Inguinal and Genital Skin Problems

Essentials

• Most skin disorders can also occur in the inguinal and genital area.
• Good history taking and examination of other skin areas form the cornerstones of correct diagnosis.
• Histological examination is important if response to treatment is poor or a skin malignancy is suspected.
• Avoid overdiagnosis and treatment of Candida infections.

History and examination

• Many common skin disorders occur in the genital area that may be difficult to differentiate based on the clinical picture alone.
• Is there any history of skin disorders? Is there a family history of atopic eczema, for example?
• Does the patient have any diagnosed contact allergy? Has the patient reacted to skin care or hygiene products or haemorrhoid medication, for example? Recurrent or intermittent symptoms associated with topical treatment suggest an allergic aetiology.
• Are the lesions itchy (atopic eczema, allergic contact dermatitis)?
• Sex life; is a venereal disease possible?
• Does the patient have pain or general symptoms (infections)?
• Skin lesions should be examined close-up, too, paying attention to the following:
  • location (symmetricity, unilaterality, etc.)
  • other areas (scalp, other skin, nails, ears, etc.).
• Before seeing a doctor, many patients may have treated their symptoms with various prescription-free topical medicines, which may distort or complicate the clinical picture.

Nappy-age children

• Nappy rash is the most common condition. Round erosions (craters) may be present in severe nappy rash but erythema and papules are the usual presentation (picture ). Atopic dermatitis is not usually seen in the nappy area.
• Detecting yeast (Candida albicans) on the skin does not prove its causative role. In genuine candidiasis there are usually satellite lesions around a primary (severely affected) patch of confluent erythema (picture ).
• During the first months of life, seborrhoeic eczema may be fulminant in the nappy area.
• Ringworm (dermatophytosis) in the inguinal region of children is nearly always a false diagnosis (take a sample for culture!).

Adults

• Various types of eczema are most common.
• Women
  • The moist, warm environment in the area of the external genitals and the high permeability of the skin and mucosa predispose women to irritation and sensitization leading to irritant or allergic eczema.
  • Irritant eczema due to leukorrhoea, vulvitis (e.g. candidal vaginitis, bacterial vaginosis) Vulvovaginitis
  • Symptoms caused by physiological vaginal discharge (itching, burning and possibly slight erythema at the vaginal introitus and in the pudendal lips)
  • Irritation due to atrophic vaginitis (vulvovaginitis)
• Both sexes
  • Irritant eczema due to excessive washing (particularly with soap)
  • Intertrigo (erythema, maceration, sometimes itching in the groin and perianal area); due to poor ventilation, frequent use of panty liners, overweight, underlying diseases, sweating, friction, inadequate hygiene
  • Atopic eczema (slight scaling and itching, in chronic forms lichenification)
  • Seborrhoeic eczema Seborrhoeic Dermatitis in the Adult (pictures ; groin, perineum, anal cleft); clearly defined, erythematous, rather moist patches possibly with fissuring and maceration at the centre, no activity at the margin as in ringworm
  • Tinea cruris Dermatomycoses is common in men (pictures ), rare in women (pictures ).

Workup

• Samples for microscopy and fungal culture are required if ringworm is suspected.
• Keep in mind that yeast (such as Candida albicans) found by culture usually represents colonization. Candidiasis is overdiagnosed.
• Bacterial and fungal culture results should be interpreted critically. Contamination and colonization are common.
• Blood glucose should be determined as necessary to exclude diabetes.
• If there is vaginal or urethral discharge, chlamydial and gonococcal samples should be taken (detection of C. trachomatis and N. gonorrhoae nucleic acid in urine).
• In the case of vulvovaginitis or irritant contact dermatitis due to vaginal discharge, yeast culture or microscopic examination (to examine yeast, Trichomonas and clue cells) can be performed.
• It is important to take a biopsy of the rash area if the diagnosis is not clear, if response to treatment is poor or if you wish to exclude the possibility of a malignant skin lesion.
• Histological examination is useful if you suspect psoriasis of the skin, lichen sclerosis et atrophicus or lichen ruber planus, as each has specific histological features.
• If the lesion is unilateral, weeping and poorly healing, it is important to exclude malignancies of the skin, such as carcinoma in situ, genital carcinoma or Paget's disease.
• Epicutaneous tests may be indicated if allergic contact dermatitis is suspected.

Treatment

• Good basic care should be used to prevent irritation (avoiding strong detergents, irritating topical care products and tight synthetic underwear, and regular use of non-medicated ointments).
• Moisturizing non-medicated ointments or skin care oils should be applied to the genital and perianal skin. Too frequent washing and use of soap should be avoided.
• Causal treatment, if possible (e.g. patients with irritant contact dermatitis should reduce the use of tight clothes and panty liners and stop epilation, and patients with allergic contact dermatitis should avoid the triggering factor)
• Ringworm of the groin is treated with topical terbinafine for 1-2 weeks or an azole preparation for 3-4 weeks. In a severe case that reaches deep into the hair follicles, the topical drug is combined with systemic drug therapy for a period of 1-4 weeks Dermatomycoses.
• Irritant contact dermatitis and intertrigo can be effectively treated by applying a powder (e.g. talc or miconazole powder) or zinc oxide paste in the morning after washing; in the evening, after washing apply an extemporaneously compounded mild glucocorticoid ointment mixed with sulphur (prescribe: hydrocortisone 1.0%, medicinal sulphur 2.0%, make up to 100.0% with non-medicated ointment), as necessary.
• In eczema, the treatment of first choice is mild topical glucocorticoids intermittently in courses of 1 to 2 weeks, for example. If necessary, you can prescribe extemporaneous addition of 2 to 3% of sulphur, e.g. 2.0% medicinal sulphur made up to 100.0 g with non-medicated cream.
• Topical calcineurin inhibitors (tacrolimus and pimecrolimus ointments) are also quite effective in the treatment of atopic eczema, often also other types of eczema and genital psoriasis.
• Mid- to high-potency (Class II-III) glucocorticoid ointments in courses of, for example, 2 to 3 weeks are needed to treat neurodermatitis and lichen sclerosus et atrophicus. In cases that are extremely difficult to treat short courses (e.g. 2 to 3 weeks) of superpotent (Class IV) glucocorticoid ointments applied once daily at night can be prescribed.
• Not all products meant for the treatment of psoriasis can be used for psoriatic lesions in the genital area; primarily low- to midpotency (Class I-II) glucocorticoid ointments should be used for topical treatment.

Pictures

Specialist consultation

• A dermatologist should be consulted in cases of severe genital eczema resistant to treatment.
• Epicutaneous tests should be performed if allergic contact dermatitis is suspected.
• If gynaecological causes are suspected, a gynaecologist should be consulted.