Lindsay Wilson, MD discusses highlights from her lecture Vulvar Diseases on Saturday, November 5, 2022 at the PA/NP Elevate-Derm Conference in Tucson, Arizona.

In this video

Dr. Wilson explains how she makes an uncomfortable exam feel safe: she takes the full history with the patient fully clothed, steps out, then works from the scalp down — checking eyes and mouth for clues before examining the vulva. Many of these patients have seen multiple providers, so she wants to give them a sense of safety and a thorough, unhurried approach, and she gives out her cell phone number for emotional reassurance even though patients rarely use it.

On biopsies, she urges providers to "stop doing punch biopsies" and stop placing sutures to close them. Because vulvar skin is thin and peels up, she places a suture (usually proline, but whatever's on hand) in the target area, lifts up on it while cutting around the lesion with curved iris scissors, and takes a broad but shallow shave. The tissue stays intact for the dermatopathologist, and the site heals faster with less pain. Aftercare is simple: petrolatum, gentle pressure if bleeding, and avoiding harsh chemicals and soaps. She also addresses lichen simplex chronicus (LSC), which she says is often unrecognized, and favors a compounded gabapentin mixed with menthol — calming the nerves and tricking them out of itch — available for about $30 and used four to five times a day.

  • Build trust first: take the history fully clothed, then examine head-to-toe before the vulva to give anxious, previously-seen patients a sense of safety and thoroughness.
  • Skip the punch — use a "stitch, lift, and snip" technique: place a suture in the lesion, lift as you cut around it with curved iris scissors for a broad, shallow shave that keeps tissue intact and heals faster.
  • Keep aftercare simple: petrolatum, hold firm pressure if bleeding, avoid harsh soaps and chemicals, and let intercourse resume when the patient feels ready (unless the site is in the vestibule).
  • For LSC, break the itch-scratch cycle first, then consider compounded gabapentin with menthol — antipruritic, soothing, ~$30, and well tolerated up to four or five times a day.
  • Test menthol tolerance first with an over-the-counter menthol product before compounding it into the gabapentin.