A 72 year-old woman is referred to your office by her internist for vulvar lesions. She denies itching or pain and states that the lesions have been there for years. Her medical history is unremarkable.
Your diagnosis is: C. Epithelial inclusion cysts
Your treatment plan is: D. No treatment required
Epithelial inclusion cysts are common and most often require no intervention. They can occur spontaneously or after vulvar trauma, such as obstetrical lacerations or episiotomies where the epithelium becomes trapped. The cysts are lined by keratinizing stratified squamous epithelium. Keratinaceous debris can accumulate, which appears “cheesy” when extruded and can sometimes have a foul odor (Figure 2). Unless the cysts are bothersome or enlarging, no intervention is necessary. If they are bothersome, excision alone or with drainage can be performed. Most patients simply can be reassured that epithelial inclusion cysts are not concerning and quite common vulvar findings.
Another condition in the differential diagnosis in this case is molluscum contagiosum (Figure 3). Molluscum contagiosum is caused by a DNA Pox virus and typically has an umbilicated center. Mollusca often occur in children but they are also seen in sexually active adults. Lesions appear 2 to 6 weeks after exposure to the virus and range in size from pin-head to pencil eraser size, with an umbilicated center. Pruritus is a common complaint and scratching further disseminates the virus onto other parts of the skin. If the lesions are asymptomatic, they can be left alone and resolve without intervention. However, if molluscum contagiosum is symptomatic, it is responsive to removal with a dermal curette, topical application of cantharidin (“blister beetle juice”), imiquimod, trichloroacetic acid, or application of liquid nitrogen. Other options for topical therapy include iodine and salicylic acid, potassium hydroxide, and tretinoin. Oral cimetidine has been used as an alternative treatment in small children when there is concern about pain associated with cryotherapy, curettage, and laser therapy or to avoid the possibility of scarring.
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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