Vulvar Lesions A.MALIBARY, M.D.

Anatomy Mons pubis Labia majora and minora Clitoris Vestibule Urethral meatus It covers and protects the entrance to the vagina, vestibule, and urethra.

Vulvar Hygiene Use mild, nondrying soap Washing underwear with mild soap and rinsing well 100% cotton underwear Avoid extra layers and tight slacks (unneeded medicines, tinted toilet tissue, all "feminine hygiene" products), excessive sweating without aeration, and public pools and hot tubs

Vulvar Hygiene It is important to be keenly conscious of what "aggravates" the skin. A dermatologic cliche is to "dry wet lesions" (soaks and compresses) and "moisturize dry lesions" (creams and ointments).

Vulvar Cancer 4th most common site of gynecologic neoplasia Squamous neoplasia most common type of neplasia HPV (16,18) infections are most commonly associated with squamous cell changes of the vulva, vagina & cervix. However the vulva tends to be more resistant to Oncogenesis Cigs are linked to the development of lower genital tract neoplasms

Vulvar Dysplasia Clinically, all these lesions appear as either red or white patches. These lesions are frequently multiple.

Carcinoma in situ

Histopathology of Vulvar Neoplasia Squamous 86% Malignant melanoma 5% Sarcoma 2% Basal Cell 1.5% Adenocarcinoma 1% Paget’s Disease 1% Undifferentiated 4%

Classification of VIN VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe atypia

Spread of vulvar Ca Local growth with extension to the perineum, anus, urethra, vagina & pelvic bone Lymphatics - inguinal & femoral nodes to the external iliac, common iliac, & para-aortic chains

Paget’s Disease Presents with extreme pruritus and soreness, usually of long duration Red or bright pink, desquamated, exzematoid areas among scattered, raised, white patches of hyperkeratosis Borders are well demarcated and raised

Paget’s Disease

Basal Cell Carcinoma Very rare Associated with a long history of pruritus Occurs over the anterior two-thirds of the labia majora, with slightly elevated margins

Verrucous Carcinoma Appears as condyloma Does not respond to treatment for HPV

Invasive Squamous Cell Carcinoma Occurs when a woman is in her 60s and 70s Presents with ulceration, friability, or induration of surrounding tissues

Sarcoma Occurs in women of all ages Rapidly expanding, painful mass

Diethylstilbestrol (DES) Exposure Used extensively in US during the 1940s and early 1950s to prevent miscarriage and premature births Studies during the late 1950s proved its ineffectiveness DES use continued through 1971 Estimated 2 million women were exposed in utero

DES Exposure Sequelae structural changes transverse vaginal and cervical ridges (cocks combs, collars, and pseudopolyps) abnormally shaped uterine cavity uterine hypoplasia vaginal adenosis shows columnar epithelium on or beneath the vaginal mucosa; it is self-limiting and gradually disappears clear-cell adenocarcinoma of the cervix or vagina may develop (incidence rises at age 15, and median age at diagnosis is 19 years increased incidences of: spontaneous abortion ectopic pregnancy premature cervical dilation premature rupture of membranes

Lesions Often present with prurutis Elevated above the skin Gray, white , red or pigmented May also look verrucous INVASIVE- all the above plus ulcerated & bleeding

Treatments Local - laser Invasive - total vulvectomy & nodes

Vulvar Lesions RED - neoplasm, inflammation, or atrophy Inflammation- Fungi - most common cause of red, nonulcerative, infectious lesion of the vulva Folliculitis - secondary to Staph. Aureus may cause painful, itchy vulva

Vulvar Lesions/ RED Noninfectious Reactive vulvitis - secondary to physical or chemical irritants such as detergents, dyes perfumes, spermicides, lubricants, hygiene sprays, podophyllin, saliva, semen. Mechanical trauma from scratching! Treatment - Burrow’s solution soaks x 30 mins tid; steroid cream, po antihistamines

Noninfectious , cont’d Vestibular adenitis Psoriasis Seborrheic Dermatitis

White Lesions/ Leukoplakia Hyperkeratosis Depigmentation Absolute or relative avascularity

Vulvar Dystrophy Benign epithelial disorders Lichen Sclerosis 70%, vulvar hyperplasia accounts for the rest Biopsy is mandatory of any white lesion!!!

White lesions continued VIN - neoplastic, premalignant lesion

Classification of VIN VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe atypia

Depigmented disorders Vitiligo - inherited, autosomal dominant Often progressive & often associated with increased incidence of Addison’s disease Thyroiditis DM Lymphoma Pernicious anemia

Intertrigo Nonspecific hyperkeratotic epithelial reaction to inflammation in the skin folds

DARK Lesions Usually secondary to increase in melanocytes or melanin production Must biopsy any dark lesion of the vulva! Lentigo - most common - freckle - no malignant potential flat, well circumscribed

Dark Lesions cont’d Nevi - moles. Localized collections of neural crest cells which are usually present from birth Asymptomatic and rarely become malignant 30% of all malignant melanomas develop from nevi Biopsy all changes, bleeding, change I color, ulceration, sudden growth, satellite lesions

Dark Lesions cont’d Neoplasms Reactive Hyperpigmentation Seborrheic keratosis

Ulcerative Lesions VIRAL - HSV - 48 hrs to 7 days after initial contact Bacterial - Syphillis, Granuloma inguinal, pyoderma, cutaneous TB Inflammatory/noninfectious - Behcet’s Disease - oral & genital ulcers Crohn’s Dz. Pemphigus & Pemphigoid

Inflammatory/noninfectious Hidradenitis Suppurativa Neoplastic

Tumors < 1cm Inflammation - condyloma acuminata(HPV) Molluscum contagiosum Cysts- epidermal inclusion, vestibular gland, mesonephric duct Neoplasia - VIN, hemangioma, hidradenoma, neurofibroma, syringoma Other - Accessory breast tissue, acrocordon, endometriosis, Fox-Fordyce Dz., Pilonidal sinus

Tumors > 1 cm Inflammatory - Bartholin’s cyst/abscess, lymphogranuloma venereum Neoplasm - fibroma, lipoma, verrucous carcinoma, sq. cell carcinoma Hernia, Edema Hematoma Other - skin tag, epidermal cysts, neurofibromatosis, accessory breast tissue