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Hi, everyone. Um Thank you for coming to part two of our session tonight. Um We're covering vulval and vaginal conditions. Um, same as last night, there will be a feedback form at the end. Um So if you can fill that in, that's greatly appreciated and I'll hand over to tonight's speaker. Hi. Um So my name is Tanya. I'm an F one doctor working in Wales. Um and I'm going to be talking about vulval and vaginal skin conditions. Um So a bit about me, I am doing a um lift program at the moment in sexual health. So that means I do um one day a week in a gum clinic um alongside my rotations. Um So I just wanted to share some of the stuff that we see quite commonly. Um and some of the kind of tips and tricks that are helpful um when doing female examinations. Um I know you guys have got exams coming up. So the way I've structured these slides is um essentially each one is formatted like a flashcard. So at the end you can, um if you want, you can just print out this um presentation and use them as flashcards as well. Um I've done them, I've kept them quite brief because I know the other speakers are going to be um, overlapping some of the conditions, um, especially like the STIs and things. So I've just focused on the skin manifestations today. Um, but yeah, if there's any questions or if you want me to go slower, um, just pop it in the chat and I'll try my best. Cool. Um, so first of all, just the normal um anatomy, um obviously, there's no such thing as normal. Um Everybody's different, but some of the landmarks to consider. Um So, firstly, when we say vulva, we mean the external female genitalia. Um So that includes the mons pubis at the top and then the labia Majora, which you can't really see in this picture. Um But yeah, and then just medial to the labia majora, you've got the labia Minora. Um And then one term which you hear a lot is the vestibule. So the vestibule essentially um it's made up of all the structures um inside the um labia Minora. Um So that's the um sort of the mucosal tissues. Um It's the urethral meatus, the vaginal orifice um and the clitoris um right at the bottom here, you've got the posterior for um the top of the clitoral hood um is also sometimes called the anterior for, so you've got the like the anterior and posterior um at the top of the bottom. Um And you've got the two LA on either side. Um The bit below the for is the perineum. Um And then you've got the anus um distal to that. So, um fine. So before we go on to sort of pathologies, um here are some sort of common things that you see, patients do get really, really worried about them, but these are no, somewhat normal um at different stages of life. Um So the first one, I'm not sure if you can see um my mouth moving, but um the image on the top left, um So that's showing these kind of pearly papules. Um This is just um above the clitoris. Um These are what's known as for disease spots. Patients can get really worried and sometimes, um you know, they think I've got lumps or herpes or whatever. These are, in fact, entirely normal. They're just in large sebaceous glands. Um And in some people, the glands are just larger than others. So they can look like these little lumps under the skin. Um Men can get them to around the friend limb and the guns. Um So super normal. Uh the next one across is just a shaving rash. So, again, benign, um patients again can get really worried about it because they can look quite nasty. You can get sort of abscesses and folliculitis and stuff under the skin. Um But yeah, so nine times out of 10 when I have a patient who's worried about rashes or lumps. Um, it's usually just a nasty shaving rash. Um, but yeah, it's just something to reassure patients about. Um, and then these bottom two pictures are, um, sort of other things that you might notice, um, in different stages of life. So, the stitches here, um, is stitches from a, a Piot toy. Um, so you might see some scar tissue, you might see some, um, sort of jagged egg, jagged edges where the um where the stitches were done. Um And it's not always nice and neat if it was a perennial tear, um depending on the stage and location, it can be um in different places, it's not usually a problem um unless it's infected or bleeding or something. Um And then we've got the changes that happen in menopause. So the most common one is vaginal atrophy. Um That's when, um and you kind of get this associated loss of rugae within the vagina. So the you kind of get a loss of texture in the walls when you look with the speculum. Um It can be quite irritating. Um It's quite um sore and quite dry. Um You get kind of thinning of the mucosa. So, um lots of women um do struggle with that and it can be easily sorted out with creams and stuff. Um So just some common um things there. Ok. So now I'm gonna go on to the actual pathologies and I've split it up into three sections So you've got the infective um noninfective and ulcerative conditions. Um OK, so just the infective conditions first. So the first one is um HSV or herpes simplex virus. Um these kind of present as ulcers or blisters. Um I've put images in here. I know when I was a med student, I always felt like when I had these lectures after the first like four or five slides, all the pictures start to look the same and they all just look a bit nasty and a bit red and you don't really know what you're looking at. So I think I really, really what I hope you guys can get out of today is just to be able to differentiate between the different ones because they do look really similar. Um And I actually, I think a spot diagnosis is, is really useful, um especially in exams and stuff. I know um most unis do online exams now. So it's a lot of times they do just put a picture um in the stem of the question and um it's really useful just to be able to look at something and go actually this is this virus. So hopefully I'm gonna try and point out like the, the actual differentiating factors of just when you're looking at it. Um So yeah, so with herpes, you get these kind of um superficial ulcers, um you, you can get them usually in clusters um not always symmetrical. Um But they usually have this kind of white border around them. You can get neuropathic pain. So the herpes virus is um in its dormant stage, it kind of lives in the nerve root ganglions. Um Hence why you get like a like a neuro distribution. Um it's quite painful, quite itchy. Um and the some patients also get um lymphadenopathy. So another important point for when you're doing examinations is anybody with a vulval or vaginal um skin change or just have a feel of the lymph nodes in the um sort of in the groin, in the medial thigh. Um If they're enlarged, then that's what can help you differentiate between infective and non infective. Um So uh what are some of the risk factors? So, for herpes type one, that's the one that causes um usually causes cold sores. Um It can spread to the genitals through oral sex. Um And then herpes type two is um direct genital contact. Uh If you've got type one, you can still also get type two. So it doesn't make you immune. Um And also usually from, from what I've seen people with herpes type two, it tends to be more um more severe, more sore infections. Um So lots more ulcers. Um The diagnosis is just a viral PCR swab. So it's a little orange swab. Patients don't like it because the lesions are very sore and you have to kind of prod it with a stick. Um But that you just kind of have to do it. Um, the treatment is with Acyclovir. So either when they have the flare ups or for people who get it all the time and they tend to be on it prophylactically. Um, and then some symptomatic relief as well because it is quite painful. So, topical lidocaine, um, aqueous creams and washes. Um, some patients find it helpful just to sit in a warm bath. Um, just, yeah, and kind of get through the flare up. Um So yeah, um the next common one are genital warts um caused by the human Papilloma virus or H PVI put lots of pictures here because warts look different in everyone. Um And yeah, like even so I was in the gum clinic today and even today alone, I saw like five cases of warts. They're all different. Um The thing which is common between all these pictures is they're all sort of raised growth, they're all quite soft. Um So it's kind of the same, um it's like the same texture as a skin tag. So, um that's another differential. Um they often appear in clusters and um they're usually painless. Um So if it's just a couple of warts, um patients might not even know that they have them. Um But yeah, so it's caused by HPV type six and 11, you're more likely to get it if you're immunosuppressed. So anybody on long term steroids, um chemo HIV, positive patients. Uh it's usually a clinical diagnosis. So, um, just by looking at it and, um, they don't tend to, they're not normally sort of bleeding or blistering. Um, they are usually quite, um, kind of non eventful. They do just sit there and they don't do much. Um, so usually the patient's main concern is the appearance of it. Occasionally they can be itchy, um, but not always. So most cases, um, can just clear up on their own. Um So the HPV virus, it sort of, it can sit in, in your body dormant for like up to two years. Um And then you just get like repeat flares um if you're stressed. Um But yeah, it was previously thought that it used to just stay there forever. Um But actually the body can self clear it or at least clear it um to an undetectable level. Um but if it's not going away on its own, um we can give creams to help. So water con or mid um in larger warts or more persistent ones, you can get them removed. So cryo um quarter or laser and yeah, most patients do continue to have recurrence unfortunately, even after the treatment. Um So yeah, many people do just have to keep coming in again and again. Ok. Um Candida or Thrush um this one I've put in there. Um It's not. No. Well, it can cause skin changes. I think the main skin um symptom that people have is just the itchiness. Um It only really has like a visible um appearance when it's in the, when it's very severe. So, um sort of edema fissures, excoriations. Um Usually that's exacerbated by the itching. Um The main complaint is the discharge. So it's quite copious. Um It's kind of got this cottage cheese um appearance. So this is um the cervix um on speculum examination and you can see the kind of clumpy white discharge, um which is quite um it is quite pathognomonic for um Candida. Uh it's also quite uncomfortable. So patients will have dysuria and dys paea as well. Um Risk factors again being immunosuppressed, um high estrogen state. So it's more common in pregnancy um having poorly controlled diabetes. Um So, Candida is um a fungi uh and it really thrives in um areas where there's high glucose. So if you've got glycose urea with your diabetes and there's lots of glucose sort of hanging about um around the genitals, then that can exacerbate it. Um and also a broad spectrum antibiotics. So, if it kills off the natural flora of the vagina, that can also um exacerbate thrush, it's diagnosed with a charcoal swab and microscopy. Um So essentially, um there's like a little um it's like a special type of um swab that you use called a wet film. Um And it looks a bit like um the little loop that you use to inoculate like Petri dishes and stuff. Um So you just take a little loop, um, fill it with um, the discharge and look at it under the microscope. Um, and it's quite obvious the, um, the cancer itself, it kind of looks like it's larger than the um normal um facia um, of the vagina and they often have like a hypha as well. Um So you'll know it when you see it. Um So I should have put a picture of um, the histology on that. Um But yeah, the other thing you can do is test the PH and that really helps you to differentiate between Candida and BV um which is another common differential and presents very similarly. Um NARU is really easy to treat. Um it's just like a one off. So just sta treatment. So either a stat um tablet fluconazole or just um one application of flutrimazole as a cream or a pessary and you can get um canin from pharmacies which um I think it's sold as Canin Duo. So you get both the tablet and the cream. Um and you just do it once and then that's it, that's the treatment done. And so yeah, the next one is syphilis, so a little bit less common. Um but super, super interesting um just to kind of as a side note, um syphilis is something which you should always um consider as a differential for anything because it can literally mimic any condition. Um We had a case recently which they thought it was like meningitis or sarcoidosis and it turned out to be syphilis. Um So it can literally be a differential in anything it's often called the Great imitator because it can literally just present as like any other condition. Um So, yeah, always have syphilis in the back of your head. Um So kind of vague nondescript symptoms. Um But anyway, I digress. So, um the kind of course of a syphilis infection you start off with, um, primary syphilis, which is just a solitary red sort of nodule. Um on the genital area, it's painless. There's only one of it. So most people, um, a lot of the time don't even realize that they have one and because it self resolves in like 1 to 5 weeks. Um, a lot of times people don't even realize because it just, it doesn't do anything. Um And it just goes away after that sort of 1 to 6 months afterwards. You can get secondary syphilis. So this is after the initial rash results. Um And you get this kind of rough bumpy rash, um, all over the body, including the vulva. And I know I said, um, all the pictures start to look the same which they might be by this point. Um Some of you might have picked up this kind of looks exactly like some of the clusters of warts. Um Definitely, if you saw this for the first time, you might think it was genital warts. Um So how would you differentiate it just by looking at it? Well, um, the first thing is syphilis, um, you wouldn't get this just isolated on the vulva. It would normally be all over the body. So hands face back and it wouldn't usually be an isolated one. Um, and the other thing is, is the risk factors. So, syphilis is much more likely if the person has what we call high risk sexual activities. So people with multiple sexual partners, um multiple episodes of unprotected intercourse. Um chem sex, um not being on prep. Um you know sex with people who are HIV, positive or group sex. So just um they will have more um episodes of what is defined as high risk activity. Um and yeah, it will just be more um systemic. So the malaise the fever, um they will just be a lot more unwell. Um, whereas with HPV, um they're fit and well in themselves, they're just, they've just got some bumps down there. Um So yeah, the investigations. Um so you can do a PCR test. Um, you can do some microscopy and you can do an S CS blood test to look at syphilis antibodies. Um, that's offered at all um sexual health clinics. Um, it's just a blood test that we do alongside the HIV test. So it, it's in the same bottle. Um, when we send a sample off for HIV, you can send it off for syphilis as well and the treatment is often just a 14 day course of IV Benpen. Um I think bash have now extended that to include procaine penicillin as well. Um Which is, I don't think that's very commonly used on the wards, but it is an option, um, or cefTRIAXone if they're um, penicillin allergic. Uh Yeah. Um I think this is the last infective condition. Um So this is molluscum contagiosum. I can't say that um, it's caused by the pox virus. Um And this one is quite a, um it's quite a distinctive appearance. So you get these um mollusca which are these kind of raised papules and they've got like, um so they're described as umbilic cases because it, it almost looks like they've got a little belly button in the middle. Um just like a dimple going in. Um They usually, so itchy. Um and actually they happen in mostly in Children under 10. Um So not always, um you know, not sexually transmitted or not related to sexual intercourse can just happen. Um Usually it happens um on other parts of the body as well. So not by any means limited to the genitals. Um And some of the risk factors for it is um atopic dermatitis. So, Children who generally have eczema sensitive skin, lots of allergies, they can get it. Um People in warm or humid climates, um Children who do a lot of swimming and things like that. Um So really, really common. Um It's a clinical diagnosis and if you really wanted to, you could do a biopsy but most of the time it's very obvious what it is. Um, and they go away on its own. Um, I think Children, it is infectious but they don't have to stay off school or anything like that. Um, and yeah, in very severe cases you can use, um, the same treatment that we use for warts. So, podophylotoxin or cryotherapy. Um, but again, that's if it's very, very distressing or kind of limiting the patient from doing things they want to do. Um But usually they go away. Oh, and this last one. So V in um stands for Vulval, intraepithelial neoplasm um or VA I which is vaginal or intraepithelial neoplasm. Um So these conditions, this in itself is not a virus, but I put it in the infectious bit because it can be linked to viruses. So um either HPV um HIV um because that immunosuppress you and increases your risk factor for HPV. Um And um having long term lichen sclerosis that will come on to lichen sclerosis in a bit. Um But yeah, essentially what it is is um changes in the uh squamous epithelium of the vulva. Um And there's sort of three stages. Um and the fourth stage is where it becomes an invasive cancer. So this is essentially um it's really similar to C in um when you think about like HPV causing cervical cancer, it's kind of the exact same pathophysiology. Um, it's just, it's in the vulva vagina, um, as opposed to the cervix, but same thing, um, that we're kind of looking at, it's important to do a biopsy to diagnose it. Um, often it's, it's very, um, what's the word? Um, it's very nondescript. So, just itchy, painful. It doesn't really feel right. Kind of hurts a bit. Um, you may get sort of this white fluffy, um, appearance where the cell changes is happening. Um One of the ways um you might pick it up is if a patient you knew they had HPV, um or they had like a long history of warts and things, they've not been vaccinated for HPV. And you might think, oh, actually they've got, you know, not feeling quite right down there. Um Some sort of white iffy skin changes. Um Actually this might be the in um so you do a biopsy and then um treatment is just with uh IIC mod cream um laser ablation or wide local excision. I think the excisions are more reserved for um stage two and three. But most of the time you can just reverse it um with the cream and then monitor them. Um So yeah, and then, ok, so those are the infections. So just a very quick um whistle stop tour um and some of the non infective conditions. So as with all sort of dermatology things, um if things that can happen anywhere on the body um can also affect the vulva and vagina. So there's, you know, there's no exception. Um things like eczema allergies. Um You know, if you can get it anywhere else, you can get it over there as well. Um So this is just how some common dermatological conditions might look um in the female genitalia. Um oh, and then also some ones which are specific to the genitals. So, um the first one is lichen sclerosis. Um This presents with sort of white scaly patches. Um I apologize, the picture isn't very good quality. Um But you get kind of this um skin atrophy and kind of a loss of architecture. So by that, we mean, um you can get adhesions. Um you can sometimes get um sort of fusion of the labia or fusion of the clitoris with the labia, things like that. Um And it almost kind of looks like I don't know how to describe it, but it almost, it looks like it's the vulva has essentially been worn down um just because it's so fused and you kind of lose the demarcations um between the different structures um in more severe cases. Um But initially, it just starts with this kind of white scaly patch. Um It's often um in like a figure of eight or an hour glass distribution. So um it, it never looks like that to me, but apparently in the picture, it's supposed to look like a figure of eight somehow if you squint. Um So yeah, uh it's really, really itchy, sore burning. Um It usually affects postmenopausal women. Um and it's essentially an autoimmune condition um which results in chronic inflammation. Um So, yeah, diagnosis is um with biopsy. Um it's really important to monitor this and treat this because it can lead to vi um and ultimately uh cancer. So uh important to keep an eye on it um because it is essentially just chronic inflammation, you treat it with steroids. Um So, clobetasone um or um tacrolimus, um also as a cream, um often just resolves it. The next one is lichen planus. Um This one is one of the more um sort of obvious ones. Uh So this affects the, so I should say flexor. So it affects the flexor surfaces and there's the six peas of lichen planus um pass me really, really like these six peas. Um I remember doing questions about this. So it's purple, it's planar, um it's polygonal, it's got these kind of edges. Um It's pruritic, very itchy, you get plaques and papules. Um and also um can be really, really itchy and can cause uh just perinea um which is pain during sex. So, um again, another autoimmune condition, um it may be activated by hepatitis C um as limited evidence. Um but anyone who has HEP C and then develops a rash like this, um you know, it can kind of increase your risk for it, I guess. Um to diagnose it. Um again, a biopsy and this usually resolves by itself in 6 to 9 months. Um That is a long time to live with such intense itching and uncomfortableness. So most patients who will just treat them. Um so topical or systemic steroids depending on the severity of it. Um And if there's no response to steroids, you might even consider light therapy um similar to what you do in psoriasis. Ok. Um The next one is Lichen Simplex Chronicus. Um And this is a type of neurodermatitis which affects the vulva. Um So you get these sort of dry scaly patches. Um So on this picture here, it's this section that we're looking at, that's the um affected section and you get this kind of um really thick leathery um ruga almost. Um So this is the sort of the inside surface of the Alaia my AA um should be quite um mucosal. Um Obviously, it is looking quite leathery there, quite uncomfortable. You might get some alopecia or broken hairs, um which is called brush sign because they're sort of the ends of the hair is thick and blunt, um a bit like a pink brush. Um And this is different from lichen planus because um if the skin is thick as opposed to atrophied um in this picture here, um you can see that it's quite um pronounced the reggae and the leatheriness of it. Uh sometimes um it can be clinically referred to as scrotal vulva because it does start to just resemble um the appearance of a scrotum essentially. Um So, yeah, and there's two types of uh lichen simplex chronicus. So it's either primary, which is where it's not triggered by anything, it just happens by itself, um or secondary, which is a lot more common, um which is uh in response to a scratch itch cycle. So people who have itchy conditions anyway, um things like um any of the other ones we mentioned, um you know, um cancer or uh eczema, things like that. Uh anything which makes an itchy down there. Um The repeated itching can just cause the skin to thicken in response and kind of um gain this texture. Um It can also be a neural mediated stimulus. So this can be in response to a neuropathy as well. Um So it's a clinical diagnosis. Um You may do a biopsy uh if you weren't sure. Um And then again, uh steroids can help but really the um the important thing is to just break that scratch itch cycle um and just help it calm down a little bit. Uh I think once you steroids help to thin the skin again, so it helps to break it down. Um And then breaking the scratch cycle, um kind of helps to ensure that it doesn't uh progress further. So, yeah. Uh and then psoriasis. So yeah, like I said, conditions which affect the whole body can also um affect the vulva. So that's no exception. Um But sometimes they do tend to look a little bit different um on the genitals. So, um on the um extensor surfaces. So like the mons pubis, um the er labia, um the psoriasis looks pretty similar to um other body parts. So just the scaly plaques quite silvery. Um However, um you can get inverse or flexural um psoriasis which is um on the inside surfaces, it sort of the, the gluteal cleft or the pudendal cleft. Um So just kind of in the creases essentially. Um And when it's in the flexures, it is um really red, um it's really angry looking, quite shiny and glossy. Um And that's because essentially they start off as silvery scaly plaques, but because these surfaces have a lot of friction, the plaques just get worn away and then there's just the sore um kind of new skin um underneath that's showing there. Um So, yeah, they're quite well demarcated, they're usually um symmetrical. Um and some of the risk factors for psoriasis. Um apart from just the normal um kind of what? So, obviously, as we know, it's um like an autoimmune condition, um you know, genetic factors, things like that um would predispose you to psoriasis. Um But yeah, also in the dental, specifically um colonization by bacteria or yeasts um or fungi like Candida um that can really um that can really um increase your risk factor for it or injury to the skin. Um So any trauma, um remember earlier, we talked about shaving rashes, um that can really exacerbate it. Um And it's something called co phenomenon or cob um which you may have heard of it's often a clinical diagnosis. Um and treatment is um the same as psoriasis anywhere else. So, topical steroids, Vitamin D analogs, um things like tacrolimus, the only difference is you do avoid light therapy. So, whereas for um other body parts, um light therapy can be useful with psoriasis. Um you tend to avoid it uh in the genitals. So, and the next one is dermatitis. Um So yeah, I'm just really conscious because ii know the pictures do look all the same after a while, but the dermatitis is um different in that. It's quite glazed and it's often quite um you can get like weeping from it so it can be quite wet to touch. Um It can be um really irritated with like excoriations and things. Um And it's also just the distribution um which um differentiate it from other conditions. So um it can extend quite far out. Um So as you can see, it's like covering the groin and the buttocks as well. Um So yeah, and then the cause is um most of the time. So 80% of the time it is uh contact dermatitis or irritant dermatitis. So, um things like soaps, um certain fabrics, vaginal washes, things like that. So it's really really important to ask the patient um in the history if they've done anything like that. Um We always just recommend all you need, you know, it's a self cleansing organon, all you need to do is just wash it with water. Um And you don't need anything fancy, um, different detergents can do it. Um It's really, really uncomfortable for the patient, but it is quite an easy fix. Um which is a good thing. Um So that's either contact with things or allergies. So this is um literally, it would be a type four hypersensitivity reaction. Um This includes things like eczema. So um just eczema affecting the groin um and the Flexeril um creases, um things like benzocaine perfumes, latex. So people with condom allergies can present like this. Um semen uh certain dyes uh so that can all do it as well. So helping um identify triggers and avoiding them um can help with this. Um So it's a clinical diagnosis usually in the history if they mention that they've used um whatever products, you know, bath bombs and things. Um And then they've got a rash like this. It's pretty obvious you kind of put two and two together. Um But you would always do an sti screen just to rule out other causes. Um usually using um sort of lotions and potions can cause um changes to your discharge and other changes as well. So, um really important to rule out sts there. Um So, yeah, so, like I said, um treatment is just reducing exposure, um avoiding whatever is irritating you. And um in cases where it's eczema um or uh allergies, sometimes uh topical corticosteroids and barrier creams and things can help. Ok. Um And the last one is a fixed drug eruption. Um So this is essentially just a um like an idiopathic course. Um It often, it often happens in uh in response to antibiotics. Uh The common one is uh Cotrimoxazole. Um which um we do sometimes give uh for uh either uti s or chest infections. So, um that can do it, nsaids, certain preservatives and like food colorings and stuff. Um And it is a type four hypersensitivity reaction. Um Yeah. Um So, yeah, essentially, you get this kind of non pigmented patch um with surrounding edema. So the borders you can see quite clearly there. Um It's flat, it's not um kind of bumpy or anything, it's literally just a color change. Um And it usually affects the mucosal surfaces. Um So you get this kind of, it's painful, it's itchy, it burns, um you can diagnose it with a biopsy or a patch test um just to kind of uh identify what the specific trigger is. Um And then it resolves very rapidly once the offending drug is stopped. Um So, yeah, and these drug eruptions um again, you can get anywhere on the body. So, yeah. And then the last um sort of subsection of this talk is just the ulcerative conditions. Um So these are um things, these are usually uh autoimmune um again, affect the whole body. Um But I just want to talk about how they present um on the vulva itself. The first one is beer's disease. Um So this is an autoimmune condition. It's characterized by um uh sort of a triad of dentinal ulcers, mouth, ulcers and conjunctivitis. Um The ulcers are um pretty superficial. Um They're usually quite um white, they usually um affect one side more than the other. Um And yeah, I think uh you would also get similar uh ulcers in the mouth. So, um when you're thinking about uh differentiating these kind of ulcers from perhaps um herpes, for example, um well, herpes also affects the mouth. Um But yeah, I think it's, it's kind of a, it's more of a clinical thing. So, looking at the patient's history, do they have a family history of autoimmune conditions? Um This is not necessarily linked to um sexual activity. So, you know, if they've got no sexual risk factors, um but they've got these kind of, um, you know, ulcers in the mouth and in on the vulva kind of looking a bit herpes. Um You might think, well, actually, do they have risk factors if not? Is it s um so, yeah, and it's diagnosed with blood and urine tests to look at the um rheumatological markers. Um There's something called a pathology test, um which is when, um, you sort of prick the skin and if it's positive you get a little red spot, um which is quite a hallmark for beer's disease. Um And the treatment is essentially with um steroids, immunosuppressants and biologics. Um So similar to uh lots of autoimmune conditions. Ok. The next one is Crohn's. Um, now, Crohn's disease can cause a, um sort of an expansive uh ulceration all throughout the gi tract. Um But also in the mouth, um, you can get like skin, skin tags around the anus. Um So lots of uh extraluminal manifestations as well. Um One of them is um, vulval ulceration and it's a very, very rare. Um When I was preparing for this talk, I looked at a study which said actually there's only like 300 recorded cases of it. Um But I just think it's really interesting. It's um because all the cases are quite similar. So you get these um, knife like ulcers which are quite line. I think that's the white arrow here. Um So, whereas we describe the ulcers as these kind of um, white, superficial um markings, this is quite, um, quite long, um, and almost quite rectangular, uh as opposed to the little circle. So that's what um differentiates it. Um And it's often missed because in a lot of cases, um patients present with these kind of vulval ulcerations first, um often years before they get the typical gi um symptoms of Crohn's so the change in bowel habits and, or the rest of it. So, actually, if a patient came to you with just this, I think it would be Crohn's would probably be very far down on your list. Um, but actually it's, it's quite an important one to consider. Um, so, yeah, and also just these excoriations and it's quite red, quite sore, quite painful. Um, you can do a biopsy, um, which would show um noncaseating granulomas. Um And the treatment is essentially just to treat the underlying Crohn's disease. Um So, you know, uh corticosteroids um to induce remission and then biologics and whatever um kind of regime works for the patient uh to maintain remission. Um I think that's usually quite um personalized um for every patient. But another thing you can add for vulval prone specifically is metroNIDAZOLE. Um And although this doesn't really have a bacterial component, but metroNIDAZOLE as well as being an antibiotic does have anti inflammatory and immuno on immunomodulatory properties, um which I didn't know. So it's quite interesting how you can kind of repurpose different medications and use them off license as well um to kind of treat some of the rarer conditions. Um And the last one, again, this is also quite rare. Um but this is something called Lipshultz ulcers. Um And this is essentially when an ulcer starts to get necrotic, it's acute, it's painful. Um You can see the kind of gray um darkened edges, um where the tissue is essentially necrosing and um this only affects the vestibule and the labia, my Nora. So only the mucosal parts of the vulva. Um It is quite nasty looking. Um But that's how you differentiate it from other conditions. So, if it's not spreading to the hair bearing parts of the vulva, um this would be one of your differentials. Um It's associated with uh generalized fever malaise. So lots of systemic symptoms. Um people can be very, very unwell with this. Um Usually there is a history of a viral illness. Um So 2 to 3 weeks before, which has gone away and then this kind of change has happened out of the blue. Um So like chest infections, gastritis, things like that. Um It's most patients are sexually inactive. Um So yeah, and there is a potential link um with EBV um to Epstein Barr virus. But I think that's not. Um there's some debate basically um about whether there's evidence to back that up. Um Diagnosis is usually clinical. Um usually a diagnosis of exclusion. So once you've ruled out your STIs s um your autoimmune conditions, things like that. Um And it is fairly treatable. So, um systemic corticosteroids um quite high dose. Um And then in the meantime, whilst the steroids are kicking in doing their job, um you can just give them some analgesia and some lidocaine gels, things like that. So, um and I think that's everything Um So that's just the references for some of the images um and the management plans there. Um Yeah, so hopefully, um it's been helpful and hopefully you're a little bit better now at identifying um some of the different conditions. Um And yeah, well, thank you so much. Has anyone got any questions while we're here? Um I'll just give a few moments for anyone to put those in the chart. Um And just a reminder as well, there will be a feedback form sent out. So if you could fill that in, very much appreciated with that, I don't think we've got any questions. Um, this was recorded tonight, so the recording and slides will be available if anyone, um, wants to go back and check anything. Um But yeah, thank you everyone for attending tonight.