Vulval Lesions

Vulval Lesions

·        Non-neoplastic epithelial disorders:

o   Lichen Sclerosis:

§  1/3 of lesions, commonest after menopause

§  Pruritic, affecting any part of the vulva

§  Multiple irregular white patches, shiny wrinkled atrophic skin 

§  ­ Risk of SCC

§  Microscopy: subepithelial homogenous collagen + band of lymphocytes 

§  Autoimmune aetiology ® treatment with steroids

o  Squamous Hyperplasia: 

§  Non specific thickening of the epithelium + inflammatory reaction below the BM: acanthosis, hyperkeratosis

§  Non specific diagnosis 

o  Other dermatoses: Lichen simplex chronicus, spongiotic dermatitis (contact dermatitis eg perfumed toilet paper), psoriasis, lichen planus

·        Vulval Intraepithelial Neoplasia (VIN):

o  Often multi-focal white-pink-red raised lesions which itch/burn/asymptomatic

o  Preinvasive dysplastic squamous lesions

o  Dysplasia is graded VIN1, VIN2, VIN3

o  Untreated 7/8 progress to SCC (unlike CIN)

o  Risk factors similar to cervical carcinoma

o  60% have lesions in other areas

·        Squamous Cell Carcinoma:

o  90% of vulval cancer and 5% of gynae cancer

o  Two types: 

§  Elderly women (70+): 65%, related to Lichen Sclerosis & squamous hyperplasia, well differentiated – islands of invading cells 

§  Younger women (40+): 35%, related to HPV, Cervical cancer risk factors, poorly differentiated

o  Raised white warty mass

o  Micro: resembles SCC at other sites

o  Often present late

o  Prognosis depends on stage.  Factors in order of importance are:

§  Lymph node metastasis

§  Depth of invasion

§  Size

·         Not all skin lesions on the genitals and surrounding areas are due to STDs

·         Normal anatomical variants:

o   Pearly penile papules: small papillae around the corona of the penis

o   Sebaceous cysts of the penis, labia minora and scrotum

o   Normal papillae in the vaginal vestibule: can be mistaken for warts

·         Dermatoses:

o   Contact dermatitis: soaps, deodorants, etc 

o   Psoriasis: especially head and corona of the penis. Red, scaly plaques. Not itchy. Look for it elsewhere

o   Reiter‟s Syndrome: urethritis, conjunctivitis, arthritis in addition to skin lesion

o   Lichen Planus: itchy plaques on the penis

·         Infections (not necessarily sexually acquired):

o   Seborrhoeic dermatitis: a fungus, red, sharply defined area covered with honey coloured scales

o   Candidiasis: red, irritating, itchy rash.  Treat with Clotrimazole (Canesten)

o   Dermatophyte infections (tinea) are common.  Characteristic spreading edge, itchy

o   Folliculitis: small pustule around a hair follicle

o   Scabies: red, itchy nodules – may not resolve despite treatment.  Treat with malathion 0.5%

o   Erythrasma: scaly, flat, brown, pigmented rash, not itchy.  Caused by corynebacterium 

o   Molluscum contagiosum: may be sexually acquired. Small, pearly umbiliated lesions on the thigh and buttocks