Diseases of the Vulva

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The vulva is affected by many non-infective inflammatory skin disorders that cause pruritus
The vulval skin is frequently affected by inflammatory skin diseases causing pruritus.

Acute contact dermatitis may follow the use of topical applications, e.g. deodorants, or ointments used for the treatment of other vulval diseases. Occasionally, an allergic dermatitis may be caused by detergents used in washing underwear.

Lichen planus is an inflammatory skin condition that may affect the vulva, producing raised, purplish lesions similar to those seen elsewhere in the skin. However, in the vulva, lichen planus is frequently erosive, causing areas of superficial ulceration.

Lichen sclerosus results in epidermal atrophy and densely collagenous upper dermal fibrosis. The condition has a particular predilection for the skin in the genital area, occurring frequently in the vulva, and less commonly in the penis (balanitis xerotica obliterans. It presents as white papules or confluent patches, which are covered by atrophic epidermis in which telangiectatic blood vessels are prominent. The histology is identical to that seen elsewhere in the skin, with compact hyalinization of the upper dermis with an underlying lymphocytic infiltrate. Long-standing lichen sclerosus may lead to narrowing of the vaginal introitus.

Constant, repeated trauma from scratching the vulval skin may cause a secondary non-specific chronic dermatitis called lichen simplex chronicus. This is a common cause of vulval thickening.
This vulva shows extensive, thick, white patches due to collagenous thickening, overlaid by an atrophic epithelium.

The most important malignant tumour of the vulva is squamous-cell carcinoma
Squamous carcinoma of the vulva, which usually occurs in elderly women, may show extensive local invasion and metastases in inguinal lymph nodes. One variant in very old women, verrucous carcinoma, produces a large, warty, cauliflower-like growth that grows slowly, invading local tissues, but almost never metastasizes. Well-differentiated squamous carcinomas of the vulva have a good prognosis provided that they are confined to the vulva and inguinal nodes; the prognosis is worse if there is local invasion to other pelvic organs (e.g. bladder, rectum), metastatic tumour in iliac lymph nodes, or evidence of blood-borne metastasis.

Vulval intraepithelial neoplasia may precede invasive carcinoma
Although most invasive squamous carcinomas of the vulva appear to arise de novo, some arise in epithelium in which there is severe dysplasia amounting to carcinoma in situ This phenomenon, vulval intraepithelial neoplasia (VIN), is generally seen in patients younger than those with invasive tumours, and there may be co-existent evidence of HPV warty change in the affected and adjacent epithelium; furthermore, HPV16 can be demonstrated in many cases of VIN. Although invasive carcinoma and VIN do occasionally co-exist in elderly women, it is thought that progression of VIN to invasive carcinoma is not common.
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