VULVA

By Gary M. White, MD

General Considerations for the Vulva

Always take a good history. Many women may be cleaning the area overly aggressively with the potential for causing a contact dermatitis. Or they may be applying a variety of products with allergens (such as fragrance) that could induce a contact dermatitis, irritant, or allergic. Make sure to address the patient's concerns. STD? Cancer? Sometimes a little education about the area and normal anatomy is helpful, e.g., normal sebaceous glands. Multifactorial processes are common on the vulva, e.g., psoriasis and contact dermatitis, contact dermatitis and herpes simplex. Iatrogenic processes also commonly occur, e.g., candidiasis after topical steroids for lichen sclerosus. For treatment, the vulva is relatively steroid-resistant and needs more potent steroids. However, the perianal area, perineum, and labiocrural folds are more sensitive, so less potent steroids or a shorter duration of therapy are appropriate. Topical calcineurin inhibitors are usually not as good as topical steroids for initial control of inflammatory disorders. Tacrolimus can be good sometimes for maintenance.

Anatomy of the Vulva

Information on Pubic Hair Grooming

See here.

Biopsy of the Vulva

Crusted

Staphylococcal Vulvovaginitis. One report described a 27-year-old woman with a 1-month history of profuse vaginal discharge, vulvar erythema, and pruritus. Vaginal yeast culture was negative. Bacterial cultures were positive for group B streptococci and S. aureus. One strain of S. aureus produced both TSST-1 and staphylococcal enterotoxin C (SEC), while the group B streptococci were non–toxin producing. For a picture, see J Low Genit Tract Dis. 2013 Jan;17(1):88-91

Enlarged

Cancer. Cancer blocking lymphatics and infiltrating the skin can cause enlargement. For a picture, see Dermatology Online Journal 19(5).

Lymphedema of the groin. Various diseases may cause lymphedema of the groin including hidradenitis suppurativa.

Crohn's Disease. For a picture, see Indian J Sex Transm Dis. 2014 Jan-Jun; 35(1): 53–55.

Lymphangioma

Finger-Like Projections

Vestibular Papillae

Itching/Lichenified

History and physical exam should exclude such things as candidiasis, tinea, erythrasma, trichomonal vaginitis, allergic contact dermatitis, irritant dermatitis, extramammary Paget's disease, and lichen sclerosus.

Lichen Simplex Chronicus. Thickened, lichenified skin that the patient scratches nightly.
Lichen Simplex Chronicus of the Groin

Nodule/Plaque

Squamous Cell Carcinoma. For a picture, see Dermatology Online Journal 14(1).

Pain

Dyspareunia

Vulvar Vestibulitis Syndrome

Papules

Condyloma
Condyloma of the Vulva

Syringomas. Syringomas of the vulva are rare.
Syringomas of the Vulva

Condyloma Lata
Condyloma Lata

Pigmented Macules and Patches

Benign Mole. Courtesy of Paul Koonings, MD
Benign Mole

Melanoma. For a picture, see Progresos Obstetricia Ginecologia

Vulvar Melanosis. For a picture, see Arch Dermatol. 1999;135(7):857-858.

Red and Scaly

Tinea Cruris
Tinea Cruris

Red Plaque(s)

Psoriasis of the Groin

Plasma Cell Mucositis

Ulcers

Behcet's Syndrome. Oral and vaginal ulcers.
Behcet's Syndrome

Lipschutz Ulcers. The acute onset of painful ulcers in a teenage girl.

Vascular

Angiokeratoma of Fordyce. These small vascular papules are common on the vulva of older women.
Angiokeratoma of Fordyce on the Vulva

Vesicles

Herpes Genitalis. Photo courtesy of Michael O Murphy, MD
Herpes Genitalis

Herpes Zoster. For a picture, see Dermatology Online Journal 14(1).

Lymphangioma Circumscriptum

White

Lichen Sclerosus. White plaques on the vulva, perineum, and perianal area.
Lichen Sclerosus

Pediatric

Genital nevi in children have a prevalence of approximately 3.5%, tend to arise before age 2 years, have a globular dermoscopic pattern, and follow a benign course. Biopsy is unnecessary unless there are particularly worrisome features (JAAD March 2014).

Vulvovaginitis, Prepubertal Girls

Pruritus Vulva

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