eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Nonneoplastic Epithelial Disorders of the Vulva: Differential Diagnoses & Workup

Author: Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Contributor Information and Disclosures

Updated: Jul 9, 2007

Differential Diagnoses

Other Problems to Be Considered

The diagnosis is entertained when symmetric white epithelium in a figure-of-eight pattern is noted. Vitiligo may be confused with lichen sclerosus, but the skin in this condition is not atrophic.

Lichen planus may mimic lichen sclerosus because lichen is a term used to describe many lesions that have closely set papules as their main characteristic; thus, terms such as lichen simplex, lichenification, lichen planus, and lichen sclerosus are used to describe lesions that resemble the mossy surface of lichen on a tree.

In differentiating lichen planus from lichen sclerosus, the former typically has an erosive vaginal component and a reticulate pattern at the introitus. In children, sexual abuse may have to be considered, especially when the lesions are hemorrhagic. Cicatricial pemphigoid is an important differential, especially when fusion is extreme; vaginal, ocular, or oral lesions, if present, are suggestive of that condition.

Workup

Other Tests

  • Thyroid function tests are indicated because approximately 21% of women with lichen sclerosis have an autoimmune disease, most commonly a thyroid disorder.

Procedures

  • If the diagnosis is not readily apparent, unaided (ie, naked-eye) or colposcopic examination of the vulva may define areas of abnormality that may warrant biopsy using a Keyes punch or biopsy forceps under local anesthesia.
  • The mainstay of diagnosis is vulvar biopsy. Furthermore, all patients with a nonneoplastic vulvar epithelial disorder should be checked at regular intervals. Areas of ulceration or foci of granulation or nodularity that develop should be biopsied to exclude malignant change. The formation of hyperkeratotic plaques or erosions that do not respond to treatment should arouse suspicions of malignancy. Multiple biopsies may be necessary.
  • Biopsy is indicated when the diagnosis is in doubt or if management strategies would be influenced by more information. An outpatient procedure with local anesthesia is almost always feasible. The request form should indicate the area from which the biopsy will be taken. Excisional biopsy is feasible for small lesions, but larger areas require sampling by punch biopsy.
  • Preliminary application of lidocaine and prilocaine (EMLA Cream) that is left on for about 10 minutes is helpful. Lignocaine 1% is infiltrated in the areas to be biopsied. Disposable 2- to 6-mm punches are used (eg, Keyes punch biopsy instruments). The 6-mm punch is used for larger legions. A rotary motion of the instrument removes a core of tissue, which is removed by snipping off at the base with scissors. Hemostasis is usually satisfactorily achieved with pressure, chemicals such as silver nitrate or Monsel solution, or electrocautery. With larger biopsies, the use of absorbable sutures, such as 4-0 Vicryl, achieves hemostasis. As a rule, late bleeding is rare and healing is rapid.

Histologic Findings

  • Lichen sclerosus is characterized by epidermal atrophy, hyalinized superficial dermis, and underlying lymphocytic infiltration.
  • Squamous cell hyperplasia is characterized by epithelial thickening (hyperplasia), thickening of the keratin layer (hyperkeratosis), elongation and widening of the epithelial rete ridges (acanthosis), and retention of nuclear material in the keratin layer (parakeratosis).

More on Nonneoplastic Epithelial Disorders of the Vulva

Overview: Nonneoplastic Epithelial Disorders of the Vulva
Differential Diagnoses & Workup: Nonneoplastic Epithelial Disorders of the Vulva
Treatment & Medication: Nonneoplastic Epithelial Disorders of the Vulva
Follow-up: Nonneoplastic Epithelial Disorders of the Vulva
References
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References

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  3. Goldstein AT, Marinoff SC, Christopher K. Pimecrolimus for the treatment of vulvar lichen sclerosus: a report of 4 cases. J Reprod Med. Oct 2004;49(10):778-80. [Medline].

  4. Li C, Bian D, Chen W. Focused ultrasound therapy of vulvar dystrophies: a feasibility study. Obstet Gynecol. Nov 2004;104(5 Pt 1):915-21. [Medline].

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Further Reading

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Keywords

vulvar dystrophy, vulvar disease, kraurosis vulvae, leukoplakia, lichen sclerosus et atrophicus, squamous cell hyperplasia, squamous cell carcinoma, SCC, human papillomavirus, HPV

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Contributor Information and Disclosures

Author

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

Medical Editor

Steven David Spandorfer, MD, Assistant Professor, Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Medical College-Cornell University
Steven David Spandorfer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, and Endocrine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals Obstetrics/Gynecology Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board; Vice Chair for Research and Education, Department of Obstetrics/Gynecology, Tufts Medical Center
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals Obstetrics/Gynecology Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board; Vice Chair for Research and Education, Department of Obstetrics/Gynecology, Tufts Medical Center
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

 
 
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