133. Vulvar Psoriasis in a Young Renal Transplant Recipient

Background Vulvar psoriasis is more common in the pediatric population than in adults. Isolated genital psoriasis occurs in 2-5% of all patients. Psoriasis has been noted as a skin manifestation in renal transplant recipients. It is important to consider psoriasis in the differential diagnosis in children with renal transplant and signs of vulvitis. Case We review a case of vulvar psoriasis in a 12 year old female with Senior-Loken Syndrome status post renal transplant at age 2 on immunosuppressants. She had a history of facial atopic dermatitis but no psoriasis. Patient presented with vulvar erythema without any pruritus, abnormal discharge, or pain. The exam noted marked erythema with sharp borders around introitus and labia minora, extending to perianal area, without ulcers, fissures or satellite lesions (Fig.1). Pediatrics and Dermatology treated her for many months with courses of hydrocortisone, clotrimazole, desitin, and aquaphor for diaper dermatitis without resolution. In the setting of persistent erythema and obtaining multiple positive cultures for group B streptococci (GBS), Pediatric and Adolescent Gynecology made a presumptive diagnosis of GBS vulvitis. It was noted GBS could have also been part of normal vaginal flora and response to antibiotics was followed closely. Given the persistence of erythema despite antibiotics, we suspected an underlying inflammatory process. Use of topical tacrolimus led to rapid and marked improvement in vulvar erythema. Biopsy was considered but deferred due to clinical improvement and patient reluctance. After cessation of all treatment during hot and humid travels abroad, she re-represented with a more clarifying clinical picture. Her exam revealed erythematous and violaceous lesions extending from the mons pubis to the anus and the thighs, satellite lesions extending to abdomen and thighs and distinctive patches of scaly lesions all consistent with the diagnosis of vulvar psoriasis (Fig.2). Patient resumed and remains on maintenance topical tacrolimus 1% daily for vulvar psoriasis. Comments This is the first reported vulvar psoriasis in a child with a renal transplant. Her presentation was confounding as she had the classic bright red clear demarcation of bacterial vulvitis, but never experienced pruritus, discharge, or pain. This persistence of vulvar erythema in a medically complex patient may have been initially attributed to GBS but was more likely exacerbated by or representative of vulvar psoriasis from the onset. Biopsy would have helped differentiate between infection vs psoriasis. We encourage physicians caring for renal transplant patients to be aware of the higher risks for skin conditions including psoriasis.