Norman F. Miller Professor of Gynecology, Director, Pelvic Floor Research, Group Director, Fellowship in Female Pelvic Medicine and Reconstructive Surgery 

John O. DeLancey, MD

Slideshows

Three more chances to test your diagnostic skills.

Can you make the right diagnoses?

Can you make the correct diagnosis and identify the best treatment plan for these common vulvar conditions?

3 more chances to test your diagnostic skills

A 56-year-old G2P2 presents with longstanding vulvar pain, difficulty swallowing, and pain and bleeding with intercourse. On vulvar examination, you see loss of the labia minora, fusion of the prepuce over the clitoris, and erosions around the introitus (

Click here for diagnosis, next step in evaluation, and discussion


	Based on this patient’s history and clinical examination, the most likely diagnosis is lichen planus (LP), a chronic inflammatory condition that can involve the skin, mucosa, scalp and nails.

 Vulvar LP is a subtype that involves the genital skin with or without involvement of the vagina. Women with vulvar LP may present with one of three subtypes-classic, papulosquamous, or erosive-and often present with complaints of itching, pain with intercourse, vaginal discharge, or bleeding. Some patients may be asymptomatic. The patient in this case represents the erosive subtype of vulvovaginal LP, which is the most common of the three. 


	LP is uncommon, often presenting in the 5

 decades of life, although it can be seen in younger and older women. The prevalence of LP is not well defined, given limited and often under-reporting of this condition. Current rates for LP in the literature are estimated to be between 0.01% and 3%,

 although prevalence data specific to vulvar lichen planus are unknown. One study of 37 women with cutaneous LP demonstrated a prevalence of 51% for vulvar involvement.


	While the exact etiology is not known, LP is defined as a chronic inflammatory condition that can involve the skin, scalp, mucosal surfaces, or nails. It is classified as an autoimmune condition with demonstrated cell-mediated autoimmunity.

 The proposed mechanism includes T-cell-mediated keratinocyte damage of the basal cell layer of the dermis.

 LP also is associated with other autoimmune diseases including thyroid disease, alopecia, and vitiligo.

 Patients with LP should be screened for other autoimmune diseases when clinically indicated. A significant association between hepatitis C and LP has also been reported in the international literature, although the relevance of this in North America is not clear.


	The clinical features vary based on subtype of vulvar LP. The classic or papular subtype most often presents with pruritus, but can be asymptomatic. On clinical examination you will see flat, papular lesions with a characteristic white, lacy pattern (Wickham’s striae). It is often seen in patients with cutaneous LP of other sites and can sometimes resolve spontaneously. Classic or papular LP does not typically cause scarring. The least common subtype is hypertrophic. Patients will typically complain of pruritus and the appearance is characterized by purple/red brown well-demarcated flat-topped shiny papules on keratinized skin.

 It is most common in the perineal and perianal area and does not involve the vagina.

 Biopsy is often required, as the plaque-like appearance can mimic other diagnoses. The most common vulvar subtype is erosive, which is seen in Figure 1. Patients will often complain of pain, including dyspareunia, or difficulties with urination. On examination you will see white, lacy papules or red erosions which may involve the vestibule (Figure 1) and vagina (Figure 2).

Erosions can lead to scarring, particularly in the vagina. Architectural changes with loss of tissue can also occur, as seen in Figure 1. Erosive LP can also involve other mucosal surfaces including urethral, oral (Figure 3) and esophageal mucosa. Vulvovaginal-gingival (VVG) syndrome is a specific erosive subtype involving each listed mucosal surface. Sites of involvement may not be concurrent, so history of prior site involvement or symptoms in those sites should be solicited.


	Clinical examination is crucial for diagnosis but biopsy may be helpful as well. When performing a biopsy, you should target areas of white reticular borders or erosion.

 If you are taking a biopsy in the area of an erosion, it is important to biopsy on the border of the erosion, including some normal skin.

 Tissue should be sent for H&E staining and also for immunofluorescence as often findings can be non-specific on histopathology.

 Of note, the specimen used for immunofluorescence should be sent fresh. In our clinic, we typically use Zeus Tissue Fixative. 

On H&E staining you will often see the following:

Thickening of the epidermis in a saw-toothed pattern

Band-like mononuclear infiltrate in the upper epidermis which hugs the dermal-epidermal junction and creates some areas of vacuolar degeneration of the basal cell layer (Figure 4)

Individual dyskeratotic keratinocytes within the epidermis 

On immunofluorescence, you will see irregular deposition of fibrinogen, IgM, cytoid bodies and occasionally granular IgG or IgA on staining of the basement membrane.

In 2013, diagnostic criteria for erosive lichen planus were created by electronic-Delphi consensus pooling of members of the International Society for the Study of Vulvovaginal Disease (ISSVD).

 Nine characteristics were identified with three of nine necessary to confirm the diagnosis (Table 1).


	The goals of treatment are to address symptoms and prevent disease progression.

 Typically papular or classic vulvar LP will respond to local treatments such as topical corticosteroids (e.g. triamcinolone 0.1% ointment or clobetasol 0.05% ointment).

 Hypertrophic vulvar LP can be resistant to topical medications. For erosive vulvar LP, topical corticosteroids such as clobetasol 0.05% ointment and augmented betamethasone ointment 0.05% are the first-line treatments.

 Intra-lesional triamcinolone acetonide (10 mg/mL) injections can be helpful for more resistant disease.

 Typically, 0.1 mL of triamcinolone would treat 1 cm

 For example, we would use 10 mg for the entire vestibule. However, do not exceed 40 mg for the entire vulva. Injections should be at least 3 to 4 weeks apart and no more than three injections overall.

 There are some reports on the use of topical tacrolimus 0.1% ointment twice daily for oral and genital erosive lichen planus.

 In some patients with hypertrophic or erosive vulvar LP, topical therapies are insufficient and systemic therapies are required to meet treatment goals. In these circumstances, we will often partner with our colleagues in dermatology. The most commonly used medications include prednisone (only for flares), methotrexate 5 mg by mouth once weekly or 5 mg subcutaneously once weekly (with folic acid supplementation) building up to 25 mg per week, mycophenolate mofetil 500 mg/day building up to 1.5  g twice daily, and hydroxychloroquine 200 mg twice daily.

 You may also treat with cyclosporine 2.5 mg/kg/day with a maximum of 5 mg per day or rituximab 1 g on Days 1 and 15 with repeat at 6 months if relapse.

 These medications require monitoring and are titrated up over time to achieve their effects.

For patients with vaginal involvement, we recommend intravaginal hydrocortisone (e.g. hydrocortisone acetate foam 40-80 mg nightly, or 25 to 200 mg suppository or cream nightly).

 For higher doses a compounding pharmacy is necessary. The patient should also dilate daily to keep the vagina open.

Despite these therapies, there are some cases in which vulvar and/or vaginal agglutination occurs despite conservative therapy (Figure 5). At the University of Michigan Center for Vulvar Diseases, we have developed and utilized a protocol to address this population of patients.

 Our protocol entails a combination of sharp dissection with blunt pressure with an end-to-end anastomosis sizer placed rectally to help define the plane between the vagina and the rectum.

 Once normal length and width are achieved, a foam dilator covered with two sterile condoms is placed in the vagina and secured via suturing the labia majora together.

 A Foley catheter is placed prior to this. The patient presents to clinic for removal of the dilator and Foley catheter 48 hours after surgery and then is started on a protocol of daily dilator therapy followed by high-dose intravaginal steroids.

 Refer to the referenced article for a video and also postoperative recommendations.

 Data from a small series at our center (11 women) have shown that 95% of patients were satisfied with their postsurgical result with 55% engaging in intercourse following surgery and 75% with improvement in voiding symptoms.

If a patient is noted to have extensive extra-genital involvement, it is important to collaborate with other specialists such as dermatology and gastroenterology for comprehensive treatment. 


	Surveillance is key as there is an increased risk of squamous cell carcinoma in cases of LP. At the Center for Vulvar Diseases at Michigan Medicine, we follow patients with LP every 6 months by clinical exam. We also recommend patients be up to date on lower genital tract cancer screening. Because the condition can also have a significant impact on quality of life due to pain and issues with sexual functioning, our clinic takes a comprehensive approach with sexual health counselors on site. If this is not available in your clinic, consider referral to sexual health counselors, psychologists, and psychiatrists to help manage these complex patients.

The authors report no potential conflicts of interest with regard to this article.

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Simpson RC, Thomas KS, Leighton P, Murphy R, Simpson RC. Diagnostic criteria for erosive lichen planus affecting the vulvaâ¯: an international electronic-Delphi consensus exercise. 

Lewis FM, Harrington CI. Vulval involvement in lichen pianus: a study of 37 women. 

. Philadelphia, PA: Lippincott Williams and Wilkins; 2004.

Usatine RP, Tinitigan M, Health T. Diagnosis and Treatment of Lichen Planus. 

Haefner H, Margesson L. Your diagnosis is? Test your knowledge of various vulvovaginal conditions. Available at 

https://medicine.umich.edu/sites/default/files/content/downloads/2

. Your Diagnosis Is Jan 2 2018.pdf. Accessed April 23, 2019.

Bradford J, Fischer G. Management of vulvovaginal lichen planusâ¯: a new approach. 2013;17(1):28-32.

Moyal-Barracco M, Edwards L. Diagnosis and therapy of anogenital lichen planus. 

Jensen JT, Bird M, Leclair CM. Patient satisfaction after the treatment of vulvovaginal erosive lichen planus with topical clobetasol and tacrolimus: A survey study. 

Goldstein AT, Thac D. Topical calcineurin inhibitors for the treatment of vulvar dermatoses. 

Fairchild P, Haefner H. Surgical Management of vulvovaginal agglutination due to lichen planus. 

Articles

What is your diagnosis when vulvar examination shows loss of the labia minora?

Vulvar pain, difficulty swallowing, and bleeding with intercourse

These three cases illustrate common diseases that patients with vulvar conditions may present with. Can you make the correct diagnosis and identify the best treatment plan?

How good are your diagnostic skills?

A 33-year-old woman is referred to you by her primary care physician for evaluation of two non-healing lesions on the vulva. She has tried multiple treatments for yeast without improvement. She is otherwise healthy.

Discussion of Cutaneous Crohn’s disease


	Crohn’s disease (CD) is characterized by a chronic granulomatous inflammatory condition primarily affecting the gastrointestinal (GI) tract. Metastatic disease includes cutaneous lesions (including vulvar lesions), as well as joint, hepatobiliary and ophthalmic involvement. Cutaneous involvement is reported in up to 19% of cases, with the vulva being most commonly affected.

 The cause is unknown but likely multifactorial.


	Incidence of vulvar CD is 10 to 20 per 100,000 person-years and the prevalence is 300 per 100,000 persons.

 Cutaneous manifestations are rare, yet probably underreported and underdiagnosed. Vulvar lesions may precede intestinal disease in 25% of cases.

 Most patients are young, with disease manifesting in the teens and twenties. A few new cases have been reported to occur after age 45.


	Often the vulva appears edematous. Linear, “knife-cut” fissures or ulcers are the hallmark of vulvar CD.

 A biopsy is indicated for diagnosis. A 4-mm punch biopsy should be performed at the edge of the lesion and in the ulcer bed (if there is also suspicion for cancer). If the patient already has a diagnosis of gastrointestinal CD, then a biopsy is not required with this classic appearance of vulvar CD. If not previously performed, endoscopic evaluation to evaluate for intestinal involvement is indicated.


	For limited disease, first-line treatment is with potent or super-potent topical corticosteroids (e.g. clobetasol 0.05% ointment or halobetasol 0.05% ointment), which can be used for short periods of time such as 2 weeks.

 To avoid steroid overuse, a switch can be made to a calcineurin inhibitor (tacrolimus 0.1% ointment twice a day) if there is no burning, if desired, although it is rarely used.

 Intralesional triamcinolone 10 mg/mL (up to 40 mg total on the vulva) is also a reasonable therapy for localized or limited disease.

 Generally, excision is avoided but it may be appropriate in some cases.

For more diffuse disease, systemic corticosteroids are needed.

 One study demonstrated that oral metronidazole can be effective in 87.5% of cases alone or in combination with steroids.

 Also,10% topical metronidazole three times daily for 4 weeks can help with perianal disease.

 If patients are recalcitrant to these therapies or you are unable to taper them off of systemic steroids, then biologic therapies are often used. The most commonly used biologic therapies are tumor necrosis factor-alpha inhibitors such as infliximab.

 There are also other steroid-sparing immunosuppressive medications that have demonstrated efficacy in cutaneous Crohn’s including azathioprine, methotrexate, cyclosporine, and thalidomide.

 We often consult our gastroenterology colleagues for assistance with these steroid-sparing agents if there is also GI involvement, or dermatology if there is no GI involvement. Because biologics have recently been very effective for some patients, they are sometimes used as first-line therapy. 

: B. Multidisciplinary approach to management

. GAS vulvovaginitis is typically thought of in prepubertal girls; however, adult women can be affected, too. Symptoms include pruritus and pain. A common sign is copious vaginal discharge. Risk factors include exposure to GAS and/or vaginal atrophy. Treatment is typically oral penicillins or topical clindamycin.

 GAS is also a cause of monomicrobial necrotizing fasciitis. Since 2010, approximately 700 to 1200 cases have occurred every year in the United States. The hallmark of this life-threatening condition is pain out of proportion to appearance and rapidly spreading erythema and induration. In later stages, dusky gray tissue may be present.

 This is a surgical emergency that requires early and extensive debridement of affected tissue in combination with parenteral antibiotics and supportive care.


	Approximately 27,000 cases of primary and secondary syphilis were reported in 2016.

 This sexually transmitted infection (STI) typically results in a single painless ulcer (chancre) in the vulvar area approximately 3 to 4 weeks after exposure.

 However the ulcer can become painful if secondarily infected. It has a punched-out appearance with raised edges but is most commonly located in the posterior commissure.

 It is often accompanied by inguinal lymphadenopathy.

 Of note, secondary syphilis occurs 8 to 12 weeks after transmission and is characterized by condylomata lata in the vulvar and perianal area (eroded papules) and a macular rash with fever and malaise.

 There can be sequelae later in life if untreated.

 Diagnosis is made from dark field microscopy with detection of Treponema pallidum or from PCR-DNA analysis in conjunction with serological testing (non-treponemal and treponemal).

Treatment for primary syphilis is with benzathine penicillin 2.4 million

 2015 Sexually Transmitted Diseases Treatment Guidelines for the most up-to-date treatment recommendations).

. Only seven cases were reported in the United States in 2016.

 It is characterized by development of a painful ulcer with suppurative discharge in the introitus.

 There may be development of multiple nonindurated ulcers around it.

 Painful, enlarged inguinal lymph nodes (buboes) develop 1 to 2 weeks afterward and this purulent fluid may drain through the skin, resulting in formation of ulcerations.

 Diagnosis is primarily based on history and physical examination as the culture media and PCR tests are not readily available.

 One treatment option is azithromycin 1 g orally in one dose but there are other antibiotic options as well (refer to the 

 Sexually Transmitted Diseases Treatment Guidelines for the most up-to-date antibiotic treatment recommendations).

 Of note, fluctuant lymphadenopathy may require incision and drainage or needle aspiration to resolve the lymphadenopathy.


	Vulvar cancer represents 0.3% of all new cancer cases in the United States. Approximately 6000 cases have been reported to date in 2019.

 SCC is the most common type of vulvar cancer, making up approximately 75% of all invasive cancers in the United States.

 It is more common among white women compared to black or Hispanic women

 Risk factors for developing SCC including history of differentiated vulvar intraepithelial neoplasia, smoking, lichen sclerosus, history of human papillomavirus- mediated disease (cervical high-grade squamous intraepithelial lsion [HSIL] or cancer, vulvar HSIL), and immunodeficiency.

 Most patients present with a single vulvar lesion which can be a plaque, ulcer or mass.

 Patients may also complain of pruritus, pain and bleeding.

 Given this, a biopsy is critical to rule out this diagnosis in the setting of a vulvar ulcer. Of note, when you perform a biopsy you should be sure to biopsy at the edge and also in the center, if the lesion is irregular and firm. You should also try to include some underlying stroma and try to avoid removing the entire lesion, if it is large, as it can make future surgical planning more difficult.

Aside from biopsy of a visible lesion, you should also consider performing vulvoscopy to further evaluate the vulva. Once SCC is identified via biopsy, it is recommended to perform cervical cytology (with colposcopy if indicated), complete blood count, biochemical profile, liver profile, HIV testing, and a chest x-ray.

 A computed tomography (CT) scan or magnetic resonance imaging of the pelvis and groin or positron emission-CT may also be helpful to evaluate extent of disease in selected cases.

 Treatment of invasive SCC is individualized and is governed by management of the primary lesion and also groin involvement (if present).

 It may include excision, radiation, and/or chemotherapy depending on the location, size, and staging.

 Referral to a gynecologic oncologist is recommended.

Hambardzumyan M, van Bodegraven A, Stoff T. Granulomatous conditions of the vulva. In: Kirtschig G CS, ed. 

. New Delhi, India: Jaypee Brothers Medical Publishers; 2015:121-128.

Ananthakrishnan A. Epidemiology and risk factors for IBD. 

Ye Y, Pang Z, Chen W, Ju S, Zhou C. The epidemiology and risk factors of inflammatory bowel disease. 

Andreani SM, Ratnasingham K, Dang HH, Gravante G, Giordano P. Crohn’s disease of the vulva. 

. 2010;8(1):2-5. doi:10.1016/j.ijsu.2009.09.012

Deckers I, Benhadou F, Koldijk M, et al. Inflammatory bowel disease is associated with hidradenitis suppurativa: results from a multicenter cross-sectional study. 

Stewart KMA. Challenging Ulcerative Vulvar Conditions: Hidradenitis Suppurativa, Crohn Disease, and Aphthous Ulcers. 

Haefner H, Margesson L. Your Diagnosis Is? Test Your Knowledge of Various Vulvovaginal Conditions. 

. Your Diagnosis Is Jan 2 2018.pdf. Published 2017. Accessed April 23, 2019.

Laftah Z, Bailey C, Zaheri S, Setterfield J, Fuller LC, Lewis F. Vulval Crohn’s disease: a clinical study of 22 patients. 

. 2015;9(4):318-325. doi:10.1093/ecco-jcc/jjv037

Maeda Y, Ng S, Durdey P, et al. Randomized clinical trial of metronidazole ointment versus placebo in perianal Crohn’s disease. 

Preston P, Hudson N, Lewis F. Treatment of vulval Crohn’s disease with infliximab. 

Rutgeerts P, Baert F. Immunosuppressive drugs in the treatment of Crohn’s disease. 

Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women. 

CDC. Group A Streptococcus (GAS) Disease. 

https://www.cdc.gov/groupastrep/diseases-hcp/necrotizing-fasciitis.html

. Published 2018. Accessed April 23, 2019.

Sexually Transmitted Disease Surveillance 2016

Sand FL, Thomsen SF. Skin diseases of the vulva: Infectious diseases. 

Workowski K, Bolan G. Sexually Transmitted Diseases Treatment Guidelines, 2015. 

Schwarz R. Chancroid and granuloma inguinale. 

Workowski K, Bolan G. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep. 2015;64:26-27.

Lockett A, Dance D, Mabey D, Al E. Serum-free media for isolation of Haemophilus ducreyi. Lancet. 1991;338(8762):326.

Cronin K, Lake A, Scott S, et al. Annual Report to the Nation on the Status of Cancer, part I: National cancer statistics. Cancer. 2018;124(13):2785-2800.

Saraiya M, Watson M, Wu X, et al. Incidence of in situ and invasive vulvar cancer in the US, 1998-2003. 

Brinton L, Thistle J, Liao L, Trabert B. Epidemiology of vulvar neoplasia in the NIH-AARP Study. 

Zacur H, Genadry R, Woodruff J. The patient-at-risk for development of vulvar cancer. 

Hacker N, Eifel P, van der Velden J. Cancer of the Vulva. 

Rogers L, Cuello M. Cancer of the vulva. 

What’s your diagnosis in a woman who has ulcerations unresponsive to treatment for yeast?

Non-healing vulvar ulcerations in a 33-year-old woman


	A 34-year-old G3P2 is referred to your clinic for evaluation due to chronic vulvar lesions that intermittently become painful with purulent discharge despite antibiotics.

The most likely diagnosis in this patient is hidradenitis suppurativa (HS) (Hurley stage 2) and you could use all of the listed treatments to address this condition. HS is a chronic inflammatory skin condition that involves skin in areas where apocrine glands are found.

 The lesions of HS can mimic other conditions such as acne, carbuncles or Crohn’s disease but they are distinct in their pattern of distribution. 

You should suspect HS if the following three criteria are met:

Lesions are nodules, abscesses, tunnels or scars; 

Location is axillae, inframammary folds, groin, perigenital, or perineal area; and 

Lesions progress (two recurrences within 6 months or chronic or persistent lesions for ≥ 3 months).

It has been suggested that HS develops due to a defect in the folliculopilosebaceous unit.

 This results in weak-walled follicles that when occluded ultimately rupture, resulting in release of multiple inflammatory factors.

 In turn, an acute inflammatory response develops in the surrounding tissue. As the body attempts to heal, chronic inflammation occurs, creating chronic tissue damage and resultant scarring.

 HS also is thought to have a genetic component, with multiple genes likely to be involved.

 Infection appears to be a secondary reaction.

 Androgens also play a role likely secondary to an increased end-organ sensitivity of androgen receptors mediated by insulin and insulin-like growth factor.

HS is seen primarily after puberty and before menopause, with women affected more commonly than men.

 Mean time to diagnosis is 7.2 years, which is unfortunate as the disease can be progressive and debilitating.

Stage 1 is characterized by transient abscess formation without scarring and sinus tracts.

 Stage 2 is characterized by recurrent abscesses (single or multiple) with sinus tracts or scarring.

 If multiple lesions are present, they are separated by normal skin.

 Finally the most severe stage is stage 3, consisting of diffuse disease with multiple connected tracts, tunnels, and significant scarring.

The therapeutic goals of treatment are to treat active disease and prevent disease progression. Most therapies target suspected underlying mechanisms. For stage 1 disease, patients are treated with general care measures, including avoiding vulvar irritants and tight clothing.

 Behavioral and dietary changes such as weight loss, smoking cessation, and elimination of dairy products are encouraged as well.

For the initial flare, amoxicillin/clavulanic acid (875 mg po every 12 hours for 7 to 10 days) helps to treat the inflammation and secondary infection. Other antibiotics that can be considered include doxycycline (100 mg po twice daily) or clindamycin (300 mg po twice daily) for 7 to 10 days. Patients are also advised to take zinc picolinate (30 mg) with copper gluconate (2 mg).

 This is available in a single pill to be taken twice a day. Other therapies offered include topical clindamycin lotion 1% twice daily. Intralesional triamcinolone injections are used at times. Anti-androgens such as drospirenone-containing oral contraceptives, spironolactone (50-100 mg po daily), or finasteride (5 mg po daily) may be helpful to control disease.

 For stage 2 disease, other oral agents can be considered (sulfamethoxazole-trimethoprim, dapsone, or a combination of rifampin, moxifloxacin, and metronidazole), with maintenance on doxycycline or minocycline for approximately 3 months. Local surgical treatments such as unroofing tracts, wide local excision of lesions, skin tissue–sparing excision with electrosurgical peeling (STEEP) surgery and carbon dioxide laser evaporation of diseased tissue may be used forstage 2 HS.

For stage 3 or severe HS, radical wide excision with skin grafting is recommended for definitive treatment (Figure 3). This is an extensive process requiring resection of HS and wound vac placement, wound vac changes, and skin grafting 1 week later, if the tissue is granulating well. A wound vac is applied over the skin graft for 5 days. 

For stage 3 HS, you can also consider medical therapy with clindamycin 300 mg BID with rifampin 300 mg BID and a TNF Î± inhibitor such as adalimumab or infliximab

. This is typically done in consultation with a dermatologist. Unfortunately, medical management is generally not a cure for patients with stage 3 HS. Surgical management of stage 3 HS has been found to have good results.

 Finally, psychosocial support is critical for patients with HS as the condition can be isolating due to its nature.


	Acne vulgaris is a chronic inflammatory skin disease that affects the pilosebaceous unit and is typically seen in adolescents and young adults.

 The skin changes can be described as open or closed comedones or as inflammatory nodules, pustules or papules.

 Inflammatory lesions look most similar to HS lesions but the topographical distribution differs. In general, acne tends to be found on the face, neck, and back.

 The two disorders also share some similarities with regards to treatment goals and minimizing comorbid conditions such as depression. 

As with HS, treatment for acne vulgaris is designed based on disease severity. First-line treatment for mild disease is primarily treated with topical medications (e.g. benzoyl peroxide, retinoids or combinations of these with or without antibiotics).

 Moderate disease is treated with topical combination therapy or topical therapy with oral antibiotics.

 Severe disease is treated with an oral antibiotic along with a topical combination regimen or with oral isotretinoin.


	Folliculitis is a bacterial infection of the hair follicles.

 It can occur in any hair-bearing area and is a common skin condition.

 Tissue trauma (e.g. shaving), excess heat (tight clothing) and immunosuppression (chronic steroid use) can predispose to development of these lesions.

 On vulvar examination, one would see papules and pustules. Diagnosis of folliculitis can be confirmed with a culture, in contrast to HS.

 Therapy usually is short-term and can include topical cleansers or medications such as chlorhexidine, benzoyl peroxide, clindamycin, fusidic acid or mupirocin.

 Oral antibiotics such as dicloxacillin, clindamycin or a macrolide can be used for cases that do not respond to topical therapy.

 Good vulvar care hygiene is key to avoid recurrence.

Saunte DML, Jemec GBE. Hidradenitis suppurativa advances in diagnosis and treatment. JAMA. 2019;318(20):2019-2032.

Zouboulis CC, del Marmol V, Mrowietz U, Prens EP, Tzellos T, Jemec GBE. Hidradenitis Suppurativa / Acne Inversaâ¯: Criteria for Diagnosis , Severity Assessment , Classification and Disease Evaluation. Dermatology. 2015;231:184-190.

What’s your diagnosis in a patient with lesions that are sometimes painful and do not respond to antibiotics?