The Elderderm: Episode 5, Deep and Dutiful Dialogues About Down Below

It's paramount to give vulvar health the attention and airtime it deserves (yes, we are coming out of the gate strong!) On this episode of the ElderDerm podcast, co-hosts Drs Jaya Manjunath and Adam Friedman welcome Dr Emily Murphy, assistant professor of dermatology, associate residency program director, and co-director of the Vulvar Health program at GW SMHS, for a focused, no fluff conversation on vulvar dermatoses in older adults. From the underdiagnosed to the misunderstood (think lichen sclerosus, vulvar atrophy, chronic irritation), we break down the barriers to better care through clinical pearls, real-world strategies, and frank discussions. Because when it comes to quality of life, this isn't niche, it's necessary.

Transcript:

Dr Friedman: Welcome back to the Elder Derm Podcast. I'm your co-host, Dr. Adam Friedman, professor and chair of dermatology at the GW School of Medicine and Health Sciences, and I'm joined by my partner in crime, almost-a-doctor—don't grow up— Jaya Manjunath. Thank you for being here, founder of the Elder Derm Conference.

We are here to welcome our second guest, Dr Emily Murphy, assistant professor of dermatology here at GW, and co-director of the Vulvar Health Program.

Correct me if I’m wrong, but I think this is one of the few GYN-derm shared clinics within several hundred miles of Washington, DC. And as no surprise, we’re going to be talking about vulvar health—especially as it relates to the elderly. Welcome, Dr Murphy.

Dr Murphy: Thank you and thank you so much for having me.

Dr Friedman: Absolutely. This was a no-brainer, right, Jay?

Dr Jaya Manjunath: Absolutely.

Dr Friedman: Let’s dive right in. First question—and probably a very relevant and pointed one—how on earth did you get interested in this unique and underserved area in dermatology?

Dr Murphy: Yeah, it’s a great question. I think all vulvar derms are asked this. A lot of us share a common story: we wanted to go into OB/GYN. That was the plan for me throughout med school. I loved women’s health—it just made sense.

So, I thought, "I'll be an OB/GYN." But when I got into my third-year rotations, I realized, one, I didn’t like delivering babies.

Dr Friedman: Requisite, I think.

Dr Murphy: Yeah. So, I thought, "I’ll just be a gynecologist, that’s great." Then I thought, "Okay, maybe a urogynecologist." But then I realized they’re surgeons, and I didn’t love the OR. I like little procedures, but not being in a case for 10 hours. Things weren’t adding up, but I was still like, “You know what? I love women’s health. I’ll figure it out.”

Then I did a derm rotation pretty late in my third year—this was at Georgetown, where I went to med school—and I learned about a vulvar derm who graduated from Georgetown, Melissa Mauskar. She explained this rare subspecialty of vulvar dermatology, and I was like, “Oh my god, that’s perfect.” So, I totally switched paths and went for dermatology. During residency, I focused on learning derm, but I knew that ultimately I wanted to specialize in vulvar derm. And here we are.

Dr Friedman: And that you are. I think a helpful lesson for those listening is about developing your brand and visibility out of the gate; in the way you structure your clinic. You have reserved slots for vulvar health referrals—patients who need more time. Kudos to you for that; it’s a great way to establish yourself and show your interest.

But beyond clinic structure, you’re doing a shared GYN-derm clinic. How do you even do that? And how do you see it adding to the experience of what you’re already doing?

Dr Murphy: Yeah, it’s a really unique thing. Even where I did my vulvar derm elective, creating a specialty clinic was a long-term goal. It’s hard to do, so the fact that we’re doing it quickly is amazing.

I think it’ll be especially great for complex patients, where we can bring different perspectives to the table. As dermatologists, we’re experts in skin and visual diagnosis, and creative with medications. Vulvar derm has maybe one on-label medication for psoriasis. So, we’re used to thinking outside the box.

OB/GYNs, on the other hand, are surgeons. They can do more complex procedures and are very creative with things like Botox for pain. In derm, we know Botox, but I haven’t used it for pain. They’re also better at managing the pain aspect, which is a huge component. Even if a primary condition triggers a pain syndrome, it’s often comorbid.

Having both specialties in the room elevates patient care. Plus, being able to discuss cases live is invaluable. I have a text chain with two vulvar derm attendings from UChicago and Northwestern, and we’re constantly sharing photos and cases. Having that real-time feedback is going to be amazing.

Dr Friedman: Just make sure not to have your phone out at dinner. Words of wisdom from a former mentor.

Dr Murphy: I know! My husband’s always like, “I can’t look at your phone anymore—it’s all crazy rashes or vulvas.”

Dr Friedman: Good plan.

Dr Murphy: Not great.

Dr Jaya Manjunath: Yeah. So, I wanted to ask—what does the day-to-day clinic look like with you and the OB/GYN attending? What's the clinic flow like?

Dr Murphy: To be determined! I may need to come back and give an update. We're planning our first clinic next month. The plan is to see 6 patients. We’ll go in together, talk with the patient, leave to discuss the plan, then go back in.

We're modeling a lot after our rheum-derm clinic, but what’s unique here is the patient comfort factor. In-room derm may have 10 people walking in at once, and that might not work for vulvar patients. We’ll have to work through that and budget around it. But it’s very exciting, and I’ll update you after we try it out.

Dr Friedman: Way to invite yourself back there.

Dr Jaya Manjunath: That is so exciting thanks for sharing that with us. Just on the note of conditions you see, I’m curious: what are the more common conditions in the older adult population that we should be aware of?

Dr Murphy: Definitely lichen sclerosus. The classic teaching is that it presents in kids or elderly patients—which isn’t entirely true; you can see it at any age—but we do see it more commonly in older patients. I had two patients today with lichen sclerosus, both in their seventies.

We also see a lot of irritant contact dermatitis. You have to consider urinary health in older patients. In younger patients, a common trigger might be pads, but in older patients, urinary leakage is a huge issue, and we see a ton of that.

The other big one is lichen simplex chronicus—where patients are itchy for whatever reason. It could be due to an atopic phenotype or an irritant contact dermatitis that triggers chronic rubbing, leading to thickened skin. Those are definitely the three hot topics in my clinic.

Dr Jaya Manjunath: Got it.

Dr Friedman: So as we think about different patient populations, common conditions can present differently—especially in the elderly—given skin changes, location, comorbid diseases, and medications. There are unique challenges to keep in mind.

When evaluating and managing vulvar dermatoses in elderly patients, what are some of the more common issues you face?

Dr Murphy: One big thing I’ve noticed is discomfort talking about it. Some younger patients are more open, but elderly patients often see it as a very private issue. They may not even share their symptoms with their spouse.

And many times, vulvar dermatoses involve itching or pain, which can make sex painful. These patients may not feel comfortable discussing that with their partners, so we often need to have long, supportive conversations to encourage openness and empower them to advocate for themselves.

Another challenge is applying the medication. They may have trouble reaching the area or even seeing it clearly. So, we do hands-on teaching: I have them hold a mirror in front of their vulva, and I use a Q-tip to show them, “You put it here, here, and here.”

There’s also a lot of topical steroid phobia in this age group. And when we do see steroid-related side effects, it’s usually because patients are using too much. So, we need to spend time explaining exactly how much to use and where.

Another big issue is how people care for their vulva. Older patients may use harsher soaps, washcloths, and vigorous scrubbing—practices that can worsen conditions like lichen sclerosus or lichen simplex chronicus.

We dive deep into hygiene routines: What kind of soap are you using? Are you using your hands or a cloth? We do a lot of counseling around gentle care.

Dr Friedman: You touched on this already, but shared decision-making is a hot topic in derm—and it’s nuanced, especially with older patients or when family members are involved.

You mentioned things like steroid phobia, and historic or non-evidence-based practices like overuse of aloe or harsh cleansers. How do you approach conversations about these habits—especially when you may be cringing internally, but still need to maintain a strong therapeutic relationship?

Dr Murphy: It’s tough. I think being seen as an expert helps. Many of these patients have seen multiple providers who told them very different things—everything from “use the steroid as much as you want” to “only use it for a week.” They come in confused.

So, I start by saying, “You’re in the right place. We’re going to do what’s right for you.” And yes, having extra time is critical. I get 30 minutes with my vulvar patients, which allows for that deep counseling.

I explain how much steroid to use—lentil-sized. Even a pea-sized amount is too much for the vulva. I’ll print out a figure of a vulva and highlight the areas where they should apply the medication. It’s all about being thorough, patient, and giving them the space to ask questions.

If they’re not comfortable with a treatment plan—like using topical steroids—they’re not going to follow it. Shared decision-making is essential.

And yes, topical estrogen or hormone replacement comes with a lot of fear due to outdated associations with breast cancer or blood clots. So, we also spend time reviewing the evidence, especially the safety of local estrogen even in patients with a history of breast cancer.

If someone wants more information, I’ll print out articles. I keep a folder of BVAA articles on common vulvar topics so I can hand them out during the visit.

Dr Friedman: Handouts are such a time-saver—and not just in the clinic. They help reduce the number of calls or portal messages afterward. Just make sure they’re digestible: good language, large enough font—especially for this population.

Dr Jaya Manjunath: Definitely. I completely agree with these unique considerations. Another important population to think about is the long-term care population.

It’s often hard to get these patients into clinic because of transportation issues or lack of caregiver support. Even screening can be a challenge. What are your thoughts on providing education or training to long-term care nurses to help with early detection and referrals?

Dr Murphy: That would be amazing. A big barrier is that once you’re no longer getting Pap smears, many women stop seeing an OB/GYN. Unless they tell their doctor they’re having a vulvar issue, no one is looking.

And many elderly patients assume it’s normal to have itching or pain. They think, “At this age, sex is supposed to be painful,” which is absolutely not true. There’s so much we can do to help—but only if we know about the issue.

If long-term care nurses felt comfortable screening patients, knew what to ask, and had a toolbox of recommendations—like moisturizers or lubricants—that would be a huge help. And they’d know when to escalate and call the doctor for something like local estrogen.

We’re actually hoping to start a nursing home series, where we give educational talks and bring goody bags with over-the-counter products I recommend for vulvar care.

It’ll be great to have both staff and patients involved, because both groups benefit from learning more.

Dr Friedman: I feel like that was a planted question. I’m calling foul play—you just got the perfect setup to talk about your expanded program, which we’re all really excited about.

Thank you, Dr Murphy, for being here and sharing your expertise. And yes—we’ll definitely invite you back.

She’ll also be joining us as faculty at Elder Derm on May 1st here at GW, at our student center, as part of the Elder Derm Conference.

And thank you, my co-director in crime—thank you, Jay—for everything you do to move the field of geriatric dermatology forward. And of course, thank you to our audience for tuning in. Be sure to catch the next episode—we have much more coming soon from Elder Derm.