Thursday, May 16, 2019

Extensive Pruritic Vulvar Plaque in an 84 year old Woman

An 84-yr-old woman presented with a pruritic vulvar plaque for more than a year.  It was increasing in size extending from the vulva to the surrounding areas. She was otherwise well and did not have any constitutional symptoms such as fever or weight loss. She had seen few doctors and a gynaecologist but did not improve. She was treated with topical fucidin cream, clotrimazole cream and moisturisers. Her past medical history was insignificant.  She is a housewife.

Examination showed an irregular asymmetrical extensive erythematous plaque on the vulva extending to the suprapubic, groins, perianal areas and anus.  Some of the lesions on the periphery appeared hyperpigmented and nodular.  Her regional nodes were not enlarged.

Diagnosis: Extramammary Paget Disease

Differentials needed to be considered included Bowen disease and malignant melanoma

A skin biopsy was done and pending results.  She may need assessment of other malignancy eg urological or gynaecological cancers.

Treatment could be challenging as the plaques are so extensive.  Surgical excision probably not advisable at her age  - may need multi disciplinary surgeons eg O & G, urologist, plastic and colorectal surgeon. Not sure about role of radiotherapy but am starting her on topical imiquimod cream every other day.




3 comments:

  1. Khalifa Sharquie wrote: Yes this is Paget’s disease of genitalia.I do not advise any surgery that would be extensive and the patient will not tolerate it.I usually treat by topical 25%podophyllin but it is not justified in this patient as it is very extensive lesion.

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  2. Dr. Bhushan KumarMay 23, 2019

    Diagnosis is Extra Mammary Paget’s Disease. The lesions are too extensive to respond to Podophyllin or Imiquimod. Excision is impractical. Radiation is the only alternative.
    All this only after the whole body scanning has ruled out any malignancy anywhere else.

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  3. From Dato Ong Cheng Leng: Yes, it’s most likely Extra-mammary Paget’s disease with the differential diagnoses of Bowen’s disease and to rule out melanoma.

    But discussing among learned dermatologists is incomplete. Once the histopathology is confirmed, may I suggest Dr Henry inviting his local consultants to a combined consultation clinic, consisting of a general surgeon, radiotherapist, and oncologist with the patient as the centre of attention, besides the dermatologist himself of course.
    Each of these colleagues has a mind of his/ her own, let all discuss, brainstorm, spar, volunteer self or others, to work out the best steps to this big problem at hand. Chinese proverbs says, the combined wisdom of three common workmen can be better than 诸葛亮 ( the wisest war strategist in the tale of three warring countries)
    You will be surprised.

    ReplyDelete

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