What is VIN?

Vulval intraepithelial neoplasia (VIN) is a skin condition of the vulva.

VIN is divided into three grades of abnormality called VIN I, VIN II and VIN III depending on where the abnormal cells are within the skin layer.

In VIN I only a third of the cells in the epithelium (skin layer) are abnormal, whereas in VIN II, two thirds of the cells are abnormal and VIN III the abnormal cells are the full thickness of the epithelium.

What are the symptoms?

The symptoms vary from woman to woman. Some have no symptoms and the area of VIN is noticed on a routine visit to the doctor. Other women complain of vulval pain or itching which can be quite severe. Others have painful sex and some women notice a lump or thickening of the vulval skin.

How is VIN diagnosed?

VIN is diagnosed by taking a small biopsy of the abnormal area after inserting some local anaesthetic to the skin.

The biopsy is examined under a microscope by specially trained doctors called pathologists.

What causes VIN?

VIN is seen in women of all age groups. The exact cause is not known, but following factors are associated with it:

  • Human Papilloma Virus (HPV): High risk types (16 and 18) are associated most commonly with VIN. They can also cause abnormal cells in the cervix, anus and vagina.
  • Smoking: VIN is more common in smokers.
  • Immunosuppression: VIN is sometimes seen in women who are immunosuppressed due to medical problems such as HIV or on drugs causing immunosuppression.
  • Other skin disorders – VIN is seen in women who are affected by a skin condition called lichen sclerosus or lichen planus. This type is not associated with HPV.
Treatment options for VIN

There is not one type of treatment to suit all women with VIN and the treatment offered to you should be tailored to suit your needs.

You will discuss the treatment options with your doctor.

Factors to consider are the severity of your symptoms, the size and location of the area affected and your general health.


Adopt an ‘active surveillance’ approach

Many women with VIN do not have any treatment at all and are kept under regular review. This is often recommended for women with large areas of VINI and in women who have no symptoms. If you are pregnant this may be an option.

VIN can resolve spontaneously and so for some treatment may not be needed at all. A decision about treatment does not need to be made immediately unless there are concerns about a cancer.

Surgery

Removing the area aims to cure localised areas that cause symptoms. This may be necessary to remove a larger area of the vulval skin so that it can be examined under the microscope to exclude cancer development.

The disadvantages relate to having the surgery and recovery from the skin removal. For very large areas that need removal there can be distortion of the vulval anatomy and shape, but many areas of VIN that are removed heal without any serious scarring.

VIN can recur following treatment. As consequence many women will be put on long term surveillance following surgery.

Laser

Laser treatment involves burning the cells. This procedure is performed in theatre with the use of a general anaesthetic. This treatment is not currently offered at NCIC.

Topical treatment (Imiquimod)


How to apply the cream

Imiquimod cream should be applied before you go to bed and washed off the following morning (6- 10 hours later).

The 5% product is supplied as a box of sachets, each containing 250 mg.

Cut the top off the sachet or pierce the sachet with a needle and squeeze out a tiny amount of cream onto your fingertip. Using a mirror to identify the area to be treated, rub the cream in gently until it has vanished. Use just enough to cover the area and note this may not be the whole sachet. Wash your hands thoroughly afterwards.

Wash the imiquimod off the following morning gently using Diprobase or Cetaben on washable flannels or cotton wool to avoid spreading of the cream.

You may also use these emollients as moisturisers and avoid using soap or shower gel on the area during treatment as this can make irritation worse.

What to expect

Imiquimod is not an easy treatment to use because it causes inflammation. It also takes time to be effective.

You WILL get some or all of the following to some degree within 3 to 5 days of starting the treatment:

  • Redness
  • Wearing away of the skin
  • Flakiness
  • Swelling
  • Blisters
  • Tenderness

The skin reaction tends to be worst in week 2 to 3 of application. Typically, the more the inflammation, the better the outcome.

Rarely, the skin may ulcerate and get infected. If that is the case contact your GP and they can prescribe you some antibiotics. If the skin becomes too sore, reduce the frequency of using the cream. Take a break for one week and then re-start applying.

All symptoms decline in severity with less frequent use. Some women get ‘flu’ like symptoms such as headache, fatigue and occasionally diarrhoea. These symptoms clear within 2 or 3 weeks of stopping the treatment.

If the area is very sore flamazine can be prescribed by your GP and applied on a daily basis.

DO NOT have sex on the night you use the cream, even with a condom, as imiquimod weakens the latex of the condom. DO NOT take it by mouth or allow it to come in contact with your eyes. DO NOT share your cream with anybody else.

Other skin measures to take

Following general vulval care principles might help to soothe the vulval skin.

• Use Cetraben or Diprobase emollient cream liberally in between imiquimod treatments.

• Keep the Cetraben or Diprobase in the fridge and apply the cold emollient cream to soothe the irritation of the affected area.

• Maintain the usual care for vulval skin. For example, don’t use soap or wash underwear in biological powder. Use cotton undergarments.

If you need to visit your GP inform them of your treatment. Stop using imiquimod, if your reaction is severe and you are unable to tolerate it.

Further advice

We hope that you have found the information in this leaflet helpful.  If you require any further advice regarding any aspect of your care please do not hesitate to ask our specialist nurse on 07766 524805

Secretaries

Gynaecology or 01228 814217 or 01946 523219

Colposcopy 01228 814220

Useful websites for further information:

https://dermnetnz.org/topics/imiquimod/

http://www.medicines.org.uk/emc/ingredient/38/imiquimod

 

 

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