Vulvar Lesions

Key Points

• Visible condyloma should be treated.

• Biopsy is indicated for treatment-resistant warts, chronic symptomatic lesions, and nevus-like, pigmented lesions.

• Biopsy of lichen sclerosus is recommended to rule out vulvar squamous cell carcinoma.

• Topical corticosteroids are the cornerstone of management for nonneoplastic epithelial disorders of the vulva.

The differential diagnosis of vulvar lesions includes external genital warts (EGWs), Candida, herpes simplex, lichen sclerosus et atrophicus, lichen planus, psoriasis, and eczema.

EGWs are caused by HPV, which is primarily transmitted through sexual contact. Although exophytic warts are usually diagnosable with the naked eye, application of acetic acid can make flat warts visible. Biopsy is indicated for treatment-resistant warts, chronic symptomatic lesions, and nevus-like, pigmented lesions. For EGWs, cryotherapy is as effective as trichloroacetic acid and more effective than podophyllin. Podophyllotoxin and podophyllin are equally effective for clearance of EGWs and useful for small, solitary lesions. Imiquimod cream is also effective and should be applied to intact skin. Topical interferon is effective and preferable to systemic interferon. Electrosurgery is at least as effective as cryotherapy and more effective than podophyllin (Buck, 2006).

Nonneoplastic epithelial lesions of the vulva include lichen sclerosus, lichen planus, and lichen simplex chroni-cus. Lichen sclerosus is most common in postmenopausal women and presents with intense vulvar pruritus. Physical examination initially reveals thickened, white skin not involving the vagina, which progresses to a thin, wrinkled, "cigarette paper" appearance. High-potency topical steroids are effective in alleviating symptoms and preventing progressive architectural damage. Lichen planus is an autoimmune disorder that may involve the vagina as well as vulva. High-potency topical steroids or hydrocortisone suppositories are effective for treatment. Lichen simplex chronicus presents as lichenified, erythematous plaques resulting from chronic itching and scratching. Breaking the itch-scratch cycle is the cornerstone of treatment (O'Connell et al., 2008).

KEY TREATMENT

For external warts, cryotherapy is as effective as trichloroacetic acid and more effective than podophyllin; electrosurgery is at least as effective as cryotherapy and more effective than podophyllin (Buck, 2006) (SOR: B).

For lichen sclerosus, high-potency topical steroids are effective in alleviating symptoms and preventing progressive architectural damage (O'Connell et al., 2008) (SOR: B). For lichen simplex chronicus, breaking the itch-scratch cycle is primary treatment (O'Connell et al., 2008) (SOR: C).

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