Condylomata acuminata on the vulva (Figure 4) are caused by certain strains of the human papilloma virus (HPV), mostly HPV-6 and -11. HPV genital infections are the most common sexually transmitted disease (STD) in the United States. The appearance of condylomata is typically more exophytic than epithelial inclusion cysts with papillary projections and a sometimes “warty” appearance, and they can be firm or cornified. The warts vary in size from quite small, skin tag-like lesions to large lesions. At times, pigmentation changes are noted.
Excision or topical administration of trichloroacetic acid (TCA) or topical imiquimod or podophyllin can be used to treat HPV and they are ideal treatments for small areas. When the disease is extensive, as in this patient, carbon dioxide laser is often used.
Figure 5 shows papillomatosis in a 20 year-old which is a normal finding on the vulva. At times, it is confused HPV infection, but with papillomatosis, each projection comes off of a single pedicle. In HPV infection, in contrast, multiple projections come off a broad, single base.
HSIL also are caused by HPV
HPV vaccination decreases the risk of developing HSIL of the vulva (Figure 6). Because cigarette smoking is a strong risk factor for HSIL, smoking cessation should be strongly encouraged. Biopsy should be performed on suspicious lesions. Treatment is recommended because HSIL is considered a premalignant condition and wide local excision is performed in cases of suspected cancer. If occult invasion is not a concern, HSIL can be excised (hair-bearing areas), laser ablated (non-hair-bearing areas) or treated with topical imiquimod (off label use).
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