Vulval disease in HIV-positive women attending a tertiary vulval dermatology clinic over a five-year period

Abstract

There is a paucity of data on vulval disease in HIV-infected women. We describe the spectrum of vulval disease in HIV-infected women attending a tertiary vulval dermatology referral centre over a five-year period. Seven vulval conditions were identified in 14 women. Most were attending for HIV care (n = 12, 86%), and on combined antiretroviral therapy (CART) with a CD4 cell count above 200 cells/µL (n = 9, 64%) at diagnosis. Imiquimod therapy was effective in treating undifferentiated vulval intraepithelial neoplasia (uVIN) – the most common diagnosis. There were no cases of invasive vulval carcinoma. Hypertrophic herpes simplex virus occurred in one woman stable on CART with good immune reconstitution. Clinicians should be vigilant about the spectrum of vulval disease in HIV-infected women and consider genital examination as part of routine care.

Keywords

Women human papillomavirus herpes simplex virus human immunodeficiency virus HIV AIDS dermatosis VIN

Introduction

Studies have shown that HIV-infected women have an increased risk of vulval intraepithelial neoplasia (VIN) and invasive vulval carcinoma,^1–4 and atypical herpes simplex virus (HSV).^5–7 We describe the spectrum of vulval disease in HIV-infected women presenting to a tertiary dermatology referral centre. Referrals to the centre are mainly received from the HIV and genitourinary medicine (GUM) service.

Case series

A case note review of all HIV-infected women attending the vulval dermatology clinic at St. John’s Institute of Dermatology, St. Thomas’ Hospital, London from January 2007 to August 2012 was performed. Cases were identified retrospectively from the clinic database. Data collected included: demography, date of HIV diagnosis and subsequent follow up, vulval diagnosis including histology and microbiology results and management.

We identified 14 HIV-infected women with seven vulval conditions over a five-year period (Table 1). Twelve (86%) were black Africans. The median age at diagnosis of vulval disease was 37 (range 24–57) years. At the time of vulval disease diagnosis, 12 (86%) were already known to be HIV-infected; of these 11 (92%) were on combined antiretroviral therapy (CART), and 10 (83%) had a viral load (VL) <400 copies/mL (3, 25% had VL <40 copies/mL). The median CD4 count at presentation of vulval disease was 491 (range 24–826) cells/µL, with only three women (21%) having a CD4 count <200 cells/µL.

Table 1.

HIV-positive women seen in vulval dermatology clinic, January 2007 to Aug 2012.

Vulval diagnosis		At time of vulval diagnosis			Treatment
Vulval diagnosis		On ART	CD4 (cells/uL)	VL copies/mL	Treatment
1	Multifocal uVIN	N/A	N/A	N/A	Imiquimod
2	Multifocal uVIN	Yes	761	235	Imiquimod
3	Multifocal uVIN	Yes	479	97	Imiquimod
4	Lichen simplex	Yes	502	366	Topical clobetasone butyrate
5	uVIN	N/A	N/A	N/A	Imiquimod
Lichen Simplex	N/A	Topical mometasone furoate, betamethasone
6	SCC in situ (outer aspect labium majus/inguinal fold)	Yes	268	<40	Complete excision
7	uVIN	Yes	318	71	Imiquimod + excision
8	Chronic hypertrophic HSV-2	Yes	590	<40	Oral aciclovir, famciclovir, valaciclovir; foscarnet gel, cidofovir (gel, intravenous)
9	Multifocal uVIN (of Bowenoid type)	Yes	826	88	Complete excision
10	Recurrent HSV-2	Yes	784	63	Oral aciclovir
11	Eczema	Yes	62	30441	Topical betamethasone diproprionate, clotrimazole
12	HPV condylomata	Yes	103	55
13	uVIN	Yes	716	<40	Imiquimod
14	uVIN	No	24	215000	Imiquimod

Eight women (57%) had undifferentiated vulval intraepithelial neoplasia (uVIN) and one (7%) had squamous cell carcinoma (SCC) in situ on the right outer labium majus at the inguinal fold. In patients with uVIN, there was resolution with imiquimod within a median of three months (range three to five months) except in one non-adherent patient, and one patient receiving ongoing therapy.

Two women (14%) had HSV-2 despite having good immune restoration on CART; one had recurrent HSV-2, whilst the other had chronic hypertrophic HSV. The latter required treatment with multiple antiviral agents including intravenous cidofovir, foscarnet and cidofovir gel. Nine (64%) women remain under regular dermatology clinic follow up.

Discussion

In this study, most women with vulval disease were already under HIV care, on CART and had a CD4 cell count above 200 cells/µL. The low number of patients may be due to management within the GUM setting, with referral limited to patients with persistent symptoms or complex disease. Atypical chronic HSV ulceration can occur in chronically virologically suppressed and immunologically restored patients,⁸ as demonstrated by case 8. The most common diagnosis was uVIN, but there were no cases of invasive vulval carcinoma in this small series. Imiquimod was effective in treating uVIN in HIV-infected patients. A combination of surgical treatment and post-operative imiquimod has been shown to be effective in treating HIV-infected women on CART with multifocal Bowen’s disease.⁹ It is possible that immune activation due to HIV infection may enhance the response to imiquimod therapy in HIV-infected individuals.

Our study demonstrates the spectrum of vulval disease in a tertiary referral clinic, although limited by small numbers. Clinicians should be vigilant about the spectrum of vulval disease in HIV-infected women and consider genital examination as part of routine care, particularly to detect early VIN. This could be performed annually with the cervical smear.

Conflict of interest

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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