Derm-it Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-it Trotter! Don't Swear About Skincare.
Your Vulva Is Not High Maintenance. Your Routine Is.
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Most people were never taught how to care for vulvar skin, and online advice can be confusing or harmful. We sit down with Dr. Emily Murphy, dermatologist and director of a vulvar health program, to separate myths from facts and share a simple, science-based routine that actually works.
We break down anatomy (vulva vs. vagina), why different areas get different conditions, and how to simplify daily care: gentle cleanser only on hair-bearing skin, wash with hands, skip douching and wipes, and use plain petrolatum for barrier support. We cover hormones and low estrogen, causes of itch and irritation, common “normal” findings, when to worry, and why pelvic floor relaxation — not more kegels — is often key. Clear, respectful vulvar health guidance without fear or gimmicks.
You really just need a little bit of soap on the parts that have hair. So, like the mons pubis and the outer labia is really all you need soap on. And definitely don't need to wash inside the vaginal canal, like no douching, none of that. Just like so simple, you know, on medicines to suppress their hormones or have had their ovaries removed, um, or people on birth control pills long term, especially as you get older or like after having babies.
SPEAKER_01:And that's another thing you point out, people don't want to talk about itching, people don't want to talk about incontinence, myth busting or things that you can think about about, you know, vaginal or vulvar skin health or care that we could really make a difference for our listeners out there.
SPEAKER_00:Welcome to Dermot Trotter, Don't Swear About Skin Care, where host Dr. Shannon C. Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
SPEAKER_01:Welcome to the Dermot Trotter, Don't Swear About Skin Care podcast. We've got an amazing episode here today. I'm with Dr. Emily Murphy. She's a board-certified derm assistant professor at George Washington University, and she serves as director of the Volvar Health Program at GW. And for those of you that don't even know what that means, this means she is an expert in vaginal health. So welcome to the podcast. It's great to have you here, Emily. Thank you so much for inviting me. Of course. This is a topic I think a lot of women, and perhaps even men, are probably wondering like, wait a minute, what why is this even on a dermatology or a skincare type podcast? So I think that's something that I'm definitely going to have you touch upon. But first, I think people might even notice, like in the beginning, we talked about vulgar health. And this is something that I have patients even come in and look at me and say, what do you mean when you're even talking about my vulva? Like, what is that versus my vagina and kind of the confusion of the anatomy? Because I think just clarifying that would help people understand when we talk about, you know, health in that area, what are we even referencing?
SPEAKER_02:Yeah, absolutely. And it's so common when I do vulgar exams that oftentimes they'll have patients use a mirror and they love just like learning. And they'll always say, like, oh my gosh, I didn't know any of that. So I think it's so common that people just don't know. Um, the big difference is the vulva is the external genitalia. So that includes the mons pubis, which is the top, you know, hair-bearing surface, the outer lips and inner lips, which are the ladia labia majora and menora, and then includes as well as you go, you know, on the inside, the clitoral hood, which sits on top of your clitoris. It kind of like sits on top and you can retract the clitoral hood. Um, and then going down where the two labia connect, that's your posterior forchette. And then, you know, you move into the perineum and the anus. And then um internally, the the entrance to the vagina, that is still technically part of the vulva. We call that the vestibule, which in a vestibule of a building is like the entrance, right? So the the entrance is the vestibule, and then you actually go into the vaginal canal. So anything outside your vulva, once you move inside the canal, then you're in the vagina.
SPEAKER_01:That's super helpful because I think you're right, people don't know what that means, and they should have a comfort with it. But I think it's just one of those things, you know, it is the genital private area, so people are a little scared to maybe know about it or have never even thought looking in that area and using a mirror and showing people exactly what they've got down there, I think is pretty helpful. And it gives people that sense of comfort. You know, what might be surprising, like we talked about before, is the fact that we're even talking about it as dermatologists. And so I wanted to have you sort of explain, you know, a little bit of how this is skin, maybe, you know, what people might think of their normal skin or what we think of skin versus maybe mucosal skin and how we sometimes, you know, as dermatologists see conditions that affect both types of skin.
SPEAKER_02:Yeah. Yeah. And I think the hair can be a big clue. So, like the sort of normal keratinized skin on the outside, which has hair, is like the mons and the labia. And then when you go inside, that's sort of a modified mucosa, which is like your labia menorah and the vestibule. And then when you enter the vagina, that's where you get into pure mucosa. And those can definitely help you make diagnoses because there's certain conditions that will affect the actual mucosa, um, like lycan planus, erosive lycan plantus is probably the most common one that will actually extend into the vaginal canal and involve that mucosa. Whereas something um called lichen sclerosis usually affects more that modified mucosa. So we'll see it on the clitoral hood, the inner labia, and you know, at that posterior forchette where the two labia come together, and then loves to go on the perineum. So those two conditions can look really similar. So what type of skin you're dealing with can be really helpful. And then, of course, with certain conditions, you know, the hair can contribute. So we'll see them more on the outside, things like hydroadenitis separativa, or we see a lot of like folliculitis, you know, inflammation of the hair follicles, like those really won't involve the mucosa at all, but they'll be involving the hair-bearing outer skin. So I think it's useful to know those differences because diseases will present in different areas and it can help us be good diagnosticians.
SPEAKER_01:Yeah, because I think for a lot of people, they don't even realize that there's so many things that can affect that skin. And probably what one of the things they're thinking about most is, you know, well, I'm just trying to figure out how do I even care for my vaginal skin, right? Like, is it the same as, you know, the skin that's on my arm, or are there certain cleansers I should be using, or things to avoid? Or, you know, obviously there's things that are marketed to people out there to cleanse sort of the vaginal area. And I think it can be confusing on, you know, what's right and what's wrong. And, you know, do they even need a particular regimen to address skin in that area as well?
SPEAKER_02:Yeah, that's a huge point. And I spend a lot of time talking to patients about that. I think first thing to think about is like, I really don't recommend products marketed for vulva or vaginal skin because I do think one, they overcharge you. Um and two, they add all sorts of stuff in them. I don't know what it is. They're all like, they say they're organic, and that really confuses people because they think organic means good, but usually organic means they're putting a bunch of like plant-based products in. And I'm like, I don't know what any of these things are, but you don't need all of this. So, and then certainly like a lot of you know, creams, sometimes they'll include like anesthetics, like benzocaine, which can be, you know, really common cause of allergic contact dermatitis. So I really like don't recommend vulvar-specific things. Um, if patients come in really liking something, you know, as long as it's not irritating, I'm okay with it. But I like tell them to keep it really simple. Um, my spiel is that I say you really just need a little bit of soap on the parts that have hair. So, like the mons pubis and the outer labia is really all you need soap on. And I recommend just kind of gentle as soap. I usually just do like dove soap for sensitive skin. And then I say you want to use your hand to wash. So a lot of people are using washcloths to really scrub the skin. I'm like, nope, just use your hands, a little soap on the outside, and then really you should just be letting water wash down, and that is all you need. Um, some people, you know, as they get older and might have some like urinary leakage or, you know, patients who have eczema, they'll often like using a barrier or a moisturizer. And there's tons of things marketed to vulvar skin. But again, like I keep it simple. Like, if you want to do the most basic, just like plain Vaseline. There's some like other brands that I'll sometimes, for people who want like something a little more elegant, I'll recommend. But I don't think you can go wrong with just like plain Vaseline, especially if you're dealing with somebody that has eczema, maybe an allergy. Um, and definitely don't need to watch inside the vaginal canal, like no douching, none of that. Just like so simple. Um, and I think those are big things. I, you know, and oh, the other big thing is like wipes. I really counsel on like, yeah, like avoiding wet wipes. Um, you know, the best thing is toilet paper, just plain water. Um in that, you know, because wipes are so, so irritating. And those especially like again, they'll be labeled organic, sensitive skin. But there's been like article after article showing that even if they say sensitive skin, it does not mean it's sensitive. So I do a lot of counseling on that and like definitely pads, like if you're worried about allergies, I'll get into discussions of trying to use cotton pads. Really, tampons are probably the least irritating because they're just on the inside, they're not affecting the vulvar skin at all. But if you're gonna use pads, trying to use cotton ones. Um, so there's a lot of sort of nitty-gritty in caring for the vulva.
SPEAKER_01:And when you talk about, you know, from the standpoint of the vulvar skin, like the hairberry skin, and you mentioned kind of moisturizing with Vaseline. What about as you get toward, you know, the labia minora and more of that mucosal transition? People are complaining of dryness there. Is it something that you recommend to moisturize as well? And do you change up then your recommendation for that type of skin?
SPEAKER_02:Yeah, good question. So you can definitely still use Vaseline on the mucosal surface, so that's totally fine. If people are having a lot of dryness in the vulvar area and going into the vagina, that should kind of trigger an alarm bell for you as to whether you should be thinking of something we call genital urinary syndrome of menopause or atrophic vaginitis, which describes that when hormone levels change, and the name of genital urinary syndrome of menopause describes that most commonly we see this in menopause, but we can see it in women who are breastfeeding, women who are pregnant, um, certainly cancer patients who have had, you know, on medicines to suppress their hormones or have had their ovaries removed, um, or people on birth control pills long term. All of those people can have lower estrogen levels to the vulva. And so that can make the skin really dry and kind of pale, and you know, you lose that normal kind of like um rugated, kind of like wavy surface of the inner labya, and it just becomes really flat. So, in those cases, the best moisturizer is actually giving back estrogen. Um, so you can prescribe um and certainly ask your doctors about local estrogen. The the generic form is that is just called estradiol cream. It is really cheap. Um, and basically you can use that inside the vagina as well as on like that vestibule that we talked about, which is the entrance to the vagina, and that can just kind of plump everything up and moisturize. Um, so that's what I usually recommend. If people have dryness inside the vulva, I'll usually try estrogen cream. And most times in those patients, you know, you ask a history and you can figure out a reason that they have um the dryness, and it's so safe. You know, studies show that there's very little absorption. And even if there's a little bit of absorption, you know, the FDA recently removed the black box warning from estrogen related to cancer. So even if there's a little absorption, you know, it's very, very safe medicine.
SPEAKER_01:And if people are experiencing dryness, like we were talking about, along with it might come a little bit of itching. So I think that's something people are afraid to maybe ask about. And I know that can really um, you know, open a can of worms to the possibilities as to why they could itch. But what are some of the things, you know, if somebody comes in and says, I'm just itching like the dickens down there, can you help me? What do I need to do?
SPEAKER_02:Yeah. I think for my itchy patients, like the first thing I do is go through their routine. Because I would say like one of the most common causes is just like washing way too much, like really scrubbing the vulva, which can trigger a lot of like eczema. We call that irritant contact, dermatitis. So um, you know, I'll go through their routine and make sure I'm eliminating, you know, any kind of products, harsh soaps. People love dial soap in the vulva. Like, I don't know what it is. They have marketed that people think they need antibacterial soap. You don't. So a lot of like dial soap, a lot of, like I said, harsh scrubbing with a washcloth. So I'll go through washing routine a lot because that's a huge thing. Um, and there's other forms of eczema that can happen in the vulvar area. So um back to irritant contact dermatitis, I would say urine is another big thing to think about. So, especially as you get older or like after having babies, and that's another thing you point out, people don't want to talk about itching, people don't want to talk about incontinence. Um, so I take a really good urine history as well. And we're dermatologists, not that I'm gonna be able to solve it, but we can talk to them about like what pads to use, about using barrier creams, and we could refer them to our colleagues, you know, and urogynecologists who can kind of expertly address the urinary incontinence. Um, and related to estrogen, giving back estrogen helps with a lot of incontinence. So if you have a patient with incontinence, you might as well start some local estrogen because that can help a lot too. Um, so that's like irritant contact dermatitis. You will run into some patients with allergic contact dermatitis. So, again, you know, a history about are they using benzocaine there? Are they using neosporin, which is a huge cause? Um, are they, you know, what topicals are they putting on? Like, could you be concerned for like a preservative allergy? Like again, nitty-gritty about what they're using. Um, and then some patients really just have eczema of the vulva. You know, I think we're taught in medical school and residency, like, oh, eczema doesn't happen in the vulva because it's an occluded area that's well moisturized. But like I see it all the time. Um, usually they'll have itching that kind of turns into some localized lichen simplex chronicus where the skin gets really thick. Um, so those are probably the most common things. And then certainly, like, you know, if you're having itching, do see your doctor because there are, you know, more rare conditions, like I mentioned, like in sclerosis earlier, that can cause a lot of itching. So you definitely don't want to ignore it because one, it can be a sign of an underlying disease, and two, we can do things to help.
SPEAKER_01:And I think that can make people just feel reassured because it is something I know that can be embarrassing that people don't want to talk about or bring up. But to know as dermatologists, you know, we're a good starting point because that is skin, and of course, we're the experts in skin, and we can always help them get where they need to go, like you mentioned. I have a lot of patients that come in and they'll simply just ask you about and they've been brave enough to take a mirror and look in the vaginal area or the vulvar area, and they're looking around and they're just like, gosh, it just looks weird. There's a lot of hyperpigmentation, or I've noticed these little purple bumps down there, or you know, I've seen other skin lesions down there. I was gonna have you just walk us through some of the more common things that people might ask you about that are normal, you know, in vaginal skin in that area in the vulgar area, versus also some things that might be alarming too.
SPEAKER_02:Yes, yeah, good point. I think a lot of people look for the first time and they're like, wait, what is going on? So sometimes like my visits are easy. I'm like, nope, this is normal. Um, totally fine. So yeah, I think in terms of hyperpigmentation, um, the vulvar skin, a lot of people is just dark and that's okay. Um, especially in, you know, skin and color patients, but even in um lighter skin patients, it can still be dark and that's normal. I think the other um big thing, hyperpigmentation-wise, is there's something called um like labial melanosis or vulvar melanosis, where you know, they just get kind of asymmetric, really dark, um like brown and even like black sometimes patches, and it can look really scary, but it's just like a totally normal thing. Um, so that's hyperpigmentation. Certainly, you can get vulvar moles and they can look really funny. So that's where watching yourself with a mirror is really important and doing like your routine skin checks. Like we talk about, you know, doing monthly self-skin checks. Really, that should include looking with the mirror too, because you can then monitor your mole. Um, other things I think people don't realize is I get a lot of complaints about, oh, my vulva is really red. Um, the vulva has a ton of blood flow. And so redness is really normal. Like it just means that it's getting blood flow. And that can change a lot with like gravity, with activity, just depending on how you're sitting. Um, so that's really, really normal. So if you have a patient who's super itchy or is having pain even, and all you're seeing is like a little bit of erythema, that's probably normal. And so it might not be a skin problem. It might be like a deeper muscle problem with the pelvic floor muscles, or it might be a nerve problem. So I think redness, to me, I'm like, nope, I don't redness is good. That's fine. That's just your blood flow. Um, other things I think people, um, you mentioned the purple spots, those are angiokerotomas. Um, people hate them, but they're so normal. They're just like these little like um vascular growths. Um, we see them a lot in women with pregnancy because that pressure, just like, you know, the baby and all the fluids sitting on the vulva just causes, you know, pressure buildup, but they're very normal. Um we see a lot of vulvar cysts, you know. Again, people don't like them. They're normal, and absolutely, you know, your dermatologist or your OPGYN can remove those for you if you don't like them. Um other growth, um, warts. Um, a lot of warts. Um, so you know, in those cases, I always discuss, you know, the HPV vaccine. I discuss if they're up to date on cervical cancer screenings. I think those are really important. Um, and then, you know, just like we treat warts elsewhere, we we can treat them in the vulvar area. Um I think those are big, kind of benign. Oh, the other thing would be like Ford Eye spots. Like a lot of people will, when they do look, they notice like, oh my gosh, what are all these like small white dots on the labia? Like it's it'll be on the inner labia, the small lips, labia menorah. Like those are your normal oil glands. So common. Like, leave them alone. They're absolutely fine.
SPEAKER_01:I think you give people probably a lot of reassurance out there. They're probably wondering, I've been wondering what these spots are. Because again, I think that fear of like going in and being told it's something scary or dangerous holds people back. But just giving some reassurance that that skin is unique like anywhere else. And so it's prone to have a lot of just normal things that aren't really concerning can be a reassuring too. Probably the one thing though in everyone's mind that you know would be concerning is what about the possibility of developing skin cancer in that area? Because one, I think, you know, patients are astonished when I tell them that I will look in that area as a part of a skin check. Like I'm always surprised, and I have several patients that will decline. They'll say, Oh, my gynecologist looks there. I don't need you to check. And I said, Well, we're kind of looking for different things, but um, you know, I don't pressure them obviously if they would prefer me not to look. But we're looking there because you know, skin cancer is a possibility, although definitely not always a sun-exposed site for most, although some people do choose to expose everything when they're out at the beach or maybe in the tanning bed as well. We do tan nude in the tanning bed. But, you know, can you talk to us a little bit more about skin cancer in that area, what you see and what people should look for?
SPEAKER_02:Yeah, and that's amazing that you do look in the bulvar area because I think that's really unique. And I think you're absolutely right that we do need some more education because a lot of people have been declined for me. Like you would think, you know, I in my vulgar clinic, people, of course, don't decline, but I do see general dermatology patients too. And a lot of times they're like, no, I'm okay because they just don't want to take their underwear off. Um, so I think some of that is education of you know, broader patients too. Um I, you know, vulvar skin cancer is extremely rare. So I, you know, should people be like worried about it on a daily basis? Like, no, it's still not very common. Um, like it probably is just like a few percent of like cancers that women will get, but um, it can happen. Um, the most common type that we see is of um the squamous cell carcinoma um pathway. And the reason for that is because um you can get skin cancer from the HPV virus that causes genital warts. If you have a high-risk subtype, that can increase your risk of getting a skin cancer. So that's probably the most common type. Um and then a few chronic bulvar conditions, um lichen sclerosis and lycumplantis, I've mentioned them a few times, those could increase your risk for developing squim cell carcinoma too. So definitely if you have a risk of war, a history of wars, if you have a history of either of those conditions, definitely a reason for higher surveillance. So for my lichen sclerosis patients and lycan plantus patients, I tell them like for the rest of your life, someone's gonna be looking at your vulva every six months to once a year. I was like, once you stop seeing your OBGYN, you have to make sure you're seeing a dermatologist still. Because I think that's what happens is when people no longer get PAP smears, they stop seeing their OBGYN, but it's still so important. Um, so those are that's like the most common. And then after that would be melanoma, which, you know, is still very, very rare in the vulva area. And then you mentioned like sun-induced being less common. So next after that is basal cell cancer, which, you know, we see them. That's the most common type on the skin, but much less common in the vulva because it is a sun-protected site. And then there's this um rarer skin cancer called extra memory pageant's disease, which is probably the one of the harder ones to diagnose because it looks more like a rash. Like people don't think of it as a skin cancer. It really looks more like an inflammatory rash, which is again why it's so important to see a dermatologist because your point of we're looking at different things than OBGOA. And I think that's like such a rare and expert rash that you know we need to be the kind of people to diagnose it. And especially like melanomas, like our dermoscopy skills, like you know, we're gonna have the opportunity to look at pigmented lesions in a different light than OVGYN. So I think it's so important to see your OBGYN, but also, you know, see your dermatologist.
SPEAKER_01:And then the last few minutes we have, I just wanted to give you an opportunity to kind of hit the big highlights. If you could list, I don't know, maybe top three or five like myth busting or things that you can think about about, you know, vaginal or vulvar skin health or care that we could really make a difference for our listeners out there that would be like, huh, maybe like think twice about it. What would you say?
SPEAKER_02:So I think we talked about this a lot, but I think most important and probably common is that like you don't need vulvar specific products, like just use things that are gentle for the skin and don't overwash. Um, like get rid of your washcloths um because you really just need your hand to wash. Um, I think one thing I briefly mentioned was about your pelvic floor muscles. So I think one big myth is that you need to do like your kegels, um which, you know, kegels, what what's that top, what's that, what's that? Oh my gosh. What we're talking about is um that you kind of like are contracting your pelvic floor. But a lot of times when people have vulvar pain, it's actually due to the muscles being too tight. So kegels can actually worsen that. So we refer a lot to pelvic floor physical therapy where you're actually working on relaxing those muscles, you know, just like when you work, yeah. Yeah, when you work out and you have a sore thigh, right? It's because the muscle's too tight. It's not that it's too loose and you need to strengthen it. So kegels are really reserved for people who have urinary incontinence who you're trying to kind of strengthen that tissue around the urethra, but everybody else, it pretty much makes things worse. So I think don't do your kegels unless you are specifically told.
SPEAKER_01:A lot of people out there, because I think people are kegel excessed. I think they are.
SPEAKER_02:Yeah, yeah. And then if you already have a tight pelvic floor, you're just making things worse for yourself. So definitely if you're having pain in the vulva area, like see an OBGN, see a dermatologist, some of that can help. And maybe pelvic floor physical therapy is a good option for you. Um, and then I think the estrogen thing, I mean, honestly, like I think as dermatologists, we should feel very empowered to be able to prescribe local estrogen. Like, of course, I'm not talking systemic estrogen that comes with other things you need to think about, but local estrogen is very safe, very cheap. I think just learning how to prescribe that um is something that can help a lot of patients. And if you're a patient, just asking your doctor, you know, hey, I heard about this. Would I be a good candidate? Because I'm having itching, I'm having dryness. Um, all of that can be helpful.
SPEAKER_01:That's fantastic. Well, I really want to thank you for coming on the podcast today. I think, you know, our listeners out there are really gonna think of the revolver or vaginal skincare a little bit differently and really understand the role that dermatologists can play to help them. So thanks so much for sharing your expertise today. Yes, thank you so much for having me. Of course, and stay tuned for the next episode of Dermot Trotter Don't Swear About Skin Care.
SPEAKER_00:Thanks for listening to Dermot Trotter. For more about skincare, visit dermittrotter.com. Don't forget to subscribe, leave a review, and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
