Letters to the Editor
Should Asymptomatic Bacterial Vaginosis Be Treated?
to the editor: The Information from Your Family Doctor handout regarding bacterial vaginosis1 in the May 1 issue states: "Some women have bacterial vaginosis without any symptoms.” It then poses the question, "Do I have to be treated?,” which is answered with an unqualified "Yes.”
Certainly there are indications to treat asymptomatic bacterial vaginosis: treatment is recommended in pregnant women at high risk for preterm delivery and women undergoing surgical procedures such as abortion and hysterectomy,2 for example; and, by extension, there are instances in which treatment is reasonable, such as prior to transvaginal procedures (e.g., intrauterine device insertion, endometrial biopsy).
However, except in the above circumstances, I am aware of no solid evidence-based recommendation for the treatment of asymptomatic women with bacterial vaginosis; treatment of asymptomatic bacterial vaginosis even in low-risk pregnant women remains controversial.2 Guidelines from the Centers for Disease Control and Prevention state that the "established benefits of therapy for [bacterial vaginosis] in non-pregnant women are to relieve vaginal symptoms and signs of infection and reduce the risk for infectious complications after abortion or hysterectomy.”2 Additionally, the natural history of bacterial vaginosis is such that it may resolve (and recur) spontaneously.3
It is hard to make an asymptomatic patient feel better; we should demand evidence before assuming that the benefits of diagnosis and therapy outweigh their burdens.
REFERENCES
1. Bacterial vaginosis. Am Fam Physician 2004;69:2193.
2. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78.
3. Joesoef M, Schmid G. Bacterial vaginosis. Clin Evid 2003;10:1824-33.
IN REPLY: We would like to thank Dr. Fox for calling our attention to this patient education handout. We agree that no evidence has shown that treating asymptomatic bacterial vaginosis improves patient outcomes. Accordingly, the handout did not advocate testing and treatment of asymptomatic women. Rather, its unqualified recommendation to treat was directed to women who present with symptoms that may be relieved by treatment. This patient education handout has been updated on our Web site (http://www.aafp.org/afp/20040501/2193ph.html).
Marjolin's Ulcer in Chronic Hidradenitis Suppurativa
to the editor: Hidradenitis suppurativa is a chronic inflammatory disease of the apocrine glands that most commonly involves the perianal, perineal, axillary, and inframammary regions.1 The etiology is poorly understood, with a genetic component, hormonal influence, and obesity being linked to the expression.2 Characteristic findings include dilated keratin-filled pores, scarring and sinus tract formation, malodorous discharge, and inflammation with secondary infection.3 Medical management consists of cleaning the areas, application of mild topical steroids with the concurrent use of systemic antibiotics,4 topical antibiotics,5 and intralesional steroids. Rarely, with chronic hidradenitis suppurativa, Marjolin's ulcer (a squamous cell carcinoma) develops.6 We report two cases of hidradenitis suppurativa in which squamous cell carcinoma developed after a latent period of 20 years and 35 years, respectively, despite repeated local excisions.
Figure. Ulcerative lesion over the left scapular region.
Case 1: A 51-year-old white man with a 35-year history of hidradenitis suppurativa presented with an ulcerated mass over the left scapular region (see accompanying figure). He previously had multiple local excisions. The entire mass was excised. After one month, the patient developed an abscess adjacent to the incision site, which proved to be squamous cell carcinoma on biopsy. Chemotherapy and radiotherapy were initiated. However, the tumor rapidly spread locally and a wider excision with latissimus dorsi flap reconstruction was performed. Unfortunately, the carcinoma spread rapidly to the axilla and neck, and the patient soon developed metastases in the lungs and spinal cord. He refused spinal decompression and died two weeks later.
Case 2: A 44-year-old black woman presented with a 20-year history of hidradenitis suppurativa involving vulvar, perianal, perineal, and inframammary regions. She had undergone more than 20 surgical procedures including skin grafts to ablate the disease. Examination revealed a large abscess at the level of the vaginal introitus and an extensive ulcerated fungating lesion involving the right labial crural fold. Her entire perianal region was ulcerated and scarred, and vaginal examination was not possible. Multiple biopsies were performed revealing infiltrating, moderately differentiated squamous cell carcinoma of the right labia, distal vagina, and urethra, with satellite lesions on the mons and right medial thigh.
Magnetic resonance imaging and computed tomography (CT) of the abdomen and pelvis revealed extensive bilateral inguinal, pelvic, and periaortic lymphadenopathy extending to a level inferior to the renal arteries. CT also revealed metastases of the squamous cell carcinoma to the right pubic bone. The patient continued to refuse operative management, instead opting for palliative high-dose radiation to control bleeding. She died from the carcinoma in six months.
Both of these patients presented with widespread metastases and a resultant terminal outcome. It would appear that a clear association between chronic hidradenitis suppurativa and squamous cell carcinoma exists. Because of the poor prognosis associated with squamous cell carcinoma, we advocate wide excision of hidradenitis suppurativa lesions when other treatments have failed and recommend biopsy of all suspicious hidradenitis suppurativa lesions.
REFERENCES
1. Slade DE, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg 2003;56:451-61.
2. Yu CC, Cook MG. Hidradenitis suppurativa: a disease of follicular epithelium, rather than apocrine glands. Br J Dermatol 1990;122:763-9.
3. Dictionnaire de medicine, un Répertoire général des sciences medicales considérées sous le rapport theorique [in French]. 2d ed. Paris: Béchet Jne., 1839:91.
4. Brenner DE, Lookingbill DP. Anaerobic microorganisms in chronic suppurative hidradenitis. Lancet 1980;2:921-2.
5. Clemmensen OJ. Topical treatment of hidradenitis suppurativa with clindamycin. Int J Dermatol 1983;22:325-8.
6. Lin MT, Breiner M, Fredricks S. Marjolin's ulcer occurring in hidradenitis suppurativa. Plast Reconstr Surg 1999;103:1541-3.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.
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Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
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