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.