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Competing Interests: Competing interests: None declared.

Background: Epidermolytic hyperkeratosis presents a particular histological image common to several clinical pictures, including that of keratinopathic ichthyoses. It may also occur fortuitously in various tumoral and inflammatory lesions. It is the elementary histopathological lesion of epidermolytic acanthoma, which may either be single or multiple, and when it occurs in the genital area, is known as epidermolytic hyperkeratosis of the genitalia or multiple epidermolytic acanthoma of the genitalia. Herein, we report two characteristic cases of epidermolytic hyperkeratosis of the genitalia., Patients and Methods: The first patient was a 50-year-old woman consulting for vulvar pain in whom clinical examination revealed the presence of multiple papules on the labia majora and minora. The second patient was a 44-year-old man consulting for verrucous lesions of the scrotum. In both cases, biopsy revealed an histopathological aspect identical with acanthosis, hyperkeratosis, changes in the keratinocytes, in which the cytoplasm contained clear vacuoles, numerous keratohyalin granules and eosinophilic bodies, resulting in a diagnosis of epidermolytic hyperkeratosis of the genitalia., Discussion: Epidermolytic hyperkeratosis of the genitalia is a rare disease, occurring in middle-aged men and women, but chiefly men. The lesions found on the genital organs may be either single, or, more frequently, multiple, and are described as hyperkeratotic papules, which are also reported under the term multiple epidermolytic acanthomas of the genitalia. The aetiology is unknown; certain authors incriminate a traumatic factor; the role of human papillomavirus (HPV) has been suggested but immunohistochemical studies and molecular biology studies generally reveal no viral DNA. Where lesions cause discomfort to the patient, treatment consists of emollients combined with destruction by cryotherapy or CO2 laser. Imiquimod, calcipotriol, tacrolimus and pimecrolimus have all resulted in regression of lesions., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Human papillomavirus (HPV) infection of the lower genital tract is common and its effects are variable. The majority of infections are transient and the related pathology is self-resolving. Condyloma accuminatum is caused predominantly by HPV 6, 11 and can be managed with medical or surgical therapy. Vulvar intraepithelial neoplasia is a treatable precursor to vulvar cancer with 2 main forms: one related to HPV and the other to chronic vulvar inflammatory conditions. It may be treated medically, surgically, or potentially via the use of therapeutic HPV vaccines. Preventive utilization of a quadrivalent HPV vaccine has the potential to decrease HPV-related lower genital disease burden substantially.

Approximately one of every 10 women has a pigmented vulvar lesion. Given the risk of melanomas and pigmented vulvar intraepithelial neoplasia (squamous cell carcinoma in situ), proper evaluation of vulvar pigmented lesions is critical. Most vulvar lesions are benign; however, vulvar lesions grossly, dermoscopically, and histologically can appear atypical compared with pigmented lesions on the rest of the body. Thus, it is imperative to use not only a keen eye but also a low threshold for biopsy., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Genital human papillomavirus (HPV) is a common, usually transient, dermatologic infection transmitted by genital contact that can cause a variety of anogenital diseases, including warts (condyloma), dysplasia (cervical, vaginal, vulvar, anal), and squamous cell carcinoma. A number of treatment modalities are available to treat anogenital warts, both patient- and provider-applied. Treatment is efficacious, but lesions can recur. Bivalent and quadrivalent vaccines are approved to prevent HPV infection. Both are indicated to prevent cervical cancer, while the quadrivalent vaccine is also approved to prevent vaginal/vulvar cancers as well as genital warts in males and females. Providers should clearly explain the natural history and potential sequelae of HPV disease, counsel patients on prevention strategies, and recommend vaccination as an effective method of prevention to their patients., (© 2010 Wiley Periodicals, Inc.)

Vulvar cancer is a rare disease and its screening is depending on the quality and the relevance of our clinical examination. Incidence of vulvar cancer and especially precancerous lesions, vulvar intraepithelial neoplasias (VIN), increased during these last years. The new terminology of vulvar intraepithelial neoplasia will help us to identify high risk groups which could develop a cancer: usual and differentiated VIN. An early diagnosis is essential to propose an adequate treatment. Management is a major point according to the rising incidence of these lesions in younger women. Until we can observe a benefit from the vaccination against human papillomavirus, we must increase the quality of screening by a careful examination of the vulva.

We present a 40-year-old woman who presented to the genitourinary medicine department with a two-year history of recurrent non-painful vulval lumps. She was in a stable relation with one male sexual partner over the preceding 20 years and her sexual health screen was negative. Clinical examination of these lumps was suggestive of anogenital warts for which she has been treated on numerous occasions over the last two-year-period with liquid nitrogen cryotherapy and podophyllotoxin 0.15% cream. As the lumps were not responding to conventional wart treatment, a biopsy from these lesions was performed. The histological appearance showed focal fibrin thrombus formation within dilated vascular channels consistent of a subepidermal cavernous haemangioma. This case demonstrates that the clinical diagnosis of anogenital warts is not always straightforward. It highlights the importance of obtaining a tissue diagnosis from the resistant or atypically looking warty lesions to avoid making the wrong diagnosis.

The recent outbreaks of sexually transmissible infections (STI) provoke professional concern and public anxiety. There is sporadically published literature reporting cases of vulval, penile and anal cancers presenting at genitourinary medicine clinics. The recent referral of a series of cases, by medical practitioners, as anogenital warts, which were later diagnosed as vulval, penile and anal cancers, is alarming. The cases reflect the current state of apprehension between patients and medical professionals regarding STI.

Objective: The purpose of this study was to determine the incidence and predictors of genital warts and vulvar intraepithelial neoplasia among women with the human immunodeficiency virus., Study Design: This was a multicenter prospective cohort study comprised of women without warts or vulvar intraepithelial neoplasia at baseline who underwent CD4 count, human immunodeficiency virus RNA measurement, examination, Papanicolaou test, and biopsy, as indicated, every 6 months. Human papillomavirus DNA typing was examined at baseline., Results: The incidence of warts among women who were human immunodeficiency virus seronegative was 1.31 versus 5.01 per 100 person-years among women who were seropositive (P < .001). Incidence of vulvar intraepithelial neoplasia among women who were seronegative was 1.31 versus 4.67 per 100 person-years among women who were seropositive (P < .001). In multivariable analysis, warts were associated with highly active antiretroviral therapy (relative hazard, 0.76), CD4 count (relative hazard, 0.91/100 cell/cm(2) increase), acquired immunodeficiency syndrome (relative hazard, 1.25), abnormal Papanicolaou test results (relative hazard, 2.18), high- or medium-risk human papillomavirus types (relative hazard, 1.91), low-risk human papillomavirus types (relative hazard, 1.48), smoking (relative hazard, 1.43), having 1 child (relative hazard, 1.54), and age (relative hazard, 0.74/10 years). Vulvar intraepithelial neoplasia was linked to highly active antiretroviral therapy (relative hazard, 0.65), CD4 count (relative hazard, 0.92), abnormal Papanicolaou test results (relative hazard, 16.03), high- or medium-risk human papillomavirus types (relative hazard, 1.37), and age (relative hazard, 0.85/10 years)., Conclusion: Warts and vulvar intraepithelial neoplasia are common among women with human immunodeficiency virus. Highly active antiretroviral therapy decreases their incidence.

Genital warts can mimic a variety of conditions. We report a middle-aged pregnant woman with lymphangiectatic lesions on the vulva resembling warts.

Lymphangioma circumscriptum (LC) is an uncommon dermatologic problem that rarely affects the vulva and it is considered to be a localised developmental defect of lymphatic tissue in the dermis. We report a case of vulval LC, clinically diagnosed as genital wart, in a 48-year-old woman without evidence of secondary lymphatic damage. The patient required extensive vulval surgery and there was no recurrence after 16 months.

Squamous cell carcinoma is a morphologically heterogenous neoplasm of specific histologic entities involved in human papillomavirus infection. The condylomatous types of squamous cell vulvar carcinoma, caused by HPV-16, most often manifest as exophytic papillary tumors mimicking condylomas.

History and Admission Findings: A 59-year-old woman had for 3 weeks been suffering from painful, moist skin changes on the external genitals, for 3 months having noticed vegetations in the anogenital and perineal region. She had been fatigued and lacking in energy since then. Her last gynecological examination had been 20 years ago. Examination of the skin on admission revealed extensive plaque and cauliflower-like warts and large areas of maceration in the anogenital region, the labia and perineum, with large areas of maceration. Nodules were clearly palpable in the left labium majora: the inner aspects were markedly reddened and had some cutaneous erosions. These findings suggested giant condyloma (GC; Buschke-Löwenstein tumour)., Investigations: Biopsy showed marked condylomatous epithelial proliferations which, with the formation of markedly thickened epithelial cones, had reached the stage of a verrucous carcinoma., Treatment and Course: Under local anti-inflammatory and adstringent medications the inflammatory reaction quickly subsided. Vulvectomy was performed to remove the tumour., Conclusion: Giant condyloma (Buschke-Löwenstein tumour) is a rare pseudocancereous lesion. If human papilloma viruses of type 16 or 18 is demonstrated in the lesions, malignant degeneration should be considered. Histological examination is essential to differentiate it from squamous cell carcinoma.

Acquired cutaneous lymphangiomata are characterized clinically by the presence of a circumscribed eruption of thin-walled, translucent vesicles. However, epithelial changes and tissue organization may occasionally give rise to firmer nodules or even warty lesions. When these arise on the vulva, diagnostic difficulties may ensue. We report two patients in whom vulval lymphangiomata resulting from treatment for cervical neoplasia were mistaken for viral warts.

By using 35S-dCTP labelled HPV16 probe, the HPV DNA sequence in 32 cases of condyloma acuminatum and suspicious condyloma acuminatum of vulva and vagina as well as 18 cases of papillomas at different anatomical sites were detected. The results showed that the HPV DNA sequences were positive in all 25 cases of condyloma acuminata which were typical both clinically and pathologically and in 6/7 of the suspicious cases; whereas in only 1/18 of the papillomas at various sites were they positive. Thus, nucleic acid hybridization-in-situ technique combined with histopathology seemed to be of great value for the diagnosis and differential diagnosis of condyloma acuminatum.

Infection of the genital organs by human papillomavirus (HPV) is the most commonly diagnosed sexually transmitted disease. Papillomaviruses lead to a contact infection of the epithelium and present with different clinical and histological signs. With the exception of the best known clinical manifestation Condylomata acuminata, subclinical infections can be only diagnosed from a stepwise examination. Physiological results from both men and women may be falsely explained as being caused by viruses, and can lead to an incorrect therapy. Genital papilla (Papillae coronae vulvae et glandis) present as atavistic cutaneous papilla a normal situation but with functional significance. Differences in clinical symptoms as well as the possibilities of further differentiation can be obtained by means of pictures taken during colposcopy.

Human papillomaviral infections are an increasing concern of clinicians and patients alike. These infections can manifest as overt disease, such as condyloma or genital dysplasias, or can be present at either a subclinical or a latent stage. Because of the correlation between human papilloma virus and lower genital tract cancers, this increased prevalence is of special concern to women and to the clinicians who treat them.

Cervicography has been shown to be a very sensitive screening tool in the general population. Its value in screening a high-risk population was explored. One hundred five women seen with vulvar condylomata or a history thereof were offered a cervigram and Papanicolaou smear. Twelve patients had abnormal smears, whereas 53 had abnormal cervigrams. Colposcopically directed biopsies in the abnormal Papanicolaou group revealed cervical intraepithelial neoplasia (CIN) I in six patients and III in two. Cervicography-positive patients exhibited CIN I in 9 cases, II in 1 and III in 2. There was some overlap. Twelve patients had cervical condylomata without dysplasia. Cervicography, in addition to cervical cytology, should be considered for all women with vulvar condylomata.

A detailed colposcopy study of the cervix, vagina and vulva was conducted in 365 women referred for genital human papillomavirus (HPV) lesions, abnormal cervico-vaginal smear or cervical intraepithelial neoplasia (CIN). Valvuloscopic abnormalities, all biopsied, were found in 144 women, i.e. 40% of the population studied. Five types of vulvoscopic abnormalities are described: diffuse acidophilia (55% of abnormalities), acidophilic maculae (17%), micropapillae (20%), papulae (4%) and leucoparakeratosis (4%). Histological examination of the biopsy specimens obtained from 144 women with abnormal vulvoscopy showed 55 typical flat condylomas (38%), 50 probable flat condylomas (35%) and no signs of condyloma in 38 cases (27%). It also revealed the presence of four vulvar intraepithelial neoplasias (VIN) stages 2-3, all of them associated with typical or probable condyloma. Comparison between the 144 abnormal vulvoscopies and a series of 14 normal vulvoscopies made it possible to establish a significant correlation between the presence of valvuloscopic abnormalities and the finding of histological signs of typical or probable flat condyloma. The vulvoscopic images of subclinical vulvar HPV infection, but apart from papulae and, to a lesser extent, leucoparakeratosis, correlations between vulvoscopic and histological images were imprecise.

A 28-year-old woman with diabetes mellitus and alcoholic hepatitis presented a rare case of Buschke Lowenstein tumor, or giant condyloma of vulva. HPV DNA of this tumor was detected by in situ hybridization using tritium labeled HPV 6 b, 16 and 18 DNA. This tumor appeared to harbour HPV 6 b DNA, but other HPV DNAs were negative. The distribution of HPV 6 b DNA was detected in the nucleus of the squamous epithelium showing koilocytosis. Total vulvectomy and resection of the clitoris were done. The postoperative course was uneventful and there has been no recurrence of tumor so far.

Seventy-five patients with anogenital warts were biopsied in the Center for Sexually Transmitted Disease of Galliera Hospital (Genoa). Bioptic specimens were processed for histologic examination, immunohistochemistry using polyclonal antibodies against HPV capsid common antigens and in situ hybridization using HPV 6/11, 16/18, 31/35/51 DNA probes. The aim of the study was to detect patients positive for HPV 16/18, 31/35/51 DNA probes. These HPV types have a higher oncogenic potential and patients with lesions harbouring them are considered to be at risk for progression to malignancy. These patients should be followed up carefully and periodically for early detection of new lesions and neoplastic transformation.

A case is presented of white sponge nevus involving the vaginal, labial, and oral mucosae of a 34-year-old woman. White sponge nevus is a rare, benign, autosomal dominant leukokeratosis that predominantly affects the oral mucosa. Less frequently, it affects extraoral sites including the vulvovaginal mucosa. In this case, histopathologic study of vulvovaginal lesions, subsequent examination of extragenital mucosae, and inquiry into the family history led to the correct diagnosis. The genetics, clinical appearance, and histopathology of white sponge nevus are discussed in relation to the differential diagnosis of oral and vaginal leukokeratoses.

We investigated human papillomavirus (HPV) DNA of vulvar diseases obtained from 18 cases of condyloma acuminatum, 3 cases of hyperplastic dystrophy without atypia, 4 cases of lichen sclerosus, 4 cases of Bowenoid papulosis, one case of Bowen disease and 8 cases of squamous cell cancer by in situ hybridization with biotinylated HPV 6, 11, 16 and 18 DNA probes. The results of in situ hybridization analysis showed that HPV 6/11 was positive in 94.4% (17/18) of condyloma acuminatum. In 17 cases of HPV 6/11 positive condyloma acuminatum, 3 cases were positive for HPV 16 and one for HPV 18, respectively. HPV 16 was positive in 75.0% (3/4) of Bowenoid papulosis and one case of Bowen disease was positive for HPV 18. In two cases of Bowenoid papulosis which were positive for HPV 16, cervical carcinoma in situ containing HPV 16 DNA sequences was also found during the follow up period. In 8 cases of squamous cell cancer, 2 cases were positive for HPV 18, one for HPV 16 and one for HPV 6/11. All cases of hyperplastic dystrophy without atypia and lichen sclerosus were negative for HPV DNA. Our results suggested HPV is closely associated with vulvar neoplasia.

Macroscopic visualization of flat vulval warts is usually obtained by application of 3-5% acetic acid for 2-5 min. However, we have recently seen two women with symptoms suggesting the presence of condylomatous vulvitis where the use of 5% acetic acid for 10-15 min. was necessary for aceto-white lesions to develop. In both women, histologic examination indicated the presence of a Human papillomavirus infection. Prolonged application of acetic acid 5% should be considered among women in whom vulval papillomavirus infection is suspected.

There are now known to be many genotypes of human papillomavirus (HPV). Types 6 and 11 are closely associated with benign lesions of genitoanal epithelia; the classical forms are condylomata acuminata and papular warts, collectively known as genitoanal or "venereal" warts, but it is now known that subclinical infections are much more common. These were first identified on the cervix uteri by colposcopy after the application of acetic acid, but they can also be found on penile and vulval epithelia by the same technique. Genitoanal HPV infection is an increasingly common disease; because it is usually sexually transmitted, it is important that before a patient is treated appropriate laboratory tests are used to identify or exclude other infections. It is also important that female patients have cervical cytology, because cervical intraepithelial neoplasia is often associated with genital HPV infection. Treatment of anogenital warts is often difficult, and no one form of therapy is effective. Treatment modalities used include cytotoxic agents (podophyllin, podophyllotoxin, fluorouracil), and destructive procedures (scissor excision, cryotherapy, electrocautery, carbon dioxide laser). Recently, the possibility of using interferons either alone or in association with other forms of treatment has been investigated.

The present casuistry study deals with condylomata acuminata-like lesions of the vulva of two sexually mature 20 and 22 years old Turkish sisters, and a 34 year old Yugoslavian women. Based on clinical and histological particularities the verruciform structures are interpreted as - atavistic? - malformation without functional significance. Their relation to the papillas of corona glans are proved in detail.

We reviewed 65 intraepithelial lesions of the vulva and distal vagina and compared the presence of koilocytosis, abnormal mitoses, and parabasal or basal nuclear enlargement with DNA microspectrophotometric distribution patterns and the presence of human papillomavirus antigen as determined by immunoperoxidase. Abnormal mitoses and cytologically atypical nuclear enlargement were specific predictors of aneuploidy and were reliable for distinguishing vulvar intraepithelial neoplasia (VIN) from condylomas. Koilocytosis was present in 100% of condylomas and 71% of aneuploid (VIN) lesions, but there were qualitative and quantitative differences in the distribution of koilocytic cells in the two classes of lesions. On the basis of these findings, criteria for distinguishing between VIN and condyloma are proposed.

Cases of carcinoma of the vulva with a warty appearance were reviewed. Altogether, 27 cases of warty carcinoma of the vulva were treated at the University of Minnesota Hospitals between 1976 and 1980, which accounted for 22.4% of all vulvar epithelial malignancies. As compared to the previous experience between 1951 and 1970, this relative frequency increased fourfold. Clinical history indicated that warty carcinoma of the vulva was not necessarily preceded by long lead periods of in situ lesions. The lesions seemed to occur in all ages after adolescence, were multifocal in one third of the cases, were frequently locally recurring, and were relatively benign despite their often large size. Many of them were originally diagnosed as condyloma acuminatum. Virus-like particles were seen in eight of the 12 cases (67%) examined with transmission electron microscopy, which included six cases of invasive lesions. These observations suggest that human papillomavirus (HPV) may be the important etiologic agent of this group of tumors. Warty carcinoma of the vulva must be clearly separated from conventional invasive squamous cell carcinoma of the vulva, as its clinical behavior and a possible etiology appear unique.

Two new cases of bowenoid papulosis are reported, one in a male with Behçet's syndrome, and the other in a young woman. The literature is reviewed, we consider the different etiopathogenic factors and we discuss its nature and nosology.