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Thank you for the opportunity to reply, here is our response.
We would like to thank the authors for their valuable comments, we believe that these comments add to and complement our article. Our article aimed to cover a wide breadth of common gynaecological conditions that can affect children and unfortunately we were therefore not able to go in to great detail for each condition covered. We would certainly agree on the importance of an early diagnosis for lichen sclerosus and collaboration with a dermatologist for treatment if available. The British Association of Dermatologists guidelines for the management of lichen sclerosus was not published when we wrote our article, we can see that this is a very valuable resource.
We read with interest the review on ‘The paediatrician and the management of common gynaecological conditions’ (1). This is an important topic but we have concerns about incorrect information in this paper with respect to vulval disorders. Most vulval conditions are dermatological rather than gynaecological and the involvement of a dermatologist in the management of these children is vital. The breadth of paediatric vulval disease is not reflected in this paper including the concept of vulval presentation of various skin conditions (eg. psoriasis, chronic bullous dermatosis of childhood, erythema multiforme) and the need to examine the rest of the skin including the hair, nails and mucosa.
There appears to be some confusion within the article, for example, a vaginal discharge is not a vulval disorder. While a discharge can lead to a vulvitis, the two problems of vaginitis and vulvitis should be distinguished as the investigation and management of each is very different.
The commonest condition seen in children presenting with vulval symptoms is an irritant dermatitis which is not specifically mentioned in the section on vulval irritation. This is often seen in those with a background of atopy and requires emollients and a mild topical steroid application intermittently with good hygiene measures. Other important disorders such as Lipschutz ulcers and genital warts have been omitted.
However, our major concerns relate to the section o...
However, our major concerns relate to the section on lichen sclerosus (LS). This is an important condition which is often under-recognized or with significant delay in diagnosis. The references used are old and not original. The major symptom is itch which is not always synonymous with irritation. One of the frequent presenting symptoms of LS in children is constipation which again is not mentioned. LS should always be treated, even if asymptomatic as it is a disease that can lead to permanent anatomical change with functional sequelae. Detailed guidelines for the management of LS have been published recently (2) and were agreed by the Royal College of Paediatrics and Child Health in the consultation process. All the evidence shows that a 3 month induction regimen of an ultra-potent topical steroid is the first line treatment (3). Thereafter, the management is individualized to maintain control of symptoms and signs (4). The management outlined in this review is incorrect and gives the wrong message. It should be corrected as otherwise it will lead to undertreatment and its potential consequences. As with all vulval disorders, these children should be under the care of those experienced in the management of this condition and should receive dermatological input as part of the multi-disciplinary team.
FM Lewis MD FRCP, St John’s Institute of Dermatology, Guy’s & St Thomas’ Hospital, London
SS Velangi FRCP Queen Elizabeth University Hospital, Birmingham
SM Taibjee MB BCh BMedSci MRCPCH CCT Derm DipRCPath (Dermatopathology) Dorset County Hospital, Dorchester
1. Ritchie JK et al. The paediatrician and the management of common gynaecological conditions. Arch Dis Child 2018;108:703-6
2. Lewis FM Tatnall FM, Velangi SS et al. British Association of Dermatologists guidelines for the management of lichen sclerosus, 2018. Br J Dermatol 2018;178:839-53.
3. Mashayeki S, Flohr C, Lewis FM. The treatment of vulval lichen sclerosus in prepubertal girls: a critically appraised topic. Br J Dermatol 2017;176:307-16.
4. Ellis E, Fischer G. Prepubertal-onset vulvar lichen sclerosus: the importance of maintenance therapy in long-term outcomes. Ped Dermatol 2015:32:461-7.