Vulvar white lesions before and after the climacteric period

　　一、发病原因

　　老年皮肤病的发生有的属于衰老生理变化，有的则属于病理变化，有的是老年期特有的或易发的病变，一般都为多种因素相互作用而发生，除与一般皮肤病相同点外，还有几个特殊的方面：

　　1、皮肤老化征主要为生理性，由于皮肤及其附属器官老化、萎缩、造成的皮肤干燥，皱纹增多、毛发稀少、脱落、变白、指甲变脆、皮肤瘙痒以及黑斑、白斑、老年疣、血管瘤、毛细血管扩张等，这些病变随年龄的增加而加重。

　　2、物理化学因素的作用各种刺激可引起皮肤损伤，若真皮胶原纤维，弹力纤维变性和破坏，造成皮肤萎缩，角化、甚至发生癌变。

　　3、系统疾病的影响某些老年的高血压、动脉硬化、糖尿病等都可引起皮肤病，例如糖尿病人的皮肤瘙痒是一个很好的例子，糖尿病人还可引起皮肤大疱化脓性细菌和真菌感染，动脉硬化引起的皮肤营养不良，下肢溃疡，坏死等。

　　二、发病机制

　　Two, pathogenesis

　　The exact etiology of vulvar leukoplakia is unknown. Some people have exchanged the vulvar lesion skin with normal skin on the patient's thigh and transplanted it, and after a period of time, it was found that the transplanted lesion turned into normal, and the normal skin transplanted to the vulva became diseased skin. Therefore, it is inferred that it may be due to a disorder of nerve and blood vessel nutrition in the deep connective tissue of the vulva, causing the skin covering it to become diseased. In recent years, some people have found that there is a stimulant in the dermis that causes local connective tissue hyperplasia and promotes epidermal metabolism at that place. In the epidermis, there is an inhibitor (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, the two are in a state of balance. Once the balance is destroyed, lesions occur. When the stimulant in the dermis is active and the inhibitor in the epidermis is reduced, cells divide and grow in large numbers, resulting in thickening of the epidermis. When the inhibitor in the epidermis is produced in excess, the growth of the epidermis is suppressed, resulting in thinning of the epidermis.

　　Atrophic type often occurs in women during or after menopause, and sometimes also occurs in middle-aged women who have artificial menopause after radiotherapy or bilateral oophorectomy, so 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 hypothesized that the disease may be caused by some unknown factor that causes 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.3In recent years, a large number of studies have confirmed that patients with lichen sclerosis (lichen) have concurrent immune diseases, and the CD4In recent years, a large number of studies have confirmed that patients with lichen sclerosis (lichen) have concurrent immune diseases, and the CD5and CD-and HLA10Hellenic: % tonychosis patients have autoimmune diseases, such as hyperthyroidism, hypothyroidism, diabetes, etc. Some studies have found that malnutrition such as female estrogen receptor (ER), progesterone receptor (PR), and androgen receptor (AR) are reduced to varying degrees, with tonychosis being the lowest. The level of dihydrotestosterone in the serum of patients with vulvar dystrophy is significantly lower than that of normal people, indicating 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 the vulvar dystrophy is significantly higher than that of the surrounding normal skin, and the latter is also 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 reduced 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 oxidative damage to the collagen fibers, reticular fibers, elastic fibers, and tissue cells of the skin tissue, as well as biological macromolecules such as proteins, nucleic acids, and fats in blood vessels and nerves, thus destroying the physiological structure of the skin tissue, hindering metabolism, and causing malnutrition, leading to vulvar dystrophy. Some reports indicate that the HLA-B and HLA-DR of patients with lichen sclerosis have varying degrees of changes. There is4The positive rate is relatively high. 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.

　　The etiology of hyperplasia is still unknown, but according to some scholars' analysis and research, a certain nutritional deficiency (hydrochloric acid, iron, vitamin B2Folic acid, vitamin A, D, B12And other) local vascular changes, estrogen deficiency, chronic stimulation, scratching, nervous and mental factors, and some external stimulating factors may all be factors contributing to the disease.

　　Xue Xiang et al. used the apoptosis inhibitory gene BCL-2Monoclonal antibody and immunohistochemical LSAB method, found BCL-2Protein has a weakly positive expression in the basal layer of normal vulvar skin, and the expression rate increases to varying degrees in hyperplastic atrophic, atypical hyperplasia, and vulvar cancer tissues, showing significant differences from lichen sclerosis and mixed type, while hyperplasia and atypical hyperplasia BCL-2There is no significant difference in the expression of gene protein (P>0.05The expression rate of vulvar cancer is the highest. Therefore, it is speculated that the incidence rate of hyperplastic vulvar lesions is related to BCL-2There is a certain relationship.

　　Due to the decreased immunity of patients in this period, the lesion area may also develop vaginal infection under the condition of infection. Before and after the perimenopausal period, due to the gradual decline and cessation of ovarian function, the gradual loss of estrogen function leads to a series of physiological changes in the external genitalia, mainly varying degrees of atrophic changes. Usually4Around the age of 0, the skin shows signs of aging, and after menopause5～10There is a significant change in the skin.

　　1Vulvar dermatitis:Mainly occurs in the labia majora and labia minora, sometimes involving the perianal area. Vulvitis caused by external stimuli, including dermatitis, folliculitis, urticaria, and non-specific dermatitis caused by psychological factors and excessive fatigue, mainly manifests as an intense itching, congestion, edema, erosion, ulcer pain, and increased secretions in the acute stage. 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 may recur repeatedly. Regardless of the severity or duration of the disease, the vulva does not deform, and the labia minora are not adherent, which is the key distinction between vulvar dermatitis and lichen sclerosis.

　　2Vulvar lichen sclerosis (atrophy):It is more common in4Around the age of 0, it can also be seen in10The young girls under the age of one, the main manifestations of this disease include dryness, itching, pain, erosion, and whitening. In the early stage, there is no obvious deformation of the vulva, and the lesion is limited to the inner side of the labia minora, with mucosal whitening. As the course of the disease progresses, the lesion spreads to the clitoris, labia majora, posterior commissure, and perianal area, while the labia minora gradually atrophy and disappear. In the middle and late stages, the vulva atrophies and deforms, flattens, resembling the shape after excision. 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, which may lead to sexual intercourse difficulties and posterior commissure lacerations. 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 the area, and the prepuce of the clitoris and the rough texture of the labia majora may change locally into white plaques.

　　3Vulvar leukoplakia:Generally without itching symptoms, can occur on the vulvar skin or mucosa, localized as clear boundary patches, white, hair in the affected area is also white, while the vulvar skin texture, shape, and luster do not change, good elasticity, and there may be hyperpigmentation around.

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

　　Protection of the skin before and after the climacteric period:

　　1Avoid various adverse physical and chemical stimuli due to the dryness and lack of water in the elderly skin, try to use less salt water, soap washing, especially alkaline soap, which is more irritating to the skin. In winter, bathing should not be too frequent, and after bathing, it is possible to apply a lubricating, protective, and moisture-retaining solution or cream.

　　2A comfortable living environment due to the decreased vascular regulatory function of the elderly skin and poor adaptability to changes in external temperature, 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 should be of appropriate size, avoid trauma and bacterial infection.

　　3A reasonable diet arrangement due to the poor adaptability and weak digestion of the elderly gastrointestinal tract, avoid overeating and binge eating, food should be diversified, low-fat, high-protein, green vegetables, eat more vitamin A, C, E foods, carrots, green vegetables, fruits, eggs, vegetable oils, animal livers, etc.

　　4Attention should be paid to the prevention and treatment of skin diseases and systemic diseases. Age spots, senile warts, and other skin damage on the elderly skin are generally benign and do not require special treatment. However, if there is a sudden outbreak of senile warts in a short period of time, it indicates the possibility of combined internal malignant tumors, and vigilance should be increased. For some elderly skin diseases with a possibility of malignant transformation, such as vulvar white lesions, regular follow-up and observation should be carried out. Many systemic diseases can cause skin diseases, such as hypertension, diabetes, and so on. It is beneficial to prevent and treat various systemic elderly diseases actively, which is good for skin health.

　　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 fissures, ulcers, protuberances, hard nodules, or roughness, and multiple samples should be taken from different lesion sites. In order to obtain biopsy from suspicious positive areas, the following several specific biopsy methods can be selected.

　　1Using1％甲苯胺蓝(toluidine blue)涂病变区。

　　2Using colposcopy to observe the lesion area.

　　3Using HPD laser fluorescence method, locate biopsy.

　　4Using固有荧光法，定位活检。

　　I. Dietetic recipes for vulvar white lesions before and after the climacteric period

　　1Gentiana scabra Egg: 10 grams of Gentiana scabra, eggs3pieces, honey30 milliliters. Decoction of Gentiana scabra with residue removed, beat in eggs to form omelette, add honey, take on an empty stomach, daily1times,5日为1个疗程。具有清热祛湿敛疮之效。

　　2、白菜绿豆芽饮：白菜根茎1个，绿豆芽30克。将白菜根洗净切片，绿豆芽洗净后同入锅中，加适量水，煎煮15分钟，去渣取汁，当茶饮用，不拘时间。具有清热解除湿的功效，可用于外阴溃疡的，治疗。

　　3、冰糖冬瓜汤：冬瓜子30克，冰糖30克。将冬瓜子洗净，研成粗末，加入冰糖，冲开水1碗，放人陶罐，文火隔水炖服。每日2次，连服数日。具有清热利湿止带之功，可用于阴痒的治疗。

　　4、苍耳猪肚：猪肚1个，苍耳子30克，补骨脂10克。将猪肚洗净，加水并与后两味药同煎，弃药食肚。具有补肾祛风止痒之效。用于预防和治疗萎缩型外阴白色病变。

　　二、围绝经期前后的外阴白色病变吃那些对身体好

　　1、宜多吃具有抗白斑作用的食物，如芝麻、杏仁、小麦、大麦、土瓜、乌骨鸡、乌贼、乌梢蛇、猪胰、菊花、乌梅、桃子、荔枝、马齿苋、鸡血、鳗鱼、鲍鱼、蟹、鲎、沙丁鱼、文蛤、玳瑁。

　　2、疼痛宜吃鲎、赤、龙虾、淡菜、海参、虎鱼、甜菜、绿豆、萝卜、鸡血。

　　3、瘙痒宜吃苋菜、白菜、芥菜、芋艿、海带、紫菜、鸡血、蛇肉、穿山甲。

　　4、Αποτελούν την ενίσχυση της φυσικής κατάστασης και την πρόληψη της μετάβασης σε άλλες περιοχές, πρέπει να τρώτε σιρόπι τριπλέ, κόκκινη σιρόπι, σκόρδο, τριπλέ, σιρόπι, σιρόπι, κόκκινο κουκουνάρι, κ.λπ.

　　Τρίτο, η λευκή παθολογία των εξωγενειών πριν και μετά την περιόδο της περιμετρικής εξόδου καλύτερα να μην τρώτε αυτά τα τρόφιμα

　　1、Αποφύγετε να τρώτε προκαταρκτικά τρόφιμα. όπως ψάρι, γαρίδα, καλαμάρι, κεφάλι κοτόπουλου, κεφάλι γουρουνιού, γουρουνάκι, γάλακτος, αλεύρι, κόκκινο κουκουνάρι, κ.λπ., μετά από το φαγητό θα επιδεινώσει την φλεγμονή του εξωγενειού.

　　2、Αποφύγετε να τρώτε πικάντικα και ερεθιστικά τρόφιμα. όπως λάχανο, κύμινο, πιπέρι, κύμινο, κεράσι, κύμινο κ.λπ.

　　3、Αποφύγετε να τρώτε τηγανητά και λιπαρά τρόφιμα. όπως τολούνα, βούτυρο, λάδι, σοκολάτα κ.λπ., αυτά τα τρόφιμα έχουν την επίδραση της ενίσχυσης της υγρασίας και της θερμότητας, θα αυξήσουν την ποσότητα του λευκού σπέρματος, δεν είναι επωφελές για τη θεραπεία της νόσου.

　　4、Καταργήστε το κάπνισμα και το ποτό. Το κάπνισμα και το ποτό είναι πολύ ερεθιστικά, θα επιδεινώσουν την φλεγμονή.

　　Πρώτο, οι προσεκτικές παρατηρήσεις πριν από τη θεραπεία της λευκής παθολογίας των εξωγενειών πριν και μετά την περιόδο της περιμετρικής εξόδου

　　Πριν από τη θεραπεία: πρέπει να κατανοήσουμε λεπτομερώς τα συμπτώματα της νόσου και τις σχετικές απαγορεύσεις.

　　Δεύτερο, η θεραπευτική μέθοδος της λευκής παθολογίας των εξωγενειών πριν και μετά την περιόδο της περιμετρικής εξόδου

　　Εως τώρα δεν υπάρχει καμία αποτελεσματική θεραπευτική μέθοδος για τη λευκή παθολογία των εξωγενειών, συνήθως χρησιμοποιείται η συνδυαστική θεραπεία για να ανακουφίσει τα συμπτώματα. Η παθολογία αυτή στο παρελθόν επιβράδυνε πολύ τη συχνότητα της καρκινικής μετάβασης, χρησιμοποιούσε συχνά την απομάκρυνση χειρουργικά, όχι μόνο η αποτελεσματικότητα ήταν κακή, αλλά η συχνότητα της επανεμφάνισης ήταν πολύ υψηλή50% έως70%, βλέπε την εικόνα8πρόσφατα10Στα τελευταία χρόνια, οι παραπάνω απόψεις έχουν καθαριστεί, αφού αποκλείστηκαν τα κακοήθη, χρησιμοποιείται συχνά η ενιαία θεραπεία της κινεζικής και της occidentalιστικής μεθόδων, η αποτελεσματικότητα είναι ικανοποιητική, η αρχή της θεραπείας είναι η αφαίρεση των πυρήνων, η βελτίωση της γενικής κατάστασης του σώματος και η θεραπεία των συμπτωμάτων (τοπική αντιφλεγμονώδης, αντιπαρασιτική, ενυδάτωση κ.λπ.).

　　1, drug treatment, combination of traditional Chinese and Western medicine treatment

　　Mostly kill insects, itching drugs, supplemented with wind-damp removing, heat-clearing and detoxifying, anticancer, swelling, blood-activating and stasis removing drugs, removing hypertrophy and keratinization, promoting circulation, promoting fissure and ulcer healing, etc.

　　)1, local: acute stage: hyperplastic type, stop itching,2%diphenhydramine cream, corticosteroids: fluticasone, dexamethasone (flumethasone), hydrocortisone cream, clobetasol propionate (Encorat), vulvar neurodermatitis, can be applied with fluvan or solvay solution, calamine lotion or10%zincoxide phenolate cream, desquamation can be used with urea lipids, etc.

　　Atrophic type:10%cod liver oil ointment or1%~2%testosterone (testosterone) cream, externally applied2%testosterone propionate, 0.1Estradiol valerate ointment or vitamin A ointment.

　　Vulvar washing formula: Cnidium monnieri15g, stemona15g, senna15g, alum15g. fumigation and washing2～3ημέρες/d，10days for1Course of treatment, not only stop itching, but also can make hyperpigmentation.

　　)2, systemic: severe itching symptoms, leading to insomnia, can take sedatives, hypnotics and desensitization drugs. Atrophic type: take a variety of vitamins A, C, E, etc., 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, form a thin frost-like crystallization that can stop itching and improve blood circulation.

　　)2, laser treatment:

　　Laser treatment methods:

　　①Single irradiation method (pulsed or continuous irradiation):

　　A, different power CO2Laser: diffused irradiation to the skin, so that the epidermal temperature reaches42℃ around, not to burn.

　　B, different power He-Ne laser:

　　②Burning plus irradiation method: using different power CO2Laser, original light beam or defocused light spot, burn the lesion, after surgery1Weeks, once every other day laser irradiation until the wound heals.

　　③Point burning plus irradiation method: CO2After the laser is focused, point burning treatment is performed in the lesion area, and daily or every other day diffusion irradiation is added after surgery.

　　)3, microwave, Bohm and other local irradiation therapy is also effective.

　　3, acupuncture treatment

　　Acupuncture for itching is also effective, acupuncture at Yanglingquan, Baichongwo and local Ashi points or acupuncture at Shenmen, lung, vulva and other auricular acupoints, has the effect of stopping itching, acute stage1ημέρες/d, in chronic stage every other day1times,5～10As a course of treatment.

　　4, surgical treatment

　　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, apply simple vulvectomy, send the specimen for examination after resection, observe whether there is residual atypical hyperplasia at the margin, and follow up regularly after surgery, be highly vigilant for cancer, atypical hyperplasia mild to moderate (I to II level) can be treated conservatively, follow up regularly, but for those who cannot follow up due to grade II, such as mountainous farmers, vulvectomy can also be performed.

　　5, other treatments

　　)1External vulvar vitiligo, if asymptomatic, no treatment is needed, and it can also be tried.30%补骨脂酊，locally applied or other traditional Chinese medicine treatment, can cause skin inflammation, promote hyperpigmentation, but the efficacy is not certain.

　　)2)顽固性皮炎，小剂量浅层X线放射，磷32贴敷。

　　)3)短棒状菌苗治疗外阴白色病变，文献报道总有效率达99％，这种菌苗是一种非特异性淋巴细胞及网状内皮系统激活剂，能增强细胞的吞噬能力以提高机体免疫反应能力，同时具有很强的抗炎作用，无明显的副作用。

　　)4)TDP辐射治疗外阴白色病变有效，主要是利用TDP的热作用，使局部血管扩张，血液循环加快，改善局部细胞营养状态，促进黏膜皲裂的修复，同时TDP发出与人体发出的波峰相近的红外线，使之发生谐振，提高机体的免疫能力，起到止痒和治疗作用。

　　)5)激素治疗：应用胎盘多肽对94例患者进行外阴局部皮内注射，1ημέρες/d，单侧病灶注射2ml，双侧病灶各注射2ml，10ημέρες, η συχνότητα1疗程，连用3个疗程治愈率64.9％，有效率为100％。

　　)6)奥古蛋白(SOD)复合酶治疗：尹菊等应用谷胱甘肽注射液，做外阴病灶局部点状皮下注射，单侧病灶注射10mg，双侧病灶各注射10mg，然后在病灶处敷以奥古蛋白(SOD)软膏，用红外线照射20min，1ημέρες/d，10ημέρες, η συχνότητα1θεραπευτική συνεδρία, συνολικά3θεραπευτική συνεδρία, μεταξύ των θεραπευτικών συνεδριών, η διακοπή5～7ημέρες, η συνολική απόδοση96.9％.

　　)7)Σύμφωνα με τα έγγραφα: Η εξωγενής ανεπαρκής τροφοδότηση και η ενζυμική οργανική χημεία, η σχέση με το τοπικό ανοσοποιητικό και την παραμονή του Panipecillin/Betalain (Kebaining) πριν και μετά την αλλαγή, τα αποτελέσματα δείχνουν ότι η εξωγενής ανεπαρκής τροφοδότηση και η ανοσορρροπία είναι σχετική με την αномαλία της καταθήκη του TIC της αλλοιωμένης ιστούς, η ενζυμική οργανική χημεία έχει αλλάξει, μετά την Panipecillin/Betalain (Kebaining) θεραπεία μπορεί να βελτιώσει την καταθήκη του TIC, πριν από τη θεραπεία η καταθήκη του TIC της υπερπλαστικής είναι42.86％，μετά τη θεραπεία21.43％，πριν από την τυροκυστική φατία50％，μετά τη θεραπεία30％，4Όλα τα κανονικά εξωγενή ιστούς είναι αρνητικά, χωρίς την καταθήκη των αντισωμάτων.

　　)8)Σύμφωνα με τα έγγραφα, υπάρχει χρήση της 5-φθοροουρίας (5-FU5-Fu)，θερμάνωση με ηλεκτροθερμότητα, Bohm, ανοσοφάκες κ.λπ. έχουν αναφέρει την απόδοση της θεραπείας.