protein in hyperplastic and atypical hyperplasia (P>0.05), and the expression rate in vulvar cancer is the highest. Therefore, it is speculated that the incidence of hyperplastic vulvar lesions is related to BCL-2 to some extent.

　　Due to the decreased immunity of patients during this period, the lesion area may also develop vaginal infection under the condition of infection. Before and after menopause, as the ovarian function gradually declines to the cessation of ovarian function, the gradual loss of estrogenic function leads to a series of physiological changes in the external genitalia, mainly varying degrees of atrophic changes. Usually, around the age of 40, the skin shows signs of aging, and the changes are significant 5 to 10 years after menopause.

　　1. Vulvar dermatitis:It mainly occurs in the labia majora and labia minora, and sometimes affects the perianal area. Vulvitis caused by external stimuli, including dermatitis, folliculitis, urticaria, and non-specific dermatitis caused by mental factors and overfatigue, is mainly characterized by excruciating itching. In the acute stage, there are symptoms such as congestion, edema, erosion, ulcer pain, and increased secretions. Due to continuous scratching or scalding, the vulvar skin gradually becomes thick and rough, leather-like. In the chronic stage, pigmentation disappears, and there is a firm white lichenoid change. Vulvar dermatitis has a long course and can recur repeatedly. Regardless of the severity or duration of the disease, the vulva does not deform, and the labia minora are not adherent. This is the key distinction between vulvar dermatitis and lichen sclerosis.

　　2. Vulvar Sclerosing (Atrophic) Lichen:This disease is more common in women around 40 years old, and can also be seen in young girls under 10 years old. The main manifestations of the disease include dryness, itching, pain, erosion, and discoloration. In the early stage, the vulva has no obvious deformation, and the lesion is limited to the inner side of the labia minora, with mucosal discoloration. As the course of the disease progresses, the lesion extends to the clitoris, labia majora, posterior symphysis, and perianal area, while the labia minora gradually atrophy and disappear. In the middle and late stages, the vulva atrophies and deforms, becomes flat, resembling the shape after excision surgery. The skin gradually becomes thin and shiny, even as thin as cigarette paper. The labia minora may become adherent, causing difficulty in urination, narrowing of the vaginal orifice, and possible sexual intercourse difficulties due to posterior symphysis laceration. Due to poor blood supply and malnutrition, the vulva is prone to erosion, fissures, or the formation of small ulcers. There is a burning sensation when urine soaks it, and the prepuce of the clitoris and the rough texture of the labia majora locally present as white patch changes.

　　3、外阴白斑：3. Vulvar leukoplakia:

　　How to prevent vulvar white lesions before and after menopause

　　Some patients with severe vulvar white lesions take regular follow-up visits to prevent malignant transformation.

　　Vulvar white lesions before and after menopause skin protection:

　　1. Avoid various adverse chemical and physical stimulation Due to the dry and less moisture in the elderly skin, it is necessary to use as little salt water and soap as possible, especially alkaline soap, which has a greater irritation to the skin. It is not advisable to take a bath too frequently in winter, and after taking a bath, it is possible to apply a solution or cream with lubricating, protective, and moisture-retaining properties.

　　2. Good and comfortable living environment Due to the reduced vascular regulatory function of the elderly skin and poor adaptability to temperature changes, the living environment should be relatively stable, the indoor temperature should be kept appropriate, clothes, shoes, and socks should be loose, soft, and warm, and they should be suitable in size, avoiding外伤and bacterial infection.

　　3. Reasonable dietary arrangement Due to the poor adaptability and weak digestion of the elderly gastrointestinal tract, it is necessary to avoid overeating, and the food should be diverse. It is advisable to consume low-fat, high-protein, green vegetables, and eat more vitamin A, C, E foods, carrots, green vegetables, fruits, eggs, vegetable oils, animal livers, etc.

　　Vaginal secretion examination, bacterial culture, tumor marker examination.

　　Histopathological examination: In order to improve the accuracy of diagnosis, biopsy should be performed at areas with cracks, ulcers, bumps, hard nodules, or roughness, and multiple samples should be taken from different lesion sites. To obtain biopsy from suspicious positive areas, the following methods of specific biopsy can be chosen.

　　1. Apply 1% toluidine blue to the lesion area.

　　2. Observe the lesion area with a colposcope.

　　3. Use HPD laser fluorescence method to locate biopsy.

　　4. Use固有荧光法定位活检。

　　One: Dietotherapy for vulvar white lesions before and after menopause

　　1. Longdan Coptis Egg: 10 grams of Longdan Coptis, 3 eggs, 30 milliliters of honey. Boil Longdan Coptis and remove the dregs, beat the eggs to make a dumpling egg, add honey, and take it on an empty stomach once a day, for 5 days as one course. It has the effect of clearing heat, removing dampness, and healing sores.

　　2. Cabbage and mung bean sprout drink: one cabbage root, 30 grams of mung bean sprouts. Clean the cabbage root and slice it, clean the mung bean sprouts and put them in a pot, add an appropriate amount of water, boil for 15 minutes, remove the residue and take the juice, drink it as tea, without any time restriction. It has the effect of clearing heat and removing dampness, which can be used for the treatment of vulvar ulcers.

　　3. Sugar-snap winter melon soup: 30 grams of winter melon seeds, 30 grams of sugar. Clean the winter melon seeds, grind them into coarse powder, add sugar, and mix with a bowl of boiling water. Place it in a clay pot and simmer over low heat. Take two doses a day, for several days in a row. It has the effect of clearing heat and promoting diuresis, which can be used for the treatment of vaginal itching.

　　4. Sowthistle and pork stomach: one pork stomach, 30 grams of sower seed, 10 grams of fructus psoraleae. Clean the pork stomach, add water, and boil with the latter two herbs together. Discard the herbs and eat the stomach. It has the effect of kidney-tonifying and wind-relieving itching. It is used for the prevention and treatment of atrophic vulvar white lesions.

　　Second, what foods are good for vulvar white lesions before and after menopause

　　1. Eat more foods with anti-white spot effects, such as sesame seeds, almonds, wheat, barley, loofah, black-bone chicken, cuttlefish, green mamba, pork pancreas, chrysanthemum, black plum, peach, lychee, horse-tail amaranth, chicken blood, eel, abalone, crab, horseshoe crab, sardine, clam, hawksbill turtle.

　　2. For pain, eat horseshoe crab, red, lobsters, oysters, sea cucumber, tiger fish, beetroot, mung beans, radish, chicken blood.

　　3. For itching, eat amaranth, cabbage, mustard greens, taro, kelp, purple kelp, chicken blood, snake meat, pangolin.

　　4. To enhance physical fitness and prevent metastasis, eat silver ear, black fungus, mushrooms, monkey head mushrooms, chicken gizzards, sea cucumber, Job's tears, walnuts, crabs, lizard, needlefish.

　　Third, it is best to avoid eating certain foods for vulvar white lesions before and after menopause

　　1. Avoid foods that may cause allergic reactions. For example: fish, shrimp, crab, chicken heads, pork heads, goose meat, chicken wings, chicken feet, etc., which may worsen itching and inflammation in the vulva after eating.

　　2. Eat less spicy and irritating foods. For example: onions, black pepper, chili, Sichuan pepper, mustard greens, fennel.

　　3. Avoid eating fried and greasy foods. For example, fried dough sticks, butter, butter, chocolate, etc., which have the effect of promoting dampness and heat, increasing the secretion of leukorrhea, and are not conducive to the treatment of the disease.

　　4. Quit smoking and drinking. Smoking and alcohol are highly irritating and can worsen inflammation.

　　First, precautions before the treatment of vulvar white lesions before and after menopause

　　Before treatment: it is necessary to have a detailed understanding of the symptoms of the disease and the related contraindications.

　　Second, Western medical treatment methods for vulvar white lesions before and after menopause

　　There is no effective treatment for the white vulvar lesions, and comprehensive treatment is generally adopted to alleviate symptoms. In the past, the high incidence of malignancy was emphasized, and surgery was often performed, which not only had poor efficacy but also a high recurrence rate of up to 50% to 70%, as shown in Figure 8. In the past decade, this view has been clarified. After excluding malignancy, a comprehensive treatment combining traditional Chinese and Western medicine is often adopted, which is relatively satisfactory. The treatment principle is to eliminate the cause, improve the overall condition, and treat symptoms (local inflammation, itching, moisturizing, etc.).

　　1. Drug treatment: combination of traditional Chinese and Western medicine treatment

　　Mainly using insecticidal and antipruritic drugs, supplemented with wind-damp removing, heat-clearing and detoxifying, anticancer, swelling reduction, blood circulation promoting, fat and keratin removal, promoting circulation, promoting cracking and ulcer healing, etc.

　　(1)Local: Acute stage: hyperplastic type, stop itching, 2% diphenhydramine cream, corticosteroids: Fluocinolone, dexamethasone (fluomethasone), hydrocortisone cream, clobetasol propionate (Encor), vulvar neurodermatitis, fluvon or penvon solution can be applied externally for calamine lotion, coal tar solution, or 10% phenol zinc oxide ointment. Desquamation can be treated with urea cream, etc.

　　Atrophic type: Apply 10% cod liver oil ointment or 1% to 2% testosterone (testosterone) cream externally, 2% testosterone propionate, 0.1 dienestrol ointment or vitamin A ointment.

　　Vulvar washing formula: Cnidium monnieri 15g, stemonae 15g, Sophora flavescens 15g, Alum 15g. Steam and wash 2 to 3 times a day, 10 days as a course. Not only can it stop itching, but it can also promote pigmentation.

　　(2)Systemic: For those with severe itching symptoms, leading to insomnia, oral sedatives, hypnotics, and desensitizing drugs can be taken. Atrophic type: Oral intake of various vitamins A, C, E, etc., and there are reports that high-dose vitamin E can significantly improve hard crust lesions.

　　2. Physical therapy - laser and cryotherapy

　　(1)Liquid nitrogen cryotherapy: Spray liquid nitrogen on the vulva to form a thin frost-like crystal that can stop itching and improve blood circulation.

　　(2)Laser therapy:

　　Methods of laser therapy:

　　①Single irradiation method (pulsed or continuous irradiation):

　　A. Different powers of CO2 laser: Diffracted radiation to the skin, so that the epidermal temperature reaches about 42℃ without causing burns.

　　B. Different powers of He-Ne laser:

　　②Combustion and irradiation method: Using CO2 laser of different powers, the original light beam or defocused light spot burns the lesion. After one week, laser irradiation is performed every other day until the wound heals.

　　③Spot combustion and irradiation method: After CO2 laser focusing, spot combustion therapy is performed in the lesion area, and daily or every other day irradiation is performed after surgery.

　　(3)Local irradiation therapy with microwave, Bom, etc., is also effective.

　　3. Acupuncture treatment

　　Acupuncture for itching is also effective. Acupuncture at Yanglingquan, Baichongwo, and local Ashi points, or acupuncture at the ear points of Shenmen, lung, vulva, etc., has the effect of stopping itching. In the acute stage, once a day; in the chronic stage, once every other day; 5 to 10 times as a course.

　　4. Surgical treatment

　　For hard crust or dermatitis, if there are persistent ulcers, nodules that do not heal after treatment, take a biopsy of living tissue. If there is severe atypical hyperplasia, perform a simple vulvectomy. Send the specimen for examination after resection, observe whether there is residual atypical hyperplasia at the margins, and follow up regularly after surgery. Be highly vigilant for cancer transformation. Atypical hyperplasia of mild to moderate severity (I to II level) can be treated conservatively, followed up regularly. However, for those who cannot be followed up at level II, such as mountainous farmers, vulvectomy can also be performed.

　　5. Other treatments

　　(1)Vulvar vitiligo, if asymptomatic, no treatment is needed, and 30% psoralen tincture can be tried locally, or other traditional Chinese medicine treatments, to cause skin inflammation, promote pigmentation, but the efficacy is not definite.

　　(2)Chronic dermatitis, superficial X-ray radiation in low doses, phosphorus-32敷贴.

　　(3) Short rod-shaped bacillus vaccine treatment for vulvar leukoplakia, with a reported total effective rate of up to 99%. This vaccine is a non-specific lymphocyte and reticuloendothelial system activator that can enhance cell phagocytic ability to improve the body's immune response ability, and it also has a strong anti-inflammatory effect without significant side effects.

　　(4) TDP radiation therapy for vulvar leukoplakia is effective, mainly utilizing the thermal effect of TDP to dilate local blood vessels, accelerate blood circulation, improve local cell nutrition, promote the repair of mucosal fissures, and at the same time, TDP emits infrared rays with a peak close to that emitted by the human body, causing resonance, enhancing the body's immune ability, and providing relief from itching and therapeutic effects.

　　(5) Hormonal Treatment: Placental polypeptide was used for intradermal injection at the vulvar lesion site in 94 patients, once a day, 2ml for unilateral lesions, 2ml for bilateral lesions, 10 times as one course, and 64.9% cure rate and 100% effective rate were achieved after 3 consecutive courses.

　　(6) Augmentin (SOD) Complex Enzyme Treatment: Yin Ju et al. applied glutathione injection for local punctate subcutaneous injection at the vulvar lesion site, 10mg for unilateral lesions, 10mg for bilateral lesions, then applied Augmentin (SOD) ointment to the lesion site, irradiated with infrared light for 20 minutes, once a day, 10 times as one course, a total of 3 courses, with an interval of 5 to 7 days between courses, with a total effective rate of 96.9%.

　　(7) Literature reports: The relationship between vulvar malnutrition and enzymatic histochemistry, local immunity, and the changes before and after treatment with the immunomodulator piperacillin/tazobactam (Cefobid) is related to immunodeficiency, abnormal TIC deposition in the lesion tissue, and changes in enzymatic histochemistry. Treatment with piperacillin/tazobactam (Cefobid) can improve TIC deposition, with a pre-treatment TIC deposition rate of 42.86% in hyperplastic lesions, 21.43% after treatment, 50% in lichen sclerosis before treatment, and 30% after treatment. Four normal vulvar tissues were negative, without immune complex deposition.

　　(8) There are reports in the literature that 5-Fu, electrothermal needles, bom, interferon, and other treatments have achieved therapeutic effects.