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Linear Vulvar Lesions

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A 30-year-old woman with congenital absence of the uterus presented to dermatology for a second opinion of vulvar lesions that were first noted during adolescence. The patient reported that the lesions had not changed and were painful during sexual intercourse. The lesions were otherwise asymptomatic, and she had no additional relevant medical history or family history of similar lesions. She denied any history of sexually transmitted infections. Physical examination revealed multiple, soft, flesh-colored, 1- to 2-mm, discrete and coalescing, filiform papules distributed symmetrically in a linear array on the inner aspect of the bilateral medial labia minora. The rest of the mucocutaneous examination was normal.

The lesions on the left medial labia minora were treated with low-voltage (3.0 V) electrodesiccation following local anesthesia with 1% lidocaine (red arrow), while the lesions on the right medial labia minora were left untreated (black arrow). The clinical image shows the left labia minora approximately 1 month after treatment; the papules on the right labia minora were unchanged from the prior examination.

What's the diagnosis?

condyloma acuminatum

condyloma latum

molluscum contagiosum

papulosquamous lichen planus

vestibular papillomatosis

The Diagnosis: Vestibular Papillomatosis

Vestibular papillomatosis (VP), the female equivalent of pearly penile papules, is characterized by multiple papules in a linear array on the labia minora and is considered a normal anatomic variant. It typically presents as monomorphous, soft, flesh-colored, filiform papules that are distributed in a symmetric fashion. In women, the papules present as linear arrays on the inner aspects of the labia minora, whereas in men, they present in a circumferential array along the sulcus of the glans penis.1 Lesions often are asymptomatic but may cause itching, burning, and dyspareunia.2 Previously believed to be associated with human papillomavirus infection,3 VP is now considered a noninfectious condition. Biopsy reveals parakeratosis and perinuclear vacuolization in the absence of true koilocytes.4,5 Dermoscopy and reflectance confocal microscopy have been used to differentiate VP from clinically similar lesions (eg, condyloma acuminatum).6,7 The prevalence of this condition is not well established; however, one study found VP in 1% of women attending genitourinary medicine clinics.3

Condyloma acuminatum, known colloquially as genital warts, is a human papillomavirus infection. Lesions tend to be painless and firm and are distributed asymmetrically with a cauliflowerlike appearance.1 Condyloma latum, found in secondary syphilis, is characterized by papules that are pale, smooth, flat topped, and moist.8 Molluscum contagiosum is an infection caused by a poxvirus presenting with flesh-colored, dome-shaped papules with central umbilication.9 The lesions of papulosquamous lichen planus are violaceous polygonal papules that affect the clitoral hood and labia minora and may cause pruritus. The cause of lichen planus is unknown; however, clinically similar lesions may occur in a lichenoid drug eruption due to certain medications.

Vestibular papillomatosis typically does not require treatment, except in symptomatic cases. To date, limited studies have reported variable treatment success utilizing destructive techniques such as CO2 laser or topical application of 5-fluorouracil or trichloroacetic acid.10

The lesions on our patient's left medial labia minora were successfully treated with low-voltage (3.0 V) electrodesiccation. Following local anesthesia with 1% lidocaine, each papule was gently electrodesiccated utilizing a standard hyfrecation electrode tip to a light gray discoloration. Postprocedural care involved only twice-daily cleansing with a gentle soap and application of petrolatum. The patient tolerated the procedure well and was satisfied with the cosmetic and functional results. She subsequently underwent treatment of the lesions on the right labia minora with equivalent treatment success.

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