Rosalyn Elizabeth Maben-Feaster, MD

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45-year-old female presents to her primary care physician complaining of changes in her vulvar skin with intermittent irritation and some bleeding. She had recently experienced severe pruritus and white discharge which she treated with an over-the-counter anti-fungal cream for vulvovaginal candidiasis. However, her symptoms were only partially alleviated. On examination, she was noted to have thickening and wrinkling of the skin of the labia majora.  Excoriations were seen (Figure 1).

The history and physical examination are consistent with the diagnosis of lichen simplex chronicus. Lichen simplex chronicus is a non-specific skin condition that results from repetitive scratching or rubbing of the skin in response to pruritus.

 Other terms that have been utilized for this condition include hyperplastic dystrophy, squamous cell hyperplasia, and pruritus vulvae.

 Lichen simplex chronicus is estimated to occur in the anogenital region in 5% of all Western European and American adults.

Patients with lichen simplex chronicus typically complain of intense pruritus which can be chronic or intermittent and exacerbated by heat, stress, or menstruation.

 On examination you will observe lichenification or hard thickened skin. You may also note wrinkling of the skin, hair loss in areas of scratching, excoriations, erosions, hyperpigmentation or white patches of skin.

The development of lichen simplex chronicus is often secondary to a trigger that causes pruritus. This would include infections such as candida which is likely the trigger in this case.  Other instigating factors include chemical or allergic irritants, underlying skin dermatoses such as eczema, psoriasis, lichen sclerosus, or lichen planus, and pre-cancers or cancers of the vulva.

It can also be provoked by metabolic conditions such as diabetes mellitus or iron deficiency anemia. These triggers then result in a cycle of itching and scratching that ultimately compromises the skin’s protective barrier and results in inflammation.

 The altered skin barrier also increases the risk for secondary infection.

The diagnosis is typically made based on history and physical examination. It is critical to obtain information about when the pruritus began, when the patient is scratching and rubbing and with what. We have had patients report using items as extreme as a wire brush. Patients will often report that there is temporary relief from the pruritus with scratching or rubbing.

In addition, patients may often complain of painful urination or defecation and sexual activity which is typically related to the excoriations that can occur as a result of repetitive scratching or rubbing.

   You should also collect information about potential inciting events as well as current vulvar hygiene practices such as the type of underwear, frequency of showers/baths, whether tight clothing is worn, and whether soaps or other feminine hygiene products are utilized on the vulvar skin as well as fragrance or dyes in detergents for clothing.

A wet mount or yeast culture should be performed to rule out candidiasis. You should also consider a biopsy if the patient does not improve with initial therapies, or the gross appearance is concerning.

 A tissue biopsy can help to rule out other causes of pruritus and skin changes such as lichen sclerosus, lichen planus, psoriasis, high grade squamous intraepithelial lesions, and cancers.

On histology, a tissue biopsy from a patient with lichen simplex chronicus will display thickening of epidermis (acanthosis) and hyperkeratosis.

 You may also see increased mitotic activity without cellular atypia in the hyperplastic epithelium and a lymphocytic infiltrate within the dermis.

At the University of Michigan Center for Vulvar Diseases, we utilize a multi-step approach to treat this diagnosis. It begins with education on appropriate vulvar care which includes keeping the area dry, avoiding potential irritants such as soaps, detergents, and fabric softener with dyes or fragrance, wearing cotton underwear, and avoiding tight clothing. We also recommend against using products with benzocaine given the risk of developing contact dermatitis from this medication.

In addition, we advise our patients to utilize vulvar comfort measures focused on reducing scratching or rubbing such as tap water soaks in tepid water followed by application of a barrier to protect the skin (e.g. petroleum jelly).  Patients are encouraged to wear cotton gloves at night to prevent scratching and wear a nightgown without underwear or cotton pajama pants with a string.

Our treatment protocol also includes using medications to help with nighttime pruritus such as amitriptyline or gabapentin or hydroxyzine. Of note, if the patient complains of more pruritus during the day as opposed to at night, citalopram can be utilized instead of the medications listed for nighttime use.

In addition, we also prescribe an antibiotic, such as cefadroxil, to decrease secondary inflammation. You may utilize clindamycin instead of a cefadroxil in the case of severe penicillin or cephalosporin allergy. Do not forget to utilize an antifungal medication, such as oral fluconazole, if candida is discovered as part of your work-up. However, caution should be exercised if you are utilizing amitriptyline for nighttime pruritus. In these cases, you should utilize a topical rather than oral antifungal to avoid drug-drug interactions.

Once the skin has had an opportunity to heal, typically over the course of 4-5 days, the patient may then start topical corticosteroids such as clobetasol propionate ointment followed by triamcinolone acetonide ointment. It is important to instruct the patient where to apply the topical corticosteroids.

 Only a thin film should be applied to avoid the side effects associated with overuse which include tissue thinning, striae and rebound dermatitis.

If the patient fails topical corticosteroids, a systemic corticosteroid burst may be needed. This can be achieved with an oral prednisone taper. If still no improvement with prednisone, an intramuscular injection of triamcinolone acetonide can be given into the gluteus muscle.

In some cases, a patient may require a longer course of topical corticosteroids for maintenance. In addition, recurrence is common even with complete resolution.

 Although, this inflammatory dermatitis does not increase the risk of malignancy, it can have significant ramifications for a patient’s quality of life.

 Thus if a patient is not responding to the treatment regimen, consider referral to a vulvar specialist.

1. Chibnall R. Vulvar Pruritus and Lichen Simplex Chronicus. 

. 2017;44(3):379-388. doi:10.1016/j.ogc.2017.04.003

2. Ellenson LH, Pirog EC. The Female Genital Tract. In: Kumar V, Abbas AK, Aster JC, eds. 

. 9th ed. Philadelphia, PA: Elsevier Saunders; 2015:991-1042.

3. Thorstensen KA, Birenbaum DL. Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus. 

4. Edwards L, Lynch P. Genital pruritus and the eczematous diseases. In: 

. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2011.

5. Nguyen HL, Yiannias JA. Contact Dermatitis to Medications and Skin Products. 

. 2019;56(1):41-59. doi:10.1007/s12016-018-8705-0

6. Weiss M, Mettang T, Tschulena U, Weisshaar E. Health-related quality of life in haemodialysis patients suffering from chronic itch: results from GEHIS (German Epidemiology Haemodialysis Itch Study). 

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Multistep approach for lichen simplex chronicus

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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.

McPherson T, Cooper S. Vulval lichen sclerosus and lichen planus. 

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. 

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

Vulvar pain, difficulty swallowing, and bleeding with intercourse

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.

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

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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. 

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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?

Author | Rosalyn Elizabeth Maben-Feaster, MD

Articles

Multistep approach for lichen simplex chronicus

Can you make the right diagnoses?

Vulvar pain, difficulty swallowing, and bleeding with intercourse

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