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A 61-year-old female presented with progressive plaques on the left forehead and right labia., (© 2024 the International Society of Dermatology.)

Objective: To investigate the characteristics, diagnosis and therapeutic effect of acquired lymphangiectasia of the vulva (ALV). Methods: A retrospective analysis of clinicopathological and follow-up data was conducted on the patients treated in Capital Medical University Affiliated Beijing Shijitan Hospital due to female ALV from July 2009 to July 2023. The patients who completed the staged operations [partial labiectomy and reconstruction + thoracic ductplasty and (or) perineal lymphovenous anastomosis] were included in the study and followed up. The improvement of perineal swelling, blister range, fluid leakage volume and frequency were evaluated through outpatient visits by the symptom rating scale of ALV (hereinafter referred to as the symptom rating scale) before and after surgery. Results: A total of 48 patients were treated due to ALV from July 2009 to July 2023, of which 98% (47/48) were postoperative pelvic malignant tumors and 94% (45/48) had a history of radiotherapy. A total of 10 patients with ALV who completed the staged operations were included in this study. (1) Clinical characteristics and diagnosis: 10 patients had a median age of 60 years old (50, 63 years old ). The median duration from cervical cancer surgery and radiation therapy to vulvar swelling was 1.5 years (0.0, 2.0 years), and the median duration from vulvar swelling to blister formation and leakage was 0.0 years (0.0, 4.8 years). Seven patients (7/10) had a history of recurrent erysipelas; 7 patients (7/10) had the most severe symptom (widespread blisters, persistent fluid leakage, and large amount of fluid leakage); noncontrast magnetic resonance lymphography (NCMRL) showed edema signals in the perineal region of all the patients, and increase of agent in the perineal region was observed in lymphoscintigram (LS). (2) Surgical treatment and postoperative pathological examination: of the 10 ALV patients who completed staged surgical treatment, 6 cases (6/10) were diagnosed with thoracic duct outlet obstruction and underwent thoracic ductplasty and partial labiectomy and reconstruction. Perineal lymphovenous anastomosis and partial labiectomy and reconstruction were performed in 4 cases (4/10) without thoracic duct outlet obstruction. Postoperative routine pathological examination of 10 patients (10/10) showed dermal papilla lymphangiectasia. Immunohistochemical tests were performed on 5 patients, all of which were positive for D2-40 and negative for CD 34 . (3) Efficacy: 8 patients completed the postoperative follow-up, and the median follow-up time was 31.0 months (17.5, 78.3 months). The perineal swelling and the blister fluid leakage were all significantly improved after the staged operations. All indexes of the symptom rating scale, including the degree of perineal swelling, blister range, fluid leakage volume and frequency, were significantly improved in 8 follow-up patients, and 3 (3/8) of them were cured; the median symptom score decreased significantly from 11.0 before surgery to 3.0 after surgery ( P <0.001). The incidence of erysipelas was significantly reduced from 7/10 before surgery to 2/8 after surgery ( P =0.035). Conclusions: The main causes of female ALV are pelvic tumor surgery and radiotherapy. The clinical diagnosis is made from relevant medical history, clinical manifestations, LS and magnetic resonance imaging. The diagnosis is confirmed by histopathological findings. Pathological results show lymphangiectasia in the dermal papilla, and immunohistochemical staining show positive for D2-40 and negative for CD 34 . The effect of staged surgery on ALV is remarkable and even cured, and could effectively reduce the incidence of erysipelas.

Background: Lichenoid vulvar dermatoses (LVD) are inflammatory diseases primarily affecting the vulva and anus. This study aims to evaluate the skin changes in patients with LVD using high-frequency ultrasound., Methods: Forty-five patients with LVD, who attended Henan Provincial People's Hospital from November 2021 to March 2024, were selected. According to the pathological conclusions, patients were divided into two groups: the vulvar lichen sclerosus (VLS) group (n = 24) and the vulvar lichen simplex chronicus (VLSC) group (n = 21). Thirty age- and BMI-matched healthy women were selected as the control group. We assessed the epidermal thickness, subepidermal low echogenic band (SLEB) thickness, dermal thickness, and vascular index (VI) among the three groups. Receiver operating characteristic curve (ROC) analysis was performed to determine the diagnostic efficacy of these ultrasound parameters for LVD. Binary logistic regression was used to investigate risk factors influencing LVD pathology in VLS patients., Results: Epidermal thickness, SLEB thickness, dermal thickness, and VI were increased in the VLS and VLSC groups compared to the control group (p < 0.05). There were no statistically significant differences in ultrasound parameters between the VLS and VLSC groups (p > 0.05). The ROC curves showed that the area under the curve (AUC) value for the dermis (AUC = 0.882) was the largest for VLS, and VI (AUC = 0.917), it was the largest for VLSC. Binary logistic regression indicated that having an allergic disease was a risk factor for VLS between VLS and VLSC groups (OR = 6.797, p = 0.028)., Conclusion: High-frequency ultrasound can detect thickening of the skin and increasing VI in patients with LVD, which can be helpful in the evaluation and management of LVD., (© 2024 The Author(s). Skin Research and Technology published by John Wiley & Sons Ltd.)

Competing Interests: The authors declare no conflicts of interest.

Mucous membrane pemphigoid is a rare autoimmune disease affecting mucosal surfaces. Pediatric cases are exceptionally rare, one subtype being vulvar pemphigoid. Juvenile vulvar pemphigoid can be challenging to diagnose due to its rarity and subtle initial symptoms. We present a case of an 8-year-old girl successfully diagnosed early in the disease course via histopathology, and immunofluorescence. Detecting MMP can be complex due to variations in epitope binding typically not included in commercial ELISA assays, necessitating comprehensive workup. Missed diagnosis may lead to progression to systemic involvement with severe consequences; thus, timely diagnosis and treatment are crucial., (© 2024 The Authors. Pediatric Dermatology published by Wiley Periodicals LLC.)

Background : Inflammatory lesions and cysts are the most common Bartholin glands pathologic diagnoses. There have been very few reports of benign solid lesions of Bartholin glands such as nodular hyperplasia. Materials and methods : Thirty-two lesions diagnosed as Bartholin duct cyst in the gynecologic specialized institute were reviewed by two expert gynecological pathologists. Results : Using specific criteria, 7 qualified as nodular hyperplasia, 25 as Bartholin duct cyst. The average age of the patients with nodular hyperplasia was 31 years (range, 24 to 43). These lesions were solid, solid and cystic or purely cystic, had a mean maximal dimension of 3.3 cm, and were frequently thought to be Bartholin cysts on clinical examination. Four lesions were diagnosed as Bartholin duct cysts, while in the review they were considered as nodular hyperplasia. Conclusion : Nodular hyperplasia of Bartholin gland may be more common than is reported in the literature. This study showed that the diagnosis of nodular hyperplasia has been overlooked due to limited literature sources., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Competing interests: None declared.

Background: A Bartholin's gland abscess is one of the most common infections in women of reproductive age. Although Bartholin's gland abscesses have been reported in prepubertal children, they are rarer in prepubertal children than in adults. Herein, we report a case of bilateral Bartholin's gland abscesses in a 4-year-old girl with vitamin A deficiency., Case Presentation: A 4-year-old girl diagnosed with autism spectrum disorder was admitted to the hospital for close examination and treatment because of persistent fever and malaise. The child was a marked fussy eater and was diagnosed with corneal ulceration and night blindness secondary to vitamin A deficiency. Both of the patient's labia were swollen, and a diagnosis of a bilateral Bartholin's gland abscess was made using computed tomography. Incisional drainage was performed under general anesthesia. The patient's postoperative course was uneventful, and she was discharged from the hospital on day 8 after the surgery. During hospitalization, attempts were made to correct the vitamin deficiency by adding nutritional supplements to the diet. Three months after the surgery, no recurrence of abscesses was noted., Conclusions: Decreased immunocompetence and mucosal barrier function due to vitamin A deficiency is thought to be the underlying cause of Bartholin's gland abscesses. Although prepubertal Bartholin's gland abscesses have been reported, they are rare. To the best of our knowledge, no reports of bilateral Bartholin's gland abscesses potentially caused by vitamin A deficiency have been reported. When prepubertal girls present with Bartholin's gland abscesses, the presence of immunodeficiency due to vitamin or trace element deficiency should also be considered., (© 2024. The Author(s).)

Objectives: The aims of this retrospective study were to evaluate the clinical applicability of the latest International Society for the Study of Vulvovaginal Disease (ISSVD) and International Federation for Cervical Pathology and Colposcopy (IFCPC) terminology for vulvar diseases, and to explore a new evaluation flow to optimize decision-making on diagnosis., Methods: A total of 1,068 patients with 5,340 qualified vulvar images were evaluated by observers using 2011 ISSVD and 2011 IFCPC terminology systems. The sensitivity, specificity, positive predictive value, negative predictive value, Youden Index and Overall Diagnostic Value (ODV) were calculated for each finding in the two systems. Then the disease diagnosis order and a diagnosis flow draft (DFD) were obtained., Results: A total of 15 kinds of vulvar diseases were diagnosed. The proportion of patients accompanied with cervical or vaginal intraepithelial neoplasia was highest (83.3 %) in vulvar Paget's disease group (p<0.001). Total area of lesions was larger in vulvar Paget's disease, lichen simplex chronicus and lichen sclerosus group (p<0.001). Among the top five findings of ODV, some findings inferred several (≥6) kinds of diseases, while some findings only exist in a certain disease. When the DFD was used, the agreement between the initial impression and histopathology diagnosis was 68.8 %, higher than those when ISSVD an IFCPC terminology systems used (p=0.028), and it didn't change with the experience of the observer (p=0.178)., Conclusions: Based on the findings in ISSVD and IFCPC terminology systems, we explored a DFD for observers with different experience on the detection of vulvar disease., (© 2023 the author(s), published by De Gruyter, Berlin/Boston.)

There is a rare subset of non-sexually acquired acute genital ulcers, previously called Lipschutz ulcers, that are often preceded by a constitutional prodrome and have been associated with multiple viral and bacterial infections. These ulcers are categorized by some as a variant of complex aphthosis, with one hypothesized etiology involving a non-specific systemic inflammatory response to acute infection or vaccination. Although painful, these lesions resolve over the course of several weeks and recurrence is rare but possible. Recently, there have been reports of genital ulcer development due to either acute infection with COVID-19 or following vaccination against the same. We report a case of non-sexually acquired acute genital ulceration that initially presented in 2008 as Lipschutz labial ulcers associated with acute Epstein-Barr virus infection, with recurrence twelve years later following administration of the second dose of the Pfizer-BioNTech COVID-19 vaccine. This case report and exhaustive literature review challenges widely accepted views regarding the typical age range of patients affected by non-sexually acquired acute genital ulceration, the sexual history of affected populations, the pathophysiology of lesion occurrence, and possibility of lesion recurrence.

Endometriosis is a benign, estrogen-dependent condition that commonly affects women during the reproductive age. Postmenopausal endometriosis is a rare condition because of the absence of estrogenic hormone production. Furthermore, extrapelvic endometriosis is a rare and complex phenomenon. For this reason, it is usually a misdiagnosed disease. An 84-year-old female patient with no medical history of endometriosis or dysmenorrhea and no hormone replacement therapy was found to have a 4.4×3 cm tender, mobile mass on the left labium majus detached from the underlying perineal muscle. The patient underwent surgical excision under sedation and local anesthesia. The mass was easily removed intact and was not adherent to the vagina or the perineal muscles. Surgical resection of the lesion should be performed in order to remove the lesion and to confirm the diagnosis histologically. The diagnosis of long-standing endometriotic cyst was made. Primary vulvo-perineal endometriosis is a rare and difficult diagnosis especially in postmenopausal women without previous surgical procedures and no history of endometriosis. A better awareness of symptoms and signs of uncommon locations of extrapelvic endometriosis should be encouraged in order to optimize patient care. Finally, more research is needed to elucidate the pathogenesis of endometriosis in postmenopausal women.

Competing Interests: The authors have declared they have no conflicts of interest.

Herein we describe the case of a Black adolescent who was found to have widely metastatic melanoma originating from a primary vulvar lesion. The lesion presented as a pink, vegetative nodule of the clitoral hood which grew in size over several years and was confirmed to be melanoma on shave biopsy. This patient's amelanotic presentation in conjunction with the rare incidence of vulvar melanoma contributed to the delay in diagnosis. This case exemplifies the challenge of early recognition of potentially malignant vulvar lesions for primary care providers in adolescents., (© 2023 Wiley Periodicals LLC.)

Background: The accessory breast is composed of residual glandular mammary tissue that persists after normal embryonic development. The entity is so rare that it is easily neglected in the diagnosis of disease., Case Presentation: We report a 24-year-old virgin Persian woman with a left-sided vulvar mass and no pain or discomfort until shortly before her presentation at our department. Ectopic breast tissue in the vulva was diagnosed. We performed wide local resection of the lesion. Pathological investigation of the lesion confirmed the presence of ectopic breast tissue with secretory changes. She had no specific developmental abnormalities and had no relevant family history. She was followed up for 10 months and had recovered fully by this time., Conclusion: Accessory breast tissue should be considered as a diagnosis when a mass is seen along the embryonic milk line, especially if the clinical findings reveal changes in the mass accompanied by changes in sex hormones., (© 2023. The Author(s).)

Abstract: The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2-3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient's characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO2) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2023 ESGO, ISSVD, EFC, ECSVD. Published by Wolters Kluwer Health, Inc. on behalf of the ASCCP.)

Objective: This study aimed to investigate the prevalence of genitourinary syndrome of menopause (GSM) in Japan using the Japanese translation of the Vulvovaginal Symptoms Questionnaire (VSQ) with online survey. In addition, we examined the relationship between sexual activity and GSM symptoms., Methods: An online survey on GSM was conducted with 4,134 women aged 40 to 79 years, who were registered in an online survey company. Several questionnaires with Japanese translations of linguistic validity were used in this study. GSM was defined as a condition in women older than 40 years with vulvovaginal symptoms on the VSQ., Results: The percentage of postmenopausal women 40 years and older was 69.6%. The percentage of women with sexual activity was 22%. The prevalence of GSM with vulvovaginal symptoms was 11.6%, and 31.7% in sexually active women. The prevalence of GSM was associated with age and was significantly lower in the 70s age group than in other age groups. Vulvar hurting and dryness were both age-related only in the sexual activity group, with a statistically significantly higher prevalence in the 70s group than in the 40s group. The prevalence of vulvar dryness during sexual activity was significantly lower in the 40s age group., Conclusions: An online epidemiological survey of GSM was conducted for the first time in Japan using the linguistically validated Japanese translation of the VSQ. The prevalence of GSM with genital or sexual symptoms was 11.6% in Japanese women 40 years and older, and 31.7% in sexually active women., Competing Interests: Financial disclosure/conflicts of interest: None reported., (Copyright © 2023 by The North American Menopause Society.)

Lipschütz ulcer is a non-sexually transmitted genital lesion of unknown etiology, which presents as a painful vulvar ulcer. Lipschütz ulcers have been described in most continents. This is the first case reported in Peru and South America. We present the case of a 33-year-old female patient with a Lipschütz ulcer after being vaccinated with the second dose of the AstraZeneca COVID-19 vaccine. She reported having had only one sexual partner in her lifetime. Laboratory results were negative for herpes simplex 2, Cytomegalovirus, Toxoplasma gondii, Epstein-Barr virus, and syphilis. The patient received symptomatic treatment. Ten days after the onset, the patient was significantly better during follow-up. This case report displays a potential adverse effect of the AstraZeneca COVID-19 vaccine as a Lipschütz ulcer triggered by the host humoral immune response. However, further research is needed to establish the causal relationship between these two., Competing Interests: The authors have completed the ICMJE conflict of interest statement and declare that they received no funding for the completion of this article; they have no financial relationships with organizations that may have an interest in the article published in the last three years, and they have no other relationships or activities that could influence the publication of the article. The forms can be requested by contacting the corresponding author., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

Synechiae of the vulva occurs especially in girls in the so-called resting hormonal period with a minimal serum concentration of estrogens. If the external genitalia of the girl are not treated properly, the mucous membrane of the vaginal entrance is not regularly checked and mechanically removed, then the smegma of the opposite mucous membranes of the vulva can stick together. The place of the adhesion of epithelium in the vaginal introitus can be covered by a new epithelium and can create a firm adhesion, synechiae of the vulva, which is usually asymptomatic and is discovered incidentally during pediatric examination. Clinically significant vulvar synechiae can cause impaired bladder evacuation and recurrent lower urinary tract infections. Dissection of synechiae in the stage of conglutination or thin adhesion is performed manually on an outpatient basis, but extensive and firm adhesions must be divided surgically under general anesthesia. Local application of cream with estriol or betamethasone is also used for the therapy of synechiae of the vulva, but this treatment is more time-consuming compared to rapid manual separation and requires good compliance of the girls and their parents. The prevention of synechiae is based on the education of parents by pediatricians and gynecologists about the need for regular checks of the external genitalia and sufficient hygiene.

This case report describes a 15-year-old female who presented with acute onset of painful genital ulcers. She denied being sexually active and tested positive for severe acute respiratory coronavirus 2 five days prior. Associated symptoms on days 1 to 3 included fatigue, nausea, headaches, and fever. Lipschutz ulcers (LUs), also known as aphthous ulcers, acute genital ulcers, and acquired genital ulcerations; are an uncommon, self-limiting, nonsexually transmitted condition characterized by the rapid onset of painful, necrotic ulcerations of the vulva or lower vagina. The pathogenesis of LUs is unclear, and the diagnosis is one of exclusion., (Copyright © 2022 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Objectives: The aims of this article were to describe 2 patients with a pathological diagnosis of differentiated exophytic vulvar intraepithelial lesion and to summarize the literature regarding this relatively new diagnosis., Materials and Methods: The existing literature was searched on December 1, 2021, using the MEDLINE database (1966-2021), and all combinations of the following search terms were used: "differentiated exophytic vulvar intraepithelial lesion" and "differentiated vulvar intraepithelial neoplasia.", Results: Patients were postmenopausal and reported persistent vulvar itch associated with white hypertrophic plaques. Initial biopsies did not identify differentiated exophytic vulvar intraepithelial lesion. Invasive squamous cell carcinoma was found in both cases after surgical excision., Conclusions: Differentiated vulvar intraepithelial lesions and invasive squamous cell carcinoma should be considered in the differential diagnosis of vulvar itch associated with hypertrophic plaques in postmenopausal women. Excision of suspicious plaques is recommended for definitive diagnosis., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2022, ASCCP.)

Vulvar disease is common, and urologists are often the first providers to see patients with a vulvar skin condition. Primary vulvar dermatoses can be localized to the anogenital area or a manifestation of more diffuse cutaneous disease. Additionally, secondary dermatoses can develop from exogenous agents and inflammatory vaginitis. Vulvar conditions are challenging to diagnose due to location and different types of skin and mucosal epithelium involved. Herein, we provide an overview of noninfectious inflammatory vulvar dermatoses (Part I) and benign and malignant vulvar neoplasms (Part II), grouped by morphologic findings. We include diagnostic evaluation, workup, and management of these conditions., Competing Interests: Conflicts of Interest None, (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Vulvar disease is common, and urologists are often the first providers to see patients with a vulvar skin condition. Primary vulvar dermatoses can be localized to the anogenital area or a manifestation of more diffuse cutaneous disease. Additionally, secondary dermatoses can develop from exogenous agents and inflammatory vaginitis. Vulvar conditions are challenging to diagnose due to location and different types of skin and mucosal epithelium involved. Herein, we provide an overview of noninfectious inflammatory vulvar dermatoses (part I) and benign and malignant vulvar neoplasms (part II), grouped by morphologic findings. We include diagnostic evaluation, workup, and management of these conditions., Competing Interests: CONFLICTS OF INTEREST None., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

In this study, a prospective study was conducted by using optical coherence tomography (OCT) in the in vivo detection of vulvar diseases. The clinical efficacy of the OCT we investigated in the detection of vulvar diseases, and the characteristics of the OCT images were defined. Overall, this study recruited 63 patients undergoing the colposcopy for vulvar lesions in three Chinese hospitals from December 20th, 2018 and September 24th, 2019. The colposcopy and the OCT examination were performed successively, and the OCT images were compared with the relevant tissue sections to characterize different lesions. The OCT diagnoses where categorized into 7 types, including normal and inflammatory vulva, condyloma acuminata, papilloma, lichen sclerosus, atrophic sclerosing lichen, fibrous epithelial polyp as well as cysts. The structural characteristics of the vulva tissue can be clearly observed in the OCT image, which are consistent with the characteristics of the tissue section. Compared with the pathological results, the sensitivity, specificity and accuracy of the OCT examination reached 83.82% (95% confidence interval, CI 72.5%-91.3%), 57.89% (95% CI 34.0%-78.9%) and 78.16%, respectively. The OCT is found with the advantages of being noninvasive, real-time and sensitive and with high resolution. It is of high significance to screening vulva diseases, and it is expected as one of the methods to clinically diagnose vulva diseases., (© 2022. The Author(s).)

Objective: To investigate the efficacy, safety, and influencing factors of secondary focused ultrasound (FU) therapy for recurrence of non-neoplastic epithelial disorders of the vulva (NNEDV)., Methods: Patients with NNEDV who have relapsed after initial FU treatment were included in this study. They were treated with secondary FU therapy between July 2015 and July 2021. Outcome measures included the degree of symptom severity and operative complications. We further analyzed the relationships between age, course, time between relapse and initial treatment, menopause status, lesion size, pathological types, severity of symptoms, and curative rate., Results: There were 98 patients enrolled in this study, with a mean age of 47.4 ± 11.4 years. All patients successfully underwent secondary FU therapy. Blisters developed among 16 (16.3%) patients, of whom 6 (6.1%) developed superficial skin ulcers. A curative response was observed among 46 (46.9%) patients, while an effective response was observed among 44 (44.9%) patients. Only 8 (8.2%) patients showed no improvement. The total response rate was 91.8%. A total of 12 (12.2%) cases recurred among all effective cases. Patients with a recurrence of NNEDV after more than 1.5 years following their first FU therapy demonstrated a higher response rate than those with a recurrence after less than 1.5 years., Conclusions: A second FU therapy remains effective for patients with recurrent NNEDV with no obvious side effects. The response rate, however, is higher for patients who experience recurrence of NNDEDV after more than 1.5 years.

Not required for Clinical Vignette.

Melanocytic pigmentation occurs in multiple sites in the lower female genital tract, but is rare within benign cysts of the vulva. We report 3 patients with multiloculated cystic lesions of the vulvar vestibule exhibiting prominent melanocytic pigmentation. The current cases differ from a previous report of melanosis in a Bartholin gland cyst in that the population of melanocytes occupies the acinar structures of the gland, rather than a squamous-lined surface. A similar cell population is demonstrated by immunoperoxidase methods in a fourth patient's nonpigmented gland, suggesting that melanin production may arise in a native, rather than metaplastic, cell population., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 by the International Society of Gynecological Pathologists.)

Crohn's disease is a multi-systemic chronic inflammatory disease that can affect various organs besides the gastrointestinal tract such as joints, uvea, and the skin. Vulvar Crohn's disease is a rare entity occurring with vulvar lesions that show typical Crohn's disease granulomatous inflammation but are not contiguous with the gastrointestinal involvement. Vulvar Crohn's disease can be easily confused with other granulomatous diseases and awareness that such involvement may precede gastrointestinal symptoms must be raised. Few cases of vulvar Crohn's disease have been reported in the literature to date. Here, we report a case of a 43-year-old woman with a 6-month history of a vulvar lesion; the patient was diagnosed with Crohn's disease of the large bowel just over a year ago., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aims: Most vulvar squamous cell carcinomas are human papillomavirus (HPV)-associated or TP53-mutant. A third category of HPV-independent TP53-wild-type lesions is uncommon and not fully understood. Differentiated exophytic vulvar intraepithelial lesion (DEVIL) has been characterised as a precursor of this latter category. The reproducibility of the diagnosis of DEVIL and its distinction from lesions with overlapping morphology has not been studied. Our aim was to establish the interobserver agreement in the diagnosis of DEVIL and its distinction from neoplastic and reactive conditions of the vulva on haematoxylin and eosin evaluation., Methods and Results: A set of 35 slides was evaluated by eight reviewers (two trainees and six practising gynaecological pathologists). The set included DEVIL, condyloma, established vulvar precursors [high-grade squamous intraepithelial lesion (HSIL) and differentiated vulvar intraepithelial neoplasia (dVIN)] with superimposed acanthosis or verruciform growth, lichen simplex chronicus (LSC), and psoriasis. Kappa (κ) values were calculated. Overall, interobserver agreement was moderate (κ = 0.56), improving to substantial (κ = 0.7) when evaluation was performed by practising pathologists. Agreement was strong for the diagnosis of HSIL (κ = 0.88), and substantial for the diagnosis of DEVIL (κ = 0.61), condyloma (κ = 0.79), and LSC (κ = 0.72). Agreement was moderate for the diagnosis of dVIN (κ = 0.59) and psoriasis (κ = 0.53). Perfect agreement (6/6) among practising pathologists was observed in 43% of cases, and majority agreement (5/6 or 4/6) was observed in 48% of cases., Conclusions: Reproducibility in the diagnosis of verruciform vulvar lesions, including the novel DEVIL, is acceptable overall. Reproducibility is higher for well-known lesions such as HSIL and condyloma than for more challenging diagnoses such as DEVIL, dVIN, and psoriasis. Agreement is higher among practising gynaecological pathologists, suggesting that training and experience improve reproducibility. Our findings support the inclusion of DEVIL as a diagnostic entity in the classification of vulvar squamous lesions., (© 2021 John Wiley & Sons Ltd.)

Seborrheic keratoses (SKs) are benign lesions of uncertain etiology, which can develop in both genital and extra-genital locations. For genital SKs, there has been conjecture about the pathogenic role of human papillomavirus (HPV), in view of the frequent association of this virus with genital lesions. In light of the potential consequences on patient management, we investigated the relationship between HPV and SKs of the female genital tract (FGT). For this, we evaluated the current evidence on this relationship by performing an in-depth review of the literature. Furthermore, to add to the evidence on this association, we investigated the presence of HPV in a series of vulvar SKs (n=15), using a novel multimodal approach. This involved whole tissue section-polymerase chain reaction (WTS-PCR) using SPF10-DEIA-LipA25 for HPV detection and genotyping. In addition, immunohistochemistry (IHC) was performed with cellular biomarkers p16 and MIB-1, and viral biomarker E4, to augment HPV-testing. Finally, laser-capture microdissection-PCR (LCM-PCR) was performed to locate HPV to specific lesional cells, and to rule out incidental detection of resident HPV with WTS-PCR. Our findings from the literature review, as well as, the case-series are presented.

Human papillomavirus (HPV) types 6 and 11 were detected in a 3-year-old girl with extensive anogenital condylomata. Although sexual abuse must be considered, non-sexual transmission is evident in at least 57% of children with anogenital warts. Perinatal transmission may occur in approximately 24.5% of infants born to HPV-positive mothers. We present an immunosuppressed child with giant condylomata and discuss transmission, work up, and treatment.

Abstract: In vulvar biopsies, we have observed histopathologic abnormalities of elastic fibers identical to solar elastosis, with thick, curled, and irregular pale grey fibers in the dermis. In severe cases, changes resemble nodular solar elastosis. We retrospectively evaluated 238 vulvar biopsies with the goal of defining and characterizing changes of vulvar elastosis. Of 238 vulvar biopsies reviewed, 107 (45%) exhibited vulvar elastosis. Patients with vulvar elastosis were older (mean = 65 years old) compared to those without (mean = 44 years old). Sixty-six (62%) were graded as mild, 27 (25%) moderate, and 14 (13%) severe. Vulvar elastosis was significantly more common in women ≥45 years old (P-value < 0.001). There was moderate correlation between age and severity (correlation coefficient = 0.55, P-value < 0.001). Vulvar elastosis was observed in a variety of inflammatory and non-inflammatory pathologies. In 5 cases, the sole pathology was vulvar elastosis presenting clinically as either a pruritic or painful white to white-yellow papule or plaque, or vulvar pain or burning without a clinical lesion. Vulvar elastosis is a novel diagnostic entity occurring in a sun-protected site and its pathogenesis may be a degenerative phenomenon possibly related to advancing age and/or hormonal changes., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Labial fusion in adolescence is uncommon and is usually secondary to other skin disorders or trauma of the vulvar area. In a five-year period, we treated five patients with labial fusion in our facility with a mean age of 16.4 years. Based on clinical presentation and biopsy of the vulvar skin, lichen sclerosus (LS) was the causative factor. Four out of five had urinary problems and one suffered from an inflamed inclusion cyst. All of them had a long history of pruritus. In all cases, blunt separation of the labia minora under general anaesthesia was performed, followed by local application of a potent glucocorticoid cream and an emollient agent. One patient received additionally oral and local antibiotics. One recurrence was noted, which resolved after re-separation and more meticulous treatment. Early identification and treatment of LS are crucial to prevent distortion of the vulvar anatomy.Impact Statement What is already known on this subject? Labial fusion is an uncommon problem in adolescence and an underlying cause should always be investigated. Lichen sclerosus typically affects the anogenital area and can lead to fusion of the labia minora. What do the results of this study add? Urinary symptoms may be the presenting feature of LS in adolescents. What are the implications of these findings for clinical practice and/or further research? Delay in diagnosis and appropriate treatment can result in irreversible changes to the vulva.

Objective: The aim of the present randomized placebo-controlled single-center study was to assess the efficacy and safety of a new vaginal gel (Meclon Idra - Alfasigma) in the treatment of vulvovaginal atrophy (VVA). The gel is composed of sea buckthorn (Hippophaë rhamnoides) oil, aloe vera, 18β-glycyrrhetic acid, hyaluronic acid and glycogen. The study assessed whether the gel can reduce VVA symptoms (vaginal dryness, itching, burning sensation) and improve sexual function in postmenopausal women over 12 weeks., Study Design: Postmenopausal women (n° = 60) reporting VVA symptoms were recruited and randomized in a 1:1 ratio to the gel or placebo. Active vaginal gel or placebo was applied for 14 days and then twice a week for 90 consecutive days., Main Outcome Measure: The Vaginal Health Index (VHI), including vaginal pH, was used to assess changes in objective signs, whereas the self-reported Female Sexual Function Index (FSFI) was used to investigate sexual function., Results: Meclon Idra was effective in reducing vaginal pain, dyspareunia and vaginal pH, with the VHI showing significant improvement at day 90 (P < .0001), and in reducing each VVA symptom (vaginal dryness, vaginal itching, burning sensation) at weeks 2 and 4, and the end of the study (P < .0001). The analysis of FSFI scores showed, after the end of treatment, an improvement of sexual function in the active-treatment group, with a statistically significant increase (P < 0.001) in all domains scores and total score (P < 0.001)., Conclusions: The present single-center randomized clinical trial demonstrated the efficacy, tolerability and safety of 12-week treatment with a new vaginal gel in postmenopausal women with symptoms associated with VVA. Based on this trial, the gel seems to be a valid choice as a single, local agent for relieving VVA symptoms and improving sexual function, and to have good compliance. This trial is registered prospectively with the Clinical Trials Registry - India, number CTRI/2019/05/01911., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The diagnosis of genital ulcers remains a challenge in clinical practice. Lipschütz ulcer is a non-sexually transmitted rare and, probably, underdiagnosed condition, characterized by the sudden onset of vulvar edema along with painful necrotic ulcerations. Despite its unknown incidence, this seems to be an uncommon entity, with sparse cases reported in the literature. We report the case of an 11-year-old girl who presented at the emergency department with vulvar ulcers. She denied any sexual intercourse. The investigation excluded sexually transmitted infections, so, knowledge of different etiologies of non-venereal ulcers became essential. The differential diagnoses are extensive and include inflammatory processes, drug reactions, trauma, and malignant tumors. Lipschütz ulcer is a diagnosis of exclusion. With the presentation of this case report, the authors aim to describe the etiology, clinical course, and outcomes of this rare disease, to allow differential diagnosis of genital ulceration., Competing Interests: The authors have no conflict of interests to declare., (Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Vulvovaginal atrophy (VVA) is a chronic disease that mostly occurs in postmenopausal women. After menopause, insufficient sex hormones affect the anatomy of the vagina and cause drastic physiological changes. The main histopathological studies of VVA show that postmenopausal estrogen deficiency can lead to the increase of intermediate/parabasal cells, resulting in the loss of lactobacillus, elasticity and lubricity, vaginal epithelial atrophy, pain, dryness. Although the role of estrogen hormones in the treatment of VVA has always been in the past, it is now widely accepted that it also depends on androgens. Estrogen drugs have many side effects. So, Dehydroepiandrosterone（DHEA）is promising for the treatment of VVA, especially when women with contraindications to estrogen have symptoms. This review is expected to understand the latest developments in VVA and the efficacy of DHEA., (Copyright © 2021 Elsevier Ltd. All rights reserved.)