In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
What Information Needs to Be Included in History Taking and Examination When Women Are Referred to the Gynaecology Clinic with Symptoms and/or Signs of a Vulval Skin Disorder to Aid Investigation and Management?
C - The history should include details of any personal or family history of autoimmune conditions.
C - The history should include details of any personal or family history of atopic conditions (hay fever, asthma, eczema).
D - The history should include any symptoms of urinary or faecal incontinence.
Which Investigations Are Useful in the Investigation of a Woman with a Vulval Skin Disorder?
D - In the initial assessment of a woman with vulval symptoms, consider testing for thyroid disease, diabetes and sexually transmitted infections if clinically indicated.
D - Skin biopsy is not necessary when a diagnosis can be made on clinical examination. Biopsy is required if the woman fails to respond to treatment or there is clinical suspicion of vulvar intraepithelial neoplasia (VIN) or cancer.
C - Women suspected of having lichen sclerosus or lichen planus should be investigated for other autoimmune conditions if there are clinical symptoms or signs.
C - Serum ferritin should be checked in women with vulval dermatitis.
What Is the Role of Skin Patch Testing in the Investigation and Management of Women with Vulval Dermatoses?
D - Skin patch testing should be performed for women seen with vulval dermatitis.
How Should Lichen Sclerosus and Lichen Planus Be Managed?
C - Ultrapotent steroids are important in the management of women diagnosed with lichen sclerosus and lichen planus. The patient and her general practitioner require clear advice on the management regime (Appendix 6 in the original guideline document describes a suitable management regime).
D - Approximately 4% to 10% of women with anogenital lichen sclerosus will have symptoms that do not improve with topical ultrapotent steroids (steroid-resistant disease). The recommended second-line treatment is topical tacrolimus under the supervision of a specialist clinic.
D - Surgery and CO2 laser vaporisation are not recommended for the treatment of symptoms of lichen sclerosus. However, these treatments have a role in restoring function impaired by agglutination and adhesions such as urinary retention or narrowing of the vaginal introitus that affect sexual function or body image.
How Should VIN Be Managed?
C - The gold standard for the treatment of VIN is local surgical excision.
D - Women undergoing surgical excision of VIN should have access to reconstructive surgery.
B - Non-surgical treatments are accepted as an alternative to surgery, but women require regular, long-term follow-up.
What Non-specific Measures and Advice Are Useful in the Control of Vulval Symptoms?
D - A key part of management is general care of the vulval skin and avoidance of any potential irritants that may worsen vulval irritation.
Emollients are widely recognised as having a key role in protecting the skin and restoring skin barrier function. General vulval care includes avoiding potential irritants that may worsen vulval symptoms. Uncontrolled studies have shown that these measures reduce symptoms and resolve contact dermatitis and lichen simplex chronicus. Vulval skin is sensitive and may react both to irritants and to allergens. Irritants are commonly encountered and include underwear, sanitary protection, textile dyes, soaps and detergents (see Appendix 3 in the original guideline document). Avoiding soap and detergents and using soap substitutes can be soothing and protective to the skin. The combined use of emollients and soap substitutes helps maintain symptom relief and is safe and inexpensive. A small, prospective, open trial of maintenance with an emollient following steroid therapy showed that a proportion of women can maintain symptom relief and reduce the use of topical corticosteroids. [Evidence level 3]
Do Women with Vulval Skin Disorders Need to Remain Under Long-Term Surveillance at the Gynaecology Clinic?
C - Women with VIN need to be seen on a regular basis for vulvoscopy or careful clinical assessment and biopsy of any suspicious area.
C - Women who have been treated for VIN are at risk of intraepithelial neoplasia at other sites. Colposcopy examination should be available at follow-up.
How Should Sexual Problems Associated with Vulval Skin Disorders Be Identified and, if Identified, What Is the Most Effective Approach to Their Management?
D - Women should be asked about the impact of their vulval disorder on sexual function and appropriate advice and care should be available.
What Is the Role of Self-Examination and What Information Should Women Be Given on This?
D - Women with vulval symptoms should be encouraged to perform self-examination to monitor their skin condition and any suspicious areas.
What Training Should General Gynaecologists Have in the Management of Vulval Disorders?
D - According to the Royal College of Obstetricians and Gynaecologists (RCOG) core curriculum, obstetrics and gynaecology trainees must have knowledge and experience of the management of common vulval disorders as a training requirement.
What Is the Most Effective Model for Care Provision for the Investigation and Management of Women with Vulval Skin Disorders?
D - Women with complex or rare vulval skin disorders or who do not respond to standard treatment should be seen at a specialist vulval clinic.
Women who have difficulty with symptom control should be referred to a specialist clinic. This includes women who require frequent or prolonged use of ultrapotent topical steroids. Such women may require additional support to use first-, second- or third-line therapy. They require biopsy of any suspicious or resistant areas. [Evidence level 4]
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++ and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g., case reports, case series
4 Expert opinion