Anda di halaman 1dari 95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Vulvarlesions:Differentialdiagnosisbasedonmorphology
Authors
LynetteJMargesson,MD,FRCPC,
FAAD
HopeKHaefner,MD

SectionEditor
DeputyEditor
RobertPDellavalle,MD,PhD,MSPH KristenEckler,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2016.|Thistopiclastupdated:Jan28,2016.
INTRODUCTIONAwidevarietyoflesionsoccuronthevulva.Someofthedisorderscausingtheselesionsarelimited
tothevulva,whileothersalsoinvolveskinormucocutaneousmembraneselsewhereonthebody.Thistopicprovidesa
morphologybasedclassificationsystemthatcanhelpclinicianswiththedifferentialdiagnosisoftheselesionsafter
performingahistoryandphysicalexamination.Thisclassificationsystemisalsousefulforguidingthechoiceof
diagnostictestsandprocedures.
Thepertinenthistory,physicalexamination,anddiagnostictestsandproceduresusedtoevaluatewomenwithvulvar
lesionsaredescribedseparately(see"Vulvarlesions:Diagnosticevaluation").Treatmentisalsodiscussedseparatelyin
topicreviewsonthesedisorders.
MORPHOLOGICDEFINITIONSFORMUCOCUTANEOUSVULVARLESIONSMucocutaneousvulvarlesionscan
beclassifiedusingthemorphologicdefinitionsdescribedinthetable(table1).
HOWTOUSETHISTOPICAfterhistory,physicalexamination,andmorphologicclassification(seetables),the
informationinthistopiccanbeusedtobegindifferentialdiagnosisofthelesion.Diagnosticentitiesarelistedforeach
morphologicclassificationandoftenlistedundermorethanonemorphologicclassificationsincemanylesionshavemore
thanonepresentation(morphologictype,color).Thecompletedescriptionofthediagnosticentityisprovidedonlyoncefor
morphologicalvariants,theentityisnotedandlinkedtoitsdescriptivesection.
REDPATCHESANDPLAQUESDifferentialdiagnosis(table2).
Candidiasis
PhysicalexaminationBrightred,sometimeserodedpatchesandplaquesinvolvingvaryingportionsofthevulva
(picture1).Inseverecases,theperianalareaandtheupperinnerthighs(picture2)mayalsobeinvolved.Aslight
scalemayoverlietheredpatchesandplaques.Small1to2mmpustulesoftenstudthesurfaceofthesepatches
andplaques,and,attheperipheryofthemainareaofinvolvement,similarsatellitered,yellow,orwhitepapules
and/orpustulesmayoccur.Thepustulesbreakeasily,leavingsmallerosionswithperipheral("collarette")scales.If
manypustulesarepresent,thedesquamatingscalecanbeprominent(picture3).Occasionally,whenintertriginous
foldsareinvolved,linearfissuresmayoccurwithinthecrease.
Vaginaldischargeduetovaginalcandidiasisisusually,butnotalways,present.Sometimes,whiteplaquesmadeup
ofamatofcandidalmyceliacanbefoundlooselyattachedtothemucousmembranesofthevaginaand/orvulvar
vestibule.
SymptomsThelesionsmaybepruriticorpainful.
DiagnosisThediagnosisisbasedoncharacteristichistory,physicalexamination,andapotassiumhydroxide
(KOH)preparationtodetectfungalelements(myceliaandspores)invulvarskinscrapingsoronasmearof
discharge.Vaginalcandidiasissupportsthediagnosis.Candidacultureisobtainedincasesofdiagnosticuncertainty.
(See"Candidavulvovaginitis".)
Atopicdermatitis(eczema)
PhysicalexaminationRed,poorlymarginated,excoriatedorlichenifiedplaquespredominatelyinvolvingthelabia
majoraandtheouteraspectofthelabiaminorathevestibuleisgenerallyspared.Weepingandcrustingmaybe
seen.Scaleisusuallypresentwithatopicdermatitis,but,whenthevulvaisinvolved,thescaleisoftenobscured
becausemoisturemaywhitenthesurfaceofthepatchesandplaques.
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

1/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

SymptomsThepredominantsymptomisseverepruritus.Incessantscratchingleadstomoreitchingandmore
scratching,whichistermedthe"itchscratchcycle."Developmentofnumerousordeepexcoriationsmaybe
associatedwithpain.
DiagnosisAdiagnosisofatopicdermatitisisusuallybasedontheclinicalfindingsrarely,patchtestingand/or
biopsyisnecessarytoidentifyanallergen/irritantorexcludeanunderlyingdermatosis.Ahistoryofatopy(hayfever
and/orasthma)ispresentinapproximately70percentofpatientsandsupportstheclinicaldiagnosis.(See"Vulvar
dermatitis",sectionon'Clinicalmanifestations'and"Pathogenesis,clinicalmanifestations,anddiagnosisofatopic
dermatitis(eczema)".)
LichensimplexchronicusLichensimplexchronicusisalocalizedvariantofatopicdermatitis[1].
PhysicalexaminationSimilartoatopicdermatitis(see'Atopicdermatitis(eczema)'above)excepttheplaquesmay
beadeeperredoraredbrown(picture4andpicture5andpicture6andpicture7).Insomecircumstances,suchas
afterpartialtreatment,inflammationisnotclinicallyvisible,sotheplaquesmaybeskincolored.Lichenificationdue
tochronicrubbingusuallypredominates,althoughsomedegreeoferosionduetoexcoriationisregularlypresent.
Excoriationcanresultinulcers.Scaleispresent,butsurfaceroughnessmaybeabsentbecauseitiscompacted,
anditmaybeobscuredbecauseofwhiteningfromchronicmoisture.
Whenthethickened,redepidermisismoistfromsweat,urine,orvaginalsecretions,itwhitens.Thisphenomenonis
similartothewhiteningseenoverthevolarfingertipsafterswimmingforaprolongedperiodoftime[1].
SymptomsThesame"itchscratchcycle"asoccursinatopicdermatitisleadstovigorousscratchingandrubbing.
DiagnosisAdiagnosisoflichensimplexchronicusisbasedontheclinicalfindings.Rarely,biopsywillbeneeded.
Ahistoryofatopy(hayfeverand/orasthma)maybepresent.(See"Vulvardermatitis".)
Psoriasis
PhysicalexaminationOneormoresharplymarginated,scaling,redplaquespredominantlyinvolvingthelabia
majora(picture8).Inmostinstances,moretypicalpsoriaticplaquesarealsolocatedelsewhere(pubis,buttocks,
scalpelbows,knees).Rarely,psoriasisislocalizedonlytothevulva.
SymptomsItchingisusuallymildorabsent,butoccasionallysomedegreeofexcoriationand/orlichenificationmay
beencountered.
DiagnosisAdiagnosisofpsoriasiscanbemadeclinically,iftypicalpsoriaticplaquesarelocatedelsewhereonthe
body.Whenonlythevulvaisinvolved,biopsyisnecessaryfordefinitivediagnosis.However,thepathologyreport
maystate"psoriaticdermatitis."Insuchinstances,theclinicianneedstodistinguishpsoriasisfromlichensimplex
chronicus(see'Lichensimplexchronicus'above),whichcanbedifficultifitchingandrubbingarepresent[2].(See
"Epidemiology,clinicalmanifestations,anddiagnosisofpsoriasis".)
AllergiccontactdermatitisMostallergiccontactdermatitisofthevulvaresultsfromtopicalmedicationsand
cosmetics,buttheconditioncanbecausedbyothersourcessuchaspoisonivyandpoisonoak.
PhysicalexaminationRed,somewhatscalypatchesandplaqueswithnonsharpborderssimilartothoseofatopic
dermatitis(see'Atopicdermatitis(eczema)'above).Largenumbersofsmallvesiclesandrarelybullaemayerupt
fromthesurfaceoftheplaques.Thevesiclesbreakeasily,leavingsmallpatchesofweepingerosions.Thisprocess
canbeconfusedwithaneczematouscandidiasisorimpetigo.Erosionsmayalsobeduetoexcoriation.The
inflammationthatislocallypresentinallergiccontactdermatitismaybesufficienttocauseappreciableerythemaand
vulvaredema(picture9andpicture10).
SymptomsThedegreeofitchingandscratchingismorevariablethanwithatopicdermatitis.Somepatients
complainofburning.
DiagnosisAclinicaldiagnosisissuggestedbythepresenceofsomecombinationofoverlyingeczematous
featuressuchaserythema,scaleformation,visibleerosion,weepingandcrustingandahistoryoftopicalmedication
use.Amorefirmdiagnosisofallergiccontactdermatitiscanbemadeifdiscontinuationofalltopicalagentsis
followedbyclearingoftheeruptionwithin10days.Biopsyisusuallynothelpfulinseparatingallergiccontact
dermatitisfromothereczematousdiseaseunlessfairlynumerouseosinophilsarepresentwithinthedermal
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

2/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

inflammatoryinfiltrate.Insomeinstances,patchtesting,ascarriedoutinadermatologistsoffice,isdesirable.(See
"Vulvardermatitis"and"Clinicalfeaturesanddiagnosisofallergiccontactdermatitis".)
Ifbullaearepresent,differentialdiagnosisincludesbullouspemphigoidandpemphigus.Bullouspemphigoidalsocan
haveitchylesions,butbullaeareusuallyunilocularandtenser.Pemphigusvesiclesandbullaeareextremelyfragile
andarenotitchy.(See'Pemphigoid'belowand'Pemphigusvulgaris'below.)
IrritantcontactdermatitisThemostcommoncauseofthisconditionisexcessivehygiene.Theresultingdryness
leadstoachappedappearance,withminutefissures.Medicationscanalsoberesponsibleforthedevelopmentofirritant
contactdermatitis.Applicationofimiquimodorfluorouracilregularlyresultsinerosionssuperimposedonpainful,red
patchesandplaques.Applicationofliquidnitrogen(forgenitalwarts),cantharidin(formolluscumcontagiosum)orbior
trichloroaceticacid(forgenitalwarts)almostalwaysresultsinblistersthatbreakdown,leavingcircularerosions,oreven
ulcers,withbitsofliftedscalepresentattheperipheryoftheerosion.
PhysicalexaminationRedpatchesandplaquessimilartothoseseeninothereczematousdisease,suchasatopic
dermatitisandallergiccontactdermatitis(picture9andpicture10)(see'Atopicdermatitis(eczema)'above).
However,theerythemamaybeduskierandmaybebrownred.Rarely,largenumbersofsmallvesiclesorbullae
mayeruptfromthesurfaceoftheplaques.Thevesiclesbreakeasily,leavingsmallpatchesofweepingerosions.
Thisprocesscanbeconfusedwithaneczematouscandidiasisorimpetigo.Fissuringmaybepresent,whichcan
resultinachappedappearance.Contactwithextremelyharshproductssuchasbiortrichloroaceticacidcancause
erosionsorulcers.
SymptomsThedegreeofitchingandscratchingismorevariablethanwithatopicdermatitis.Somepatients
complainofburning.
DiagnosisAdiagnosisofirritantcontactdermatitisisbasedonahistoryofeitherexcessivehygieneorthe
persistentpresenceoftoomuchmoisture,suchasmightoccurindiaperdermatitisorinbedridden,incontinent
adults.Irritantcontactdermatitismayalsobeinducedbyapatientsapplicationofharshchemicals(suchas
undilutedbleach,strongdetergents,andrubbingalcohol)oracliniciansapplicationofcausticmedications(suchas
podophyllin,fluorouracil,imiquimod,andbiortrichloroaceticacid).(See"Vulvardermatitis"and"Irritantcontact
dermatitisinadults".)
Ifbullaearepresent,differentialdiagnosisincludesbullouspemphigoidandpemphigus.Bullouspemphigoidalsocan
haveitchylesions,butbullaeareusuallyunilocularandtenser.Pemphigusvesiclesandbullaeareextremelyfragile
andarenotitchy(see'Pemphigoid'belowand'Pemphigusvulgaris'below).
Lichenplanus(papulosquamousform)Thecauseoflichenplanusisunknown,thoughlesionssimilarinclinicaland
histologicalappearancecanoccurinsomedrugreactionsandingraftversushost(GVH)disease.
PhysicalexaminationLichenplanuspresentsinseveraldifferentwaysintheanogenitalarea.Themostcommonis
erosivelichenplanus(see'Erosivelichenplanus'below).Lessoften,itoccursasredorviolaceous,sharply
marginated,flattoppedpapulesand/orplaques.Inthispapulosquamousform,scaleisusuallyunapparent.
Occasionally,thereisevidenceoftheKoebnerphenomenon(theappearanceoflesionsatsitesoftrauma),andthe
configurationofthelesionsmaybelinearorangularratherthanround.Thedistributioninthepapulosquamousform
oflichenplanussparesthemucosalsurfacesofthevestibuleandthevagina,and,instead,lesionsarefoundonthe
labiamajoraandsurroundingcutaneousareas.Extragenitallesionsareusuallyfoundinwomenwiththis
papulosquamousformoflichenplanus.
Alacy(latticelike)networkofthin(<1mm)whiteorgreylinesmaybepresent(picture11).Similarchanges,called
Wickhamsstriae,mayalsobepresentonthebuccalsurfacesofthemouth(picture12).
SymptomsErosivelichenplanusispainful,oftenexquisitelyso.Thepapulosquamousformoflichenplanusis
eitherasymptomaticorsomewhatpruritic.
DiagnosisAclinicaldiagnosisisoftenpossible,butshouldbeconfirmedbybiopsy.Asforlichensclerosus,
biopsiestoruleoutsuperimposedsquamouscellcarcinoma(SCC)shouldbeperformedfornotablythickenedor
ulceratedareas.(See"Vulvarlichenplanus",sectionon'Papulosquamouslichenplanus'.)
Tineacruris
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

3/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

PhysicalexaminationSharplymarginated,slightlyscaling,duskyredpatchesorplaquesbilaterallyontheupper
innerthighs,possiblyextendingtothebuttocks(picture13).Thelabiamajoraaretypicallyspared.Adistinctive
featureistheregularpresenceofclearing(normalappearingskin)inthecenterofthesepatchesorplaquesgivingan
annularappearance.Thecolloquialterm,"ringworm,"hasbeenusedtodescribethischaracteristicfinding.
SymptomsPruritus,sometimesmarked,isusuallypresent,but,insomepatients,thelesionsmaybe
asymptomatic.
DiagnosisAclinicaldiagnosisisoftenpossible,butshouldbeconfirmedbyscrapingsomescalefromthe
peripheryofthelesionandeithersubmittingitforfungalcultureormicroscopicallyexaminingthescaleforhyphae
usingapotassiumhydroxide(KOH)wetmount.(See"Dermatophyte(tinea)infections",sectionon'Tineacruris'.)
PerianalstreptococcalinfectionPerianalstreptococcalinfectionisabacterialinfectioncommoninchildren,but
uncommoninadults.
PhysicalexaminationRedpatchesontheperianalskinand,veryrarely,onthevulva.Littlescaleispresent,but
minorfissuring,weeping,andcrustingmaybenoted.
SymptomsThedegreeofitchingisvariable.
DiagnosisThisdiagnosiscanbeconsideredwhenotherdiseasesareruledoutand/orwhentreatments(topical
steroids,lubrication,antifungalandanticandidalagents,etc)usedforotherdiseaseshavefailedtoimproveorclear
theeruption.Atthatpoint,bacterialculturedemonstratingstreptococcalspeciesisnecessary.(See"Cellulitisand
erysipelas".)
VulvarintraepithelialneoplasiaVulvarintraepithelialneoplasia(VIN)occursintwoforms:humanpapillomavirus
(HPV)related("usualtype")andnonHPVrelated("differentiatedtype").VINwasformerlytermedBowensdisease,but
thistermhasbeendiscarded.
PhysicalexaminationVINoccursintwoforms:
Themostcommon"usualtype"iscausedbyHPV16,18,31and33andotherrare,highrisktypes.Itpresents
withvaryingnumbersofredorredbrown,sharplymarginated,flattoppedpapulesanywhereonthevulva
(picture14)however,thelesionsmaybewhite,brown,black,orskincolored(picture15andpicture16and
picture17).Similarappearing,largerplaques(upto3cmindiameter)maybepresentwhenthepapuleshave
undergonecentrifugalorconfluentgrowth.Thesurfacemaybehyperkeratoticand/oreroded.Scaleisusually
notapparent.Theselesionstendtooccurinyoungerwomen.
Thelesscommonbutmoreserious"differentiatedtype"(nonHPVrelated)oftenpresentswithasolitary,white
topink,red,skincolored,orbrownishpapuleornodule2to5cmindiameter,locatedonthevulva,usually
withinthevestibule.However,itcanpresentwithoneorseveralred,sharplymarginatedplaqueswithvarying
amountsofoverlyingscale.AlthoughnotHPVrelated,thislesioncanbesimilarinappearancetotheusual
typeifitarisesdenovofromnormalappearingskin.However,morecommonly,itdevelopsagainsta
backgroundofotherdisease,mostofteninthesettingoflichensclerosusorlichenplanus.Lessoften,itis
associatedwithotherinflammatorydisorderssuchashidradenitissuppurativaorcutaneousCrohndisease.It
tendstooccurinolderwomen.
SymptomsBothtypesofVINarerelativelyasymptomatic.
DiagnosisAdiagnosisofusualordifferentiatedtypeVINmaybesuspectedbasedonclinicalfindings,butshould
beconfirmedbybiopsytodefinitivelyruleoutpsoriasis,lichenplanus,andSCC.Thebiopsyshouldbetakenfroma
notablythickenedareaorthemarginofanychronicerosionorulcerthatfailstorespondtomedicaltherapy,
especiallyinthesettingofvulvarlichensclerosusorerosivelichenplanus.Thebiopsyrequestformshouldindicate
thatdifferentiatedtypeVINissuspectedas,withoutthatinformation,thepathologistmayinterpretthespecimenas
abenignacanthoticprocesssuchasoccursinpsoriasis,psoriaticdermatitis,andlichensimplexchronicus.(See
"Vulvarintraepithelialneoplasia".)
Rarediseases
Plasmacellvulvitis(table3).(See'Plasmacellvulvitis'below.)
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

4/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

ExtramammaryPagetdiseasepresentsasoneormoreredpatchesorplaques.Theselesionsmaybesharply
marginatedordiffuselymarginated.Forpracticalpurposes,thisdiseaseoccursonlyinwomenovertheageof60
years.Thesurfaceofthelesionsusuallydemonstratesmultipleshallowerosions.Biopsyisrequiredfordiagnosis.
(See"Vulvarcancer:Clinicalmanifestations,diagnosis,andpathology",sectionon'ExtramammaryPagetdisease'.)
HaileyHaileydisease[3]andtherelatedpapularacantholyticdyskeratosis[4]usuallypresentasredpatchesand
plaques,oftenwithvaryingdegreesoferosion(picture18).Theselesionsmimictheappearanceofthosedescribed
forextramammaryPagetdisease.However,ifthereissignificanthyperkeratosis,thesurfaceofthelesionmay
appearwhitewhenmoist.Thisdiseasefirstappearsinyoungerwomen,andtherearealmostalwayssimilarplaques
onthechest,back,andaxillae(table2)andapositivefamilyhistoryforsimilarlesions.Biopsyisrequiredfor
diagnosis.(See"HaileyHaileydisease(benignfamilialpemphigus)".)
Tineaversicolorconsistsofasymptomaticpink,sharplymarginatedmaculesandsmallpatches.Scaleispresent,
butmaynotbedetectable.Thevulvaisrarelyinvolved,but,whenitis,additionalpink,red,white,orbrownlesions
willbefoundelsewhere,especiallyoverthechestandback.Itisadisorderofyoungwomen.Thediagnosisrequires
identifyingcharacteristicmyceliaandsporesinapotassiumhydroxide(KOH)wetmountofascraping.(See"Tinea
versicolor(Pityriasisversicolor)".)
Pityriasisroseaconsistsofsharplymarginated,ovalshaped,redpatchesandplaques.Thevulvaisrarelyinvolved,
andinvolvementisalwaysassociatedwithsimilarovallesionsinatypical"Christmastree"distributionoverthe
chestandback.Diagnosisisbasedclinicalfindings,butcanbeconfirmedbybiopsy,ifnecessary.(See"Pityriasis
rosea".)
REDPAPULESANDNODULESDifferentialdiagnosis(table4).
FolliculitisandkeratosispilarisThepathophysiologyoffolliculitismaybeinfectiousornoninfectious.Infectionsmay
beduetoeitherastaphylococcalbacterialordermatophytefungaletiology.Thepresentationsforthesetwotypesof
infectionaresimilar,althoughfungalfolliculitisalmostalwaysoccursinthesettingoftineacruris(ringworm)ontheupper
innerthighs,whereasbacterialfolliculitisoccursdenovoasisolatedlesions.
Bothbacterialanddermatophyteinfectionsmanifestasscatteredorgroupsofperifollicular,small(2to5mm),red
papules,mostcommonlyonthehairyareasofthemonspubis,innerthighs,andbuttocks,ofteninshavedareas(picture
19).Thecentersurfaceofthepapulesmaybecappedwith1to2mm,whiteoryellowwhitepustules.
Keratosispilarisisanoninfectiousfolliculitisconsistingofnumerous,closelyset,minute,redpapulesthatlackthe
pustularsummitofinfectiousfolliculitis.Itusuallyaffectstheskinofthebuttocks,lateralthighs,andlateralupperarms
(picture20).
TheclinicaldiagnosisofinfectiousfolliculitiscanbeconfirmedbyrecoveryofStaphylococcusaureusonculture,
identificationofmyceliaonapotassiumhydroxide(KOH)preparation,orrecoveryofanyoneofseveraldermatophyte
fungalspeciesonculture.Thediagnosisofkeratosispilarisisbasedonphysicalexaminationwithidentificationofthe
typicallesionsinthecharacteristicdistributionpattern,butcanbeconfirmedbybiopsy,ifnecessary.(See"Keratosis
pilaris"and"Infectiousfolliculitis".)
CherryangiomaCherryangiomasarecommon,benignneoplasmsmadeupofclusteredcapillariesandbloodvessels.
Othernamesincludesenileangiomasor"CampbelldeMorganspots."Theypresentas0.5to5mm,smooth,firm,bright
todeepredpapules(picture21).Thelocationisusuallyonthetrunkandproximallimbs,alsothemonspubis.Thelesions
increaseinnumberwithpregnancy.Thediagnosisisclinical,basedoncharacteristicappearance.(See"Overviewof
benignlesionsoftheskin",sectionon'Cherryangioma'.)
AngiokeratomasAngiokeratomasareasymptomatic,darkred,purple,blue,orblack,smoothsurfaced,domeshaped,
benignpapules.The2to8mmfirmpapulesaremadeupofdilatedsuperficialbloodvesselswithhyperkeratosisofthe
overlyingepidermis.Bleedingmayoccursecondarytotrauma.Thelesionsareoftensolitary,butseveralmaybepresent.
Theydevelopbetweentheagesof20to50yearsandincreaseinnumberinpregnancy.Incontrasttocherryangiomas,
angiokeratomasarelocatedonlyonthelabiamajoratheircolorisalsodifferent.
HemangiomasHemangiomasarevascularmalformationsthatarepresentatbirthordevelopininfancyandchildhood.
Theyhaveapredilectionforthefaceandanogenitalarea,butmayoccuranywhere.Thelesionmaypresentvariouslyas
anindividual,small,redpapulediffusetelangiectaticpatcheswiththickerplaquesorbrightredorduskypurplepapules
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

5/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

thatmaygrowintolargenodulesoverthefirstninemonthsoflifeandthenresolvebyage9or10years.Thedeeper,
cavernoushemangiomasarepurple,nodularswellingsandcanpersistintoadultlife.Ulcerationisthemostcommon
complicationofhemangiomas(picture22).Large,segmentallesions,especiallyintraumapronelocations,suchastheone
oftheperineumdepictedabove,areatincreasedriskforulceration.
Furunculosis
PhysicalexaminationDeep,walledoffcollectionofpustypically2to4cmindiameterandusuallyassociatedwith
afollicle.Whennotassociatedwithafollicle,thelesioniscalledanabscess.Lesionsbeginasatender,red,firm
papulethatrapidlyenlargesandbecomesadeepseatednodulethatlastsfordays.Thenodulemaybecappedbya
whiteoryellowwhitepustule.Itmaygraduallyexpandundertheskinorpointatthesurfaceandrupturepurulent
material.Rarely,aggregatesofinfectedfurunclesformlarge,deepredmasses.Theyoccurinareasofskintrauma,
especiallywherethereismoisturefromhyperhidrosisalongtheedgesofthemonspubisandperianally.Furuncles
andabscessesmaybeselflimitedorrecurrent.
SymptomsThesearepainfullesions.Whenlargeanddeep,theymayalsobeassociatedwithsystemicsymptoms
ofmalaise,fever,andchills.
DiagnosisFurunclesandabscessesarecausedmainlybyS.aureus,increasingly,methicillinresistantS,aureus
(MRSA).Diagnosisisbasedontheclinicalpresentationandappropriatebacterialcultures,whichtypicallyshowa
singlespeciesofbacteria(S.aureus).Theselesionsmustbedifferentiatedfromaninfectedepidermalcystandfrom
hidradenitissuppurativa.Furunculosiswilltypicallyrespondtoappropriateantibioticsin7to10days,incontrastto
thelongerlastinghidradenitissuppurativa.(See"Skinabscesses,furuncles,andcarbuncles"and"Vulvarabscess"
and"Hidradenitissuppurativa(acneinversa):Pathogenesis,clinicalfeatures,anddiagnosis".)
HidradenitissuppurativaHidradenitissuppurativaisalsoreferredtoas"acneinversus."
PhysicalexaminationDeepseated,inflamedpapulesandnodulesthatmayoccuranywhereintheanogenitalarea,
mostcommonlyintheinguinalandlabiocruralfolds,monspubis,andperianalarea(picture23andpicture24).The
inflammatorypapulesandnodulesaresometimescappedbywhiteoryellowwhitepustules(picture25).Inaddition,
solitarypustulesmayoccurunassociatedwithinflammatorypapulesandnodules.
Anindividuallesionmayincreaseinsize,formadeepabscess,rupture,anddrainpurulentmaterial,thenresolve
and/orrecurtoformachronicsinus.Thelesionsareusuallyassociatedwitholdscarsthataresimilartothosethat
canoccurwithcysticacne.Averydistinctiveclinicalfeatureisthepresenceofclassicmultiheadedortombstone
comedones("blackheads").
Vulvaredemafrequentlyaccompaniestheinflammatorylesionswhenthediseaseoccursonthelowerabdominal
wall,thevulva,and/ortheperianalarea.Theedemaregularlyinvolvesthelabiamajora,butlessofteninvolvesthe
labiaminora.Theedemaisskincolored,unlessinflammatorylesionsinvolvethevulvaoradjacentskin,inwhich
casetheedemaiserythematous.Theedemaissoftearlyonandbecomesmorefirmlater.Thediagnosisis
establishedwhenthevulvaredemaisaccompaniedbythetypicallesionsofhidradenitissuppurativa.
SymptomsThelesionsareverypainful.
DiagnosisThediagnosisofhidradenitissuppurativaismadeusingfourcriteria:presenceofclinicallytypical
lesionsdistributioninthetypicallocations(axillae,groin,andunderthebreasts)failuretorespondwithindaysto
antibiotictherapyandchronicity.Thelesionsofhidradenitissuppurativaaredifferentiatedfromfurunclesand
abscessesbybacterialculture(inhidradenitissuppurativa,culturesareusuallynegativeorshowonlynonpathogenic
organismshowever,secondaryinfectionofthelesionsdoesoccur).Otherdistinctivefeaturesincludeamarked
tendencyforrecurrenceatthesamesiteandthepoorresponse,eventolongtermantibiotictherapy.Hidradenitis
suppurativalesionsmustbedifferentiatedfromdeepfungalandmycobacterialinfections,granulomainguinale,
inflammatorycysts,andCrohndisease.(See"Hidradenitissuppurativa(acneinversa):Pathogenesis,clinical
features,anddiagnosis".)
VestibularpapillomatosisVulvarpapillaeareanormalvariantofthevulvaranatomy.Thesearebenign,
asymptomatic,monomorphous,closelysettubularprojections1to2mmthataresymmetrical,soft,andlocated
inthevulvarvestibule.Theyaregenerallythesamecolorasthesurroundingmucosalsurfaces,butoccasionally
redderthanthesurroundingtissue.Theyarecommonlymistakenforwarts(condylomaacuminata),whichare
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

6/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

morefirm,oftenwithacauliflowertypeappearance(multipleprojectionsoffasinglebase)andaredistributedina
lesssymmetricalfashion.
Epidermalcysts(inflamed)Epidermalcystsarethemostcommoncystsonthevulva.Theyarelinedbyepithelial
cells,andtheirinteriorisfilledwithkeratinmadebytheseepithelialcells.Thelesionsaresmooth,mobile,round,firm,
papulesornodules,ranginginsizefrom2mmto2cmindiameter.Theyoccuronthelabiamajora,butnotinthevulvar
vestibule.Largerepidermalcystsareusuallyskincolored(ifdeepinthetissue)(table5)orwhite(ifmoresuperficial)(table
6).Occasionally,especiallyinmoredarklypigmentedindividuals,theywillhaveayellowhue(table7).Extrusionofkeratin
fromthecystintotheadjacentdermiscausesforeignbodytypeinflammation,withconsequentreddeningofthenodule.
Theinitialinflammationisnotcausedbybacterialinfection,although,rarely,secondaryinfectionofanalreadyinflamed
cystoccurs.
Small(1to3mm)epidermalcysts(milia)areusuallywhitepapules,butthesealsomayhaveaslightlyyellowcolor.
Inflamedlesionsareslightlypink,skincoloredtored.Uninflamedlesionsarewhitetoyellowwhite(table6).Oneortwoor
manylesionsmayoccur,isolatedoringroups.
Adiagnosiscanusuallybemadeclinically.Inflamedlesionscanbedifferentiatedfromfurunclesandcarbunclesbythe
historyofapreviouslynoninflamednodule,color,theopeningtothesurface,thecheesymaterial,andthegroupedpattern.
BartholinductabscessesBartholinductabscessesarered,painful,fluidfilled,infected,cysticcavitiesoccurringon
thevulva(picture26).Thelabiumminusbisectsthemiddleoftheabscess.Theabscessmaypointanddrainviaoneor
moretracts.Bartholinductabscessisdifferentiatedfromavulvarabscess,furuncle,andhidradenitissuppurativabyits
clinicalappearanceasasolitarylesionintheclassiclocation(the5o'clockpositiononthevestibule).
Diagnosisisusuallypossibleclinicallybecauseoftheunilateralityoftheswellingandthefactthatthelabiumminus
overliesitsmiddleaspect.Thediagnosiscanbeconfirmedbyincisionanddrainageofthecystcontents.Ifinflammation
isclinicallypresent,thepurulentfluidshouldbesentforbacterialculture.(See"Bartholinglandmasses:Diagnosisand
management"and"Vulvarabscess".)
PrurigonodularisPrurigonodularisresultsfromchronicscratchingatoneormorediscreetspots.Persistent
scratchingandpickingresultinathickenedcalluslikereaction.Thelesionsaretypically1to1.5cm,pink,red,orbrown
papuleswithsecondaryexcoriationandserosanguineouscrustingonthesurface.Prurigonodularisinvolvingthevulva
usuallydevelopsonthelabiamajora.Thediagnosisisbasedonahistoryofchronicscratchingandthecharacteristic
clinicalpresentation.Ifabiopsyisperformed,theresultsshowanonspecific,acanthoticpattern.(See"Prurigonodularis".)
UrethralcarunclesUrethralcarunclesaresingle,asymptomatic,brightredpapuleslessthan1cmindiameteratthe
urethralmeatusinolderwomen(picture27).Theymaybepedunculatedordomeshaped.Thesurfacebleedseasily.The
differentialdiagnosisisaurethralprolapse.(See"Urethralcaruncle".)
UrethralprolapseUrethralprolapseisaredpapuleattheurethralmeatusthatisseeninpremenarchalor
postmenopausalwomen.Dysuriamaybepresent.Thelesionisdifferentiatedfromtheurethralcarunclebyitspresentation
asacircumferential,brightrednodulearoundthemeatus,makingadonutshapearoundtheurethralorifice.
CrohndiseaseCrohndiseasecanpresentinmanywaysonthevulvaandintheperianalarea.Themostcommonly
identifiedlesionsincludefistulae,linear(knifecut)ulcers(table8)(especiallyintheskinfolds),abscesses(which
frequentlybreakdowntoformulcers),largeperianalskintags,anddiffusevulvaredema(picture28andpicture29and
picture30andtable9).
InWesterncountries,theknifecutulcersarethemostcharacteristiclesionsand,ifpresent,arepracticallypathognomonic
forCrohndisease.Mostoften,theseanogenitallesionsoccurafter,oratthesametime,thatadiagnosisofintestinal
Crohndiseaseismade.
Thefistulaearesurroundedbygranulationtissuealongtheedges,formingslightlyfriable,redpapulesorsmallnodules
thatmaycoverthefistuloustractandcloselymimictheappearanceofhidradenitissuppurativa.Forthisreason,theaxillae
andthebreastsshouldbeexaminedaslesionsintheselocationssuggestthatthevulvarlesionsarethoseofhidradenitis
suppurativaratherthanCrohndisease.
VulvaredemaoccursinalargepercentageofwomenwithCrohndisease,especiallywhentherectumisinvolved.Skin
coloredorredswellingoccursinboththelabiaminoraandlabiamajora.Earlyon,itissoftandpitseasilylater,it
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

7/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

becomesmorefirmandpitslesseasily.Diagnosisisestablishedwhenedemaofthevulvaoccursinthesettingof
establishedintestinalCrohndisease.Inaveryfewinstances,thevulvaredemaprecedesadiagnosisofintestinalCrohn
disease.Forthisreason,ahistoryofgastrointestinalsymptomsandpossiblyaworkupforinflammatoryboweldisease
shouldbeobtainedinthepresenceofwhatappearstobeidiopathicvulvaredema.
AclinicaldiagnosisofCrohndiseasecanbeconfirmedbybiopsyofvulvarabnormalities,whichmayshowgranulomatous
inflammationsuggestiveofCrohndisease.However,thegranulomasinanogenitallesionsmaybelesstypicalthanthose
inthegastrointestinaltractandmaybeverysimilartothegranulomatouschangesthataresometimesfoundinbiopsiesof
hidradenitissuppurativa.(See"Clinicalmanifestations,diagnosisandprognosisofCrohndiseaseinadults".)
SquamouscellcarcinomaSquamouscellcarcinoma(SCC)isthemostcommonvulvarmalignancy.Itmayoccur
alone,butin30to40percentofcasesitisassociatedwithunderlyinglichensclerosusorlichenplanus(picture31).
InvasiveSCCmaybeassociatedwithvulvarintraepithelialneoplasia(VIN)(see'Vulvarintraepithelialneoplasia'above),
whichcanbeaprecursortoSCC.
PhysicalexaminationTheclinicalappearanceofSCCissimilartothatforVIN.Thelesionsarefirm,white,red,or
skincoloredpapules,nodules,orplaques.Varyingdegreesoferosionorulcerationmayoccur.Thesurfaceisoften
friable.
ThesurfaceofinvasiveSCCmaybreakdown,leavingeitheranerosionoranulcer[5].Thisismostcommonwith
thelatenodularstageofthedifferentiatedtypeofSCC,suchasmalignanciesthatdevelopinlichensclerosusand,
lessoften,inlichenplanus.Thesamephenomenonoccurslessfrequentlyinthehumanpapillomavirus(HPV)related
(usual)typeofSCC.Althoughmelanomaisencounteredonlyrarely,alargepercentageofthesenodulartumors
presentwithanerodedorulceratedsurface.
SymptomsInvasiveSCCmaybeasymptomatic,painful,orveryitchy.
DiagnosisDiagnosisrequiresbiopsyasdifferentiatingSCCfromVINisusuallynotclinicallypossible.Separate
identificationofHPVrelatedcarcinomafromnonHPVrelatedcarcinomaishelpfulastheprognosisisgenerally
betterwiththeformertypeofmalignancy.ThebiopsyrequestformshouldindicateSCCasasuspecteddiagnosis
as,withoutthatinformation,thepathologistmayinterpretthespecimenasabenignacanthoticprocess.(See"Vulvar
cancer:Clinicalmanifestations,diagnosis,andpathology"and"Vulvarintraepithelialneoplasia".)
MolluscumcontagiosumMolluscumcontagiosumisapoxvirusinfectionthatcanpresentanywhereontheskinof
children,but,whenitoccursinadults,itisusuallylocatedonlyintheanogenitalarea,monspubis,andinnerthighsof
youngadults(picture32).Theselesionsarefirm,smooth,skincolored(table5),white(table6),and,wheninflamed,red
domeshapedpapulesthatare2to3mmindiameter.Milditchingmaybepresent.
Typically,thelesionshaveacentralumbilicationwithawhitecore(molluscumbody)thatcanbescrapedfromthelesion
bycurettage.Whenthismaterialisflattenedonamicroscopeslide,aGiemsastainwillshowthepathognomonicinclusion
bodiesmadeofviralprotein.Alternatively,ashavebiopsycanbeusedtoconfirmthediagnosis.Thesefindings
differentiatemolluscumcontagiosumfromcondylomaacuminata,nevi,basalcellcarcinoma,andthelesionsofherpes
simplexvirus(HSV)infection.Lymphangiectaticlesions(superficiallymphangiomas)arefirm,morecysticlooking,and,
whenpiercedwithaneedle,yieldclearfluid.(See"Molluscumcontagiosum".)
InsectbitesBitesfromanyinsectcancausered,inflamed,itchyorsorepapulesornodulesonthevulva.Bitesmaybe
individuallyscatteredoverthemonspubisorbuttocks,orsometimesalongthepantylineinthecaseofchiggers,orin
groups,asfromfleas.Insectbitescancauseasignificantreactioninapersonwhohasbeenpreviouslysensitized.
Historyandclinicalpatternsuggestthediagnosis.Abiopsydemonstratinganeosinophilinfiltrateaddsadditionalevidence
supportingthediagnosis.Similarlesionsarisefromascabiesinfestation.(See"Insectbites".)
Rarediseases
PyogenicgranulomaPyogenicgranulomaisareactive,vascularneoplasmseldomseenonthevulvaand
consistingofveryred,friable,oftenbleedingpapulesornodulesonapinchedinbase.Differentiationfromamelanotic
malignantmelanomaisimportant.Shaveexcisionisrecommended.(See"Pyogenicgranuloma(Lobularcapillary
hemangioma)".)

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

8/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

KaposisarcomaKaposisarcomaisexceedinglyrareonthevulva.Itcanpresentwithduskyredtopurplepapules
inapatientwithhumanimmunodeficiencyvirus(HIV)/acquiredimmunedeficiencysyndrome(AIDS).(See"Classic
Kaposisarcoma:Clinicalfeatures,staging,diagnosis,andtreatment".)
HidradenitispapilliferumHidradenitispapilliferum(alsoknownasmammarylikeglandadenoma)isabenign,
solitary,0.25to1cm,pinktoredpapulethatcanbesolidorcystic.Itoccursinmiddleagedwomen.Abiopsywill
confirmthediagnosis[6].
EndometriosisEndometriosisuncommonlyoccursonthevulva.Itappearsasa1to2cmredorpinkpapuleor
nodule,butmaybeskincolored,blue,orpurplish[7].(See"Endometriosis:Pathogenesis,clinicalfeatures,and
diagnosis".)
PseudowartPseudowartsarepinktored,wartylookingpapulesornoduleswiththick,scalysurfacesthatare
sometimesmaceratedoreroded.Thesecallusedskinpapules,oftenformingingroupsoflesions,developfrom
chronicirritationfromdiapersinbabiesortheincontinentolderadult.Ahistoryofurinaryincontinenceisimportantto
differentiatetheselesionsfromwartsandprurigonodularis.(See'Prurigonodularis'above.)
LangerhanscellhistiocytosisLangerhanscellhistiocytosispresentsinadultsasredpapulesornodulesinthe
skinfolds,withorwithoutareasoferosionandulceration.(See"Clinicalmanifestations,pathologicfeatures,and
diagnosisofLangerhanscellhistiocytosis".)
SarcoidosisSarcoidosisrarelyinvolvesthevulva,but,whenpresent,itappearsassmoothsurfaced,skincolored
tored/brownishpapulesandnodules.(See"Extrapulmonarymanifestationsofsarcoidosis".)
AmelanoticmelanomaAmelanoticmelanomaisarareformofmalignantmelanomathatcanpresentasaskin
colored,pink,reddish,firmpapuleornoduleonthevulva.Biopsiesofthelesionareusuallydiagnostic.(See
"Mucosalmelanoma",sectionon'Vulvovaginalmelanoma'.)
WHITEPATCHESANDPLAQUESDifferentialdiagnosis(table10).
VitiligoVitiligorepresentsdepigmentationoftheskinduetoautoimmunelymphocyticattackagainstmelanocytes.It
presentsasflat,white,sharplymarginatedpatchesthatcanexpandcentrifugally(picture33).Thereisnoscale.Inthe
anogenitalregion,itmayinvolvethelabiamajora,perineum,andperianalskin.Althoughinsomepatientsvitiligois
restrictedtotheanogenitalarea,morecommonlyothersitessuchastheaxillae,dorsalhands,elbows,knees,and
periorificialfacialskinareinvolved.
Aclinicaldiagnosisofvulvarvitiligoispossiblewhentheclassicalsitesarealsoinvolved.Vitiligomustbedifferentiated
fromlichensclerosusandfrompostinflammatoryhypopigmentation,inwhichonlypartiallossofpigmentationoccurs.If
necessary,biopsydemonstratingtheabsenceofmelanocytescanbeperformed.(See"Vitiligo:Pathogenesis,clinical
features,anddiagnosis".)
PostinflammatoryhypopigmentationPostinflammatoryhypopigmentationpresentsasflat,whitepatchesofskin
similartothoseseeninvitiligo.However,thepatchesarenotaswhite,andthemarginsofthepatchesarelessclearly
definedthaninvitiligo.Moreover,thereisahistoryofprecedinginflammationatthesite.Postinflammatory
hypopigmentationoccursmoreoften,oratleastisrecognizedmoreoften,inindividualswithnaturallydarkerskincolor.
Thedisorderisaconsequenceofinflammationinduceddamagetopigmentproducingmelanocytesandoftenoccurswith
precedingeczematousdiseaseofvaryingtypes.
Thediagnosisismadeclinicallywhenthelighteningoftheskinoccursatthesiteofpreviousorconcomitantinflammatory
disease.Inrarecases,biopsydemonstratingthatmelanocytesremainpresentisnecessary.
Lichensclerosus
PhysicalexaminationTheearliestlesionsoflichensclerosusarewhitepatches,whichmaybehardtodifferentiate
frombothvitiligoandpostinflammatoryhypopigmentation(picture34)however,closeinspectionoftheskinsurface
showsslightwrinkling("cigarettepaper"wrinkling)inlichensclerosus.Theseearlylesionsaremostnotableonthe
labiamajora,butalsocommonlyinvolvetheperineumandtheperianalskininafigureeightpattern(picture35).The
diseasemaybeunilateralorbilateralandsymmetrical.Extragenitalinvolvementoftheskinoccursinapproximately
20to30percentofwomen.
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=5

9/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Thewhitenedtissuebecomesincreasinglythickenedasthediseaseprogresses(picture36).Thelabiamaybecome
adherentinthemidline,partiallyclosingoffthevestibule.Gradually,thelabiaminorashrinkandmaybecome
completelyeffaced(picture37).Thickeningoftheclitoralhoodoftenleadstopartialorfullentrapmentoftheclitoris
(picture38).
Purpuraandfissuringoftheinvolvedtissuemayalsooccur(picture39).Erosionsfrequentlydevelopinlichen
sclerosus(see'Erosivelichensclerosus'below).Bullaecanoccur,butarerare.
SymptomsItchingisusuallyprominent,butitcanbereplacedbypainifthereiswidespreaderosion.Prepubertal
onsetingirlsmayleadtoconstipationduetofissuringoftheperianalskin,leadingtopainatthetimeofdefecation.
Thepresenceofpurpuraandfissuresintheseyounggirlsmayrequireinvestigationtoexcludethepossibilityof
childhoodsexualabuse.
DiagnosisThediagnosisoflichensclerosusisusuallypossibleonclinicalexamination,butbiopsytoruleout
vitiligoandconfirmadiagnosisoflichensclerosusisusuallydesirable,exceptpossiblyinchildren.Biopsyto
excludesquamouscellcarcinoma(SCC)isnecessarywhenulcersorthickenedareasfailtorespondtotherapy
(picture31).(See"Vulvarlichensclerosus".)
LichenplanusLichenplanusisinthedifferentialdiagnosisofredpatchesandplaques(table2).However,theintact
tissuesurroundingtheerosionsinlichenplanus(table3)mayappearwhiteorgray.Often,theselesionsoccurinalacyor
netlikepattern.(See'Erosivelichenplanus'belowand'Lichenplanus(papulosquamousform)'above.)
LichensimplexchronicusLichensimplexchronicusisinthedifferentialdiagnosisofredpatchesandplaques(table
2).However,thesurfaceofthelichenifiedtissuemayappearwhiteasaresultofprolongedmoistureretention.(See
'Lichensimplexchronicus'above.)
CandidiasisCandidiasisisinthedifferentialdiagnosisofredpatchesandplaques(table2)andyellowpapulesand
pustules(table7).However,thesloughingouterskinlayerincandidiasismayappearwhiteasaresultofmoisture
retention.(See'Candidiasis'above.)
Humanpapillomavirusinfection(warts)Humanpapillomavirus(HPV)infectioncausesbenignwarts(condyloma
acuminata),whichcanbelocatedanywhereonthevulva,perineum,and/orperianalareas(picture40).Thefirm,irregularly
roughpapillomaonabroadbasemaybeskincolored,red,pink,tan,brown,black,orwhite(duetoovergrowthofepithelial
cellsandavaryingdegreeofincreasedkeratininamoistlocation).Coalescencecanleadtoformationoflarge,
cauliflowerlikemasses.However,themorphologycanalsobesmallplaques,nodules,orflattoppedpapules.Brown
lesionscanlooklikeseborrheickeratoses.
Biopsyshouldbeperformedonarepresentativesampleofthelesionstoconfirmthediagnosisandtoruleoutvulvar
intraepithelialneoplasia(VIN)andinvasiveSCC.(See"Condylomataacuminata(anogenitalwarts)inadults".)
VulvarintraepithelialneoplasiaVINcanbered(table2)orwhite(table6andtable10),butisinthedifferential
diagnosisofothermorphologies(table11andtable5).Thedisorderisdiscussedabove.(See'Vulvarintraepithelial
neoplasia'above.)
SquamouscellcarcinomaSCCisusuallyred(table4),butmaybewhite(table6)orskincolored(table5).The
disorderisdiscussedabove.(See'Squamouscellcarcinoma'above.)
Rarediseases
Whitespongenevusoccursasanasymptomatic,fairlywellmarginated,whiteplaquewithinthevulvarvestibule[8]
andmayoccurintheoralcavity(picture41).Apositivefamilyhistoryforsimilarlesionsisusuallypresent.Thewhite
coloroccursbecauseofthemoisthyperkeratosis.Diagnosisrequiresbiopsy.
HaileyHaileydisease[3]andtherelatedpapularacantholyticdyskeratosis[4]usuallypresentasredpatchesand
plaques,oftenwithvaryingdegreesoferosion(picture18).Theselesionsmimictheappearanceofthosedescribed
forextramammaryPagetdisease.However,ifthereissignificanthyperkeratosis,thesurfaceofthelesionmay
appearwhitewhenmoist.Thisdiseasefirstappearsinyoungerwomen,andtherearealmostalwayssimilarplaques
onthechest,back,andaxillaeandapositivefamilyhistoryforsimilarlesions.Biopsyisrequiredfordiagnosis.(See
"HaileyHaileydisease(benignfamilialpemphigus)".)
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

10/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Verrucouscarcinomausuallyappearsasalarge,firm,skincolorednodulewithapapillomatous(cauliflowerlike)
surface[9].Thesurfacemaybewhiteduetothepresenceofmoisthyperkeratosis,orthesurfacemaybeeroded,as
inSCC.Excisionalbiopsyisgenerallynecessarytodifferentiatethismalignanttumorfromthatofalarge,benign
wart.(See"Clinicalfeaturesanddiagnosisofcutaneoussquamouscellcarcinoma(SCC)",sectionon'Verrucous
carcinoma'.)
WHITEPAPULESANDNODULESDifferentialdiagnosis(table6).
FordycespotsFordycespotsarenormalvariantsrepresentingenlargedsebaceousglands.The1to2mmpapulesare
whitetoyellow,singleormultilobular,andcanformsheets.Theyoccurinasymmetricalpatternonthemedialaspectsof
thelabiaminoraandlesscommonlyonthelabiamajoraortheprepuceandclitoris.Fordycespotsmustbedifferentiated
fromcondylomaacuminata,milia,andmolluscumcontagiosum.Thediagnosisisbasedonlocationandmorphology.
MiliaMiliaarefirm,white,verysmall(1to2mm)epidermalcyststhatareuncommononthevulva.Afternickingthe
surfacewithasmallneedle,thetiny,firm,whitecystcanbeextractedandoftenremainsintact.
EpidermoidcystsEpidermoidcystsareinthedifferentialdiagnosisofredpapulesandnodules(table4)andyellow
papulesandpustules(table7).Thekeratincontainedwithinepidermoidcystsiswhite.Ifthecystisnotinflamedand
sufficientlysuperficial,theappearanceofthenodulewillbewhite(table10)ratherthanskincolored.(See'Epidermalcysts
(inflamed)'above.)
MolluscumcontagiosumMolluscumcontagiosumisinthedifferentialdiagnosisofredpapulesandnodules(table4).
However,thedomeshapedpapulesofmolluscumcontagiosum,whichareoftendimpled,maybewhite,pink,orskin
colored(table5).(See'Molluscumcontagiosum'above.)
Humanpapillomavirusinfection(warts)Wartsareinthedifferentialdiagnosisofbrown,blue,orblacklesions(table
11)andskincoloredlesions(table5).However,theymayappearwhitewhentheyoccurinmoistareas,duetothe
retentionofmoistureinthickenedsurfaceepithelium(table10).(See'Humanpapillomavirusinfection(warts)'above.)
VulvarintraepithelialneoplasiaVulvarintraepithelialneoplasia(VIN)isinthedifferentialdiagnosisofredpatchesand
plaques(table2)andbrown,blue,orblacklesions(table11).However,VINmayappearwhitewhenitoccursinmoist
areas,duetotheretentionofmoistureinthickenedsurfaceepithelium(table10).(See'Vulvarintraepithelialneoplasia'
above.)
SquamouscellcarcinomaSquamouscellcarcinoma(SCC)isinthedifferentialdiagnosisofredpapulesandnodules
(table4),butmayappearwhitewhenitoccursinmoistareas,duetoretentionofmoistureinthickenedsurfaceepithelium.
(See'Squamouscellcarcinoma'above.)
ScarAvulvarscarcanbewhiteorskincolored.Apreviouspunchbiopsymayleavearound,flatscar.Anepisiotomy
maycausealinear,whitescaralongtheposteriorfossa,extendingontotheperineum.Ahistoryoftraumatothearea
helpstomakethediagnosis.Abiopsyisnotusuallyneeded,butcanconfirmthediagnosis.
Rarediseases
Verrucouscarcinomausuallyappearsasalarge,firm,skincolorednodulewithapapillomatous(cauliflowerlike)
surface[9].Thesurfacemaybewhiteduetothepresenceofmoisthyperkeratosisorthesurfacemaybeeroded,as
inSCC.Excisionalbiopsyisgenerallynecessarytodifferentiatethismalignanttumorfromthatofalarge,benign
wart.(See"Clinicalfeaturesanddiagnosisofcutaneoussquamouscellcarcinoma(SCC)",sectionon'Verrucous
carcinoma'.)
Condylomalataistheanogenitalformofsecondarysyphilis.Itappearsassharplymarginated,smooth,flattopped
1to2cmmoistpapulesandsmallplaques(picture42andpicture43).Theselesionsmaybeskincolored,white,
pink,oryellow.Differentialdiagnosisincludeshumanpapillomavirus(HPV)infectionandVIN.Aclinicaldiagnosis
canbesuspected,butwillrequireconfirmationbypositiveserologicaltestsforsyphilis.
YELLOWPAPULESANDPUSTULESDifferentialdiagnosis(table7).
CandidiasisCandidiasisisinthedifferentialdiagnosisofredpatchesandplaques(table2).However,pustules,when
theyoccurinvulvarcandidiasis,areoftenyelloworyellowwhiteduetothepresenceofpus.(See'Candidiasis'above.)

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

11/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

FolliculitisFolliculitisisinthedifferentialdiagnosisofredpapulesandnodules(table4).However,thepapulesof
infectiousfolliculitismaybewhiteoryellowwhitewhentheyarecappedbyapustule.Retentionofkeratincancausea
whiteappearanceinthepapulesinkeratosispilaris,anoninfectiousdisorder.(See'Folliculitisandkeratosispilaris'above.)
FurunculosisTheredpapulesandnodulesoffurunculosis(table4)mayhaveawhitesummitwhentheycometoa
pointandformapustule.(See'Furunculosis'above.)
HidradenitissuppurativaHidradenitissuppurativaisinthedifferentialdiagnosisofredpapulesandnodules(table4).
However,whenpustulesforminhidradenitissuppurativa,theyarewhite.(See'Hidradenitissuppurativa'above.)
MolluscumcontagiosumMolluscumcontagiosumisinthedifferentialdiagnosisofredpapulesandnodules(table4)
andskincoloredlesions(table5).However,thepapulesofmolluscumcontagiosumveryrarelyhaveayellowtint.(See
'Molluscumcontagiosum'above.)
EpidermalcystEpidermalcystsareinthedifferentialdiagnosisofredpapulesandnodules(table4),whitepapules
andnodules(table6),andskincoloredlesions(table5).However,epidermalcystsmayhaveyellowtint,especiallywhen
theyoccurinheavilypigmentedskin.(See'Epidermalcysts(inflamed)'above.)
VestibularmucinouscystThesmoothsurfacedpapulesandsmallnodulesofmucinouscystsmayappearyellowor
skincolored(table5).(See'Vestibularmucinouscyst'below.)
Rarediseases
FoxFordycediseaseisarare,extremelypruritic,eruptionofmonomorphous,1to2mm,closelyset,domeshaped,
follicularpapulesaroundthepubichairs.Thepapulesmaybeskincolored,yellow,red,orbrown.Similarlesionsmay
occurintheaxilla.Theclinicaldiagnosisisbasedonthedistinctiveappearanceofthisdisorder,butconfirmationcan
beobtainedbybiopsy.Differentialdiagnosisincludesfolliculitisandtinymolluscumcontagiosum.
Pustularpsoriasisisararevariantofpsoriasisvulgaris.Thediseasepresentswithsmall(1to10mm)pustules
studdedthroughouttypicalpsoriaticredpatchesandplaques.Thepustulesarefragileandquicklybreakdown,
leavingcollarettescaleencirclingtheperiphery.Itisunlikelythatthisconditionwouldbeconfinedtothevulva
usually,thereiswidespreadinvolvementelsewhere.Adiagnosiscanoftenbemadeclinically,butconfirmationcan
beobtainedwhenbacterialculturesarenegative.(See"Pustularpsoriasis:Pathogenesis,clinicalmanifestations,
anddiagnosis".)
Subcornealpustulardermatosishasasimilarappearancetopustularpsoriasis,bothclinicallyandhistologically
however,ithasagreaterpredilectionforintertriginousdistribution.Bacterialculturesarenegative,andbiopsymaybe
warranted.(See"Pustularpsoriasis:Pathogenesis,clinicalmanifestations,anddiagnosis".)
Condylomalataistheanogenitalformofsecondarysyphilis.Itappearsassharplymarginated,smooth,flattopped
1to2cmmoistpapulesandsmallplaques.Theselesionsmaybeskincolored,white,pink,oryellow(picture42and
picture43).Differentialdiagnosisincludeshumanpapillomavirus(HPV)infectionandvulvarintraepithelialneoplasia
(VIN).Aclinicaldiagnosiscanbesuspected,butwillrequireconfirmationbypositiveserologicaltestsforsyphilis.
(See"Syphilis:Epidemiology,pathophysiology,andclinicalmanifestationsinHIVuninfectedpatients",sectionon
'Clinicalmanifestations'.)
BROWN,BLUE,ORBLACKMACULES,PAPULES,PATCHES,ANDPLAQUESDifferentialdiagnosis(table11)
[10,11].
PhysiologicalhyperpigmentationPhysiologicalhyperpigmentationpresentsasasymptomatic,symmetrical,flat,
smooth,brownorbrownblackpatchesonthelabiamajoraandouteredgeofthelabiaminora.Itismoreprominentin
womenwithnaturallydarkskincolor.Endogenousorexogenoussexhormonesmayleadtofurtherdarkening.The
diagnosisisclinicalandcanbedifferentiatedfrompostinflammatoryhyperpigmentationbecausethelatterisnotas
symmetricalandevenincolor.
PostinflammatoryhyperpigmentationPostinflammatoryhyperpigmentationmayariseatsitesofprevious
inflammationfromanycause,includingtrivialinsultssuchasascratchoracne.Thecolorvariesfromlighttantogray,
blue,brown,orblack.Thepigmentationisflatandusuallysmooth,butslightscalemaybepresentwhenthepreceding
inflammationwasrelatedtoaneczematousprocess.Thesiteandpatternwilldependontheprecedinginflammation.
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

12/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Lichensclerosusandlichenplanusoftenhavereticulatedorpatchypigmentedmaculesorregularpatchesalongthe
peripheraledgesofthevestibuleorperineum.
Ahistoryofapriorinflammatoryprocessortraumawillhelptomakethediagnosis.Whenthepatternisblackorirregular,
vulvarmelanosis(lentiginosis)andmelanomamustbeconsidered.Severalbiopsiesmayneedtobetakentomakea
definitivediagnosis.
Humanpapillomavirusinfection(warts)Genitalwartsareusuallyskincolored(table5),buttanandbrownhuescan
bepresent.Theyarealsointhedifferentialdiagnosisofwhitelesions(table6andtable10).(See'Humanpapillomavirus
infection(warts)'above.)
VulvarintraepithelialneoplasiaThelesionsofvulvarintraepithelialneoplasia(VIN)areinthedifferentialdiagnosisof
red(table2),white(table6andtable10),andskincoloredlesions(table5).However,theymaybebrown,grey,orblack
astheresultofretainedmelaningranulesinthethickenedepithelium.(See'Vulvarintraepithelialneoplasia'above.)
MelanocyticnevusMelanocyticneviarecommon90percentofneviarethetypical,benigntype,presentingasa
symmetrical,tanorbrownmacules(junctionalnevi)orpapules(compoundorintradermalnevi).Theedgesaresharply
marginated,thecolorishomogenous,andmostarelessthanacentimeterindiameter.Slightvariationincolorandoutline
isnormal.
Theseneviaredifferentiatedfrommelanomabytheirsymmetry,sharpborder,homogenouscolor,andsmallsize.Theyare
differentiatedfromotherpigmentedlesions,suchasseborrheickeratosisandhumanpapillomavirus(HPV),bytheir
smoothsurface.Neviand,rarely,malignantmelanomascanoccurwithinthelesionsoflichensclerosus.Anyquestionable
lesionshouldhaveacompletenarrowexcisionoradequatebiopsy.(See"Acquiredmelanocyticnevi(moles)".)
Intradermalneviareusuallyskincoloredoronlylightlypigmented.
SeborrheickeratosesSeborrheickeratosesaresmall,benign,wartygrowthsthatoccuranywhereonthebody,but
mostcommonlyonthetorso.Whentheyoccurintheanogenitalarea,theyarerestrictedtononmucosal,keratinizingskin.
Theytypicallydevelopafter35to40yearsofage.Thelesionsaresharplymarginated,tan,brown,orblackpapuleswitha
warty,stuckonappearance.Sizeisvariablefrom3mmtoover2cm,andthesurfaceiselevated2to10mmabovethe
surroundingnormalskinsurface.Thesurfacescalecanbescrapedoffwithresultingpinpointbleeding.Onhigh
magnification,theremaybeminutepitsormilialikekeratininclusions.
Whenseborrheickeratosesoccuronthevulva,differentiationfromwartsandVINcanbedifficult.HPVlesionsareusually
smallandmultiple,whereasseborrheickeratosesareoftensolitaryonthevulva,buttheremaybealargenumber
elsewhereontheskin.Otherpigmentedlesionsthatcanmimicvulvarseborrheickeratosesincludebasalcellcarcinoma,
dysplasticnevi,andmelanoma.Ashavebiopsyisdiagnostic.(See"Overviewofbenignlesionsoftheskin",sectionon
'Seborrheickeratosis'.)
AngiokeratomasThepapulesofangiokeratomasareinthedifferentialdiagnosisofredpapulesandnodules(table4),
buttheyareoftenblue,violaceous,orevenblack.(See'Angiokeratomas'above.)
Skintag(acrochordon)Skintags(acrochordaorfibroepithelialpolyps)arecommon,benign,soft,skincolored,tan,or
brownpapuleswithshort,thinstalksthatare1to3mm.Theyoccurassinglelesionsoringroupsontheinguinalfolds.
Theyaremorecommonlyfoundandmorenumerousinnumberinobesewomen.Whentraumatized,theycanbeblue,
purpuric,orswollenandblack.
Afibroepitheliomatouspolypisalarger,solitary,skincoloredorbrownlesionwithalong,narrowstalkandbroadtip.
Differentiatingthesefrompedunculatednevimaynotbepossible,exceptwithbiopsy.(See"Overviewofbenignlesionsof
theskin",sectionon'Acrochordon(skintag)'.)
Vulvarmelanosis/lentiginosisVulvarlentiginesarenotuncommon.Alentigoisanasymptomaticflat,tan,brown,or
blackpigmented,macule,2to8mmindiameter.Theselesionsmaybepoorlydemarcated,irregularinoutline,and
asymmetricinshape.Theyarefoundmostlyonthelabiaminora.(See"Benignpigmentedskinlesionsotherthan
melanocyticnevi(moles)",sectionon'Lentigo'.)
Vulvarmelanosisisalarger,asymptomatic,hyperpigmentedpatch.Thecolorisdarkerandisusuallydeepbrownorblack.
Thelesionmaybepoorlydemarcated,irregularinoutline,andasymmetricisshape.Vulvarmelanosisdevelopsinadult
womenandismostoftenlocatedalongtheedgesofthelabiaminoraandthevulvartrigone.Itmaydevelopwithinthe
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

13/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

lesionsoflichensclerosus.Thedifferentialdiagnosisincludespostinflammatoryhyperpigmentation,VIN,dysplasticnevi,
andmelanoma.Severalbiopsiesmaybeneededfordiagnosis.
LichenplanusLichenplanusisinthedifferentialdiagnosisofredpatchesandplaques(table2)andvulvarerosions
(table3).However,thepapulosquamousformoflichenplanusmaybegreyorbrown.(See'Lichenplanus
(papulosquamousform)'aboveand'Erosivelichenplanus'below.)
AtypicalmelanocyticnevusAtypicalnevicanpresentonthevulva(labiaminoraormajora),usuallyinolderchildren
andyoungwomen.Thepigmentedmaculesaresmoothsurfaced,>6mmindiameter,withoneormoreatypicalfeatures
suchasasymmetry,nonsharpmargins,largersize,andvariablepigmentationwithinthelesion.Thedifferentialdiagnosis
ismalignantmelanoma.Anexcisionalbiopsyisrecommended.(See"Atypical(dysplastic)nevi".)
VaricosityVaricoseveinsonthevulvaareoftenseeninpregnantwomen(picture44).Theycanbeisolatedorin
groups.Thesmallonesaremoderatelydarkredorblack,andthelargeronesarebluer.Compressionwithaglassslide
resultsinlesiondisappearance,confirmingthediagnosis.(See"Vulvovaginalvaricositiesandpelviccongestion
syndrome".)
Rarediseases
PigmentedbasalcellcarcinomaThelesionsofpigmentedbasalcellcarcinomamostlyoccuronthelabiamajora
inolderwomanassolitary,usuallyskincoloredtopinkandsometimestantobrownpapules,smallplaques,or
nodules.Sometimes,thesurfaceiserodedorulcerated.(See"Epidemiologyandclinicalfeaturesofbasalcell
carcinoma".)
HidradenomapapilliferumHidradenomapapilliferum(mammarylikeglandadenoma)isarare,benign,smooth
surfaced,softtofirm,0.5to1cm,translucent,skincolored,pinkredoroccasionallydarklesiononthelabia[6].
AcanthosisnigricansAcanthosisnigricansisanuncommonvulvarconditionaffectingthosewithobesity(picture
45),thyroiddisease,and,occasionally,metabolicsyndrome.Itpresentsasbrownareasinthebodyfolds,especially
aroundtheneckandintheaxillae,butalsointhecruralfolds.Thesurfaceisthickenedandvelvety,whichgivesthe
skinadirtyappearance.Abiopsywillconfirmtheclinicaldiagnosis.(See"Acanthosisnigricans".)
SKINCOLOREDPAPULES,NODULES,ANDPLAQUES(MAYBEPINKONMUCOSAE)Differentialdiagnosis
(table5).
VestibularpapillomatosisVestibularpapillomatosisisinthedifferentialdiagnosisofredpatchesandplaques(table
2),butthesmall,closelyset,softpapulestendtomatchthecolorofthemucosaltissueofthevestibule.(See'Vestibular
papillomatosis'above.)
Skintag(acrochordon)Thesesoft,elongatedpapulesmaybeskincolored,tan,orbrown(table11).(See'Skintag
(acrochordon)'above.)
Humanpapillomavirusinfection(wart)Truecondylomaaccuminata(stalklikewithabranchedtip)areskincolored,
butflattopped,commonwartstendtobepink,red,brown,orblack(table11).Theyarealsointhedifferentialdiagnosisof
whitelesions(table6andtable10).(See'Humanpapillomavirusinfection(warts)'above.)
MolluscumcontagiosumThedomeshaped,oftenumbilicated,papulesofmolluscumcontagiosummaybered(table
4),white(table6andtable10),orskincolored.(See'Molluscumcontagiosum'above.)
LichensimplexchronicusThelichenifiedplaquesoflichensimplexchronicusoccurastheresultofchronicrubbing
andscratching.Theymayred(table2),white(table6),orskincolored.(See'Lichensimplexchronicus'above.)
ScarScarsaremostoftenskincolored,butmaybewhite(table6).(See'Scar'above.)
VulvarintraepithelialneoplasiaHumanpapillomavirus(HPV)relatedvulvarintraepithelialneoplasia(VIN)(usualtype)
ismoreoftenpink,red(table2),brown,orblack(table11),whereasnonHPVrelated,differentiatedVINismoreoften
white(table6andtable10)orskincolored.(See'Vulvarintraepithelialneoplasia'above.)
EpidermalcystNoninflamed,keratinfilledepidermalcystsareusuallyskincolored,butmaybewhite(table6).
Inflamedepidermalcystsarered(table4).(See'Epidermalcysts(inflamed)'above.)

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

14/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

BartholinductcystCysticenlargementoftheBartholinductduetopluggingresultsinunilateralskincoloredorred
swellingofthevulvathatmimicstruevulvaredema.Itmaybeasymptomaticorsymptomatic.Ruptureorinfectionof
thesecystsleadstounilateralerythematousinflammatoryswelling(table4).
Diagnosisisusuallypossibleclinicallybecauseoftheunilateralswellingandthefindingthatthelabiumminusoverliesthe
middleoftheswelling.Thediagnosiscanbeconfirmedbyincisionanddrainageofthecystcontents.Thecystmay
becomeinfected,formingaBartholinductabscess.Ifpusispresent,thepurulentfluidshouldbesentforbacterialculture.
(See'Bartholinductabscesses'above.)
IntradermalmelanocyticnevusIntradermalneviareoftenskincolored,butmaybetanorbrown(table11).(See
'Melanocyticnevus'above.)
VestibularmucinouscystVestibularmucinouscystsaresolitary,benign,soft,smoothsurfaced,domed,translucent
papulesorsmallnodulesfilledwithclear,viscousmucinandinthevulvarvestibule.Theyareusuallythepinkcolorofthe
surroundingvestibularmucosalsurface,butmaybeeitheraverylightblueorlightyellow(table7).Thelesionis
asymptomatic.
Aclinicaldiagnosisispossibleinmostcases.Incision,whichallowsthejellylikemucinousmaterialtoextrude,confirms
thediagnosis.
SquamouscellcarcinomaThenodulesofsquamouscellcarcinoma(SCC)maybered(table4),white(table6and
table10),orskincolored.(See'Squamouscellcarcinoma'above.)
Rarecauses
BasalcellcarcinomaThelesionsofpigmentedbasalcellcarcinomamostlyoccuronthelabiamajorainolder
womanassolitary,usuallyskincoloredtopinkandsometimestantobrownpapules,plaques,ornodules.
Sometimesthesurfaceiserodedorulcerated.(See"Epidemiologyandclinicalfeaturesofbasalcellcarcinoma".)
Hidradenomapapilliferum(mammarylikeglandadenoma)isarare,benign,smoothsurfaced,softtofirm,0.5to1
cm,translucent,skincolored,pinkredoroccasionallydarklesiononthelabia[6].
Syringomasarebenignneoplasmsmadeupofsweatglansandsweatducts.Theyarerare,2to20mm,skin
colored,asymmetricallydistributed,smoothsurfaced,papulesthatcanbesingleormultiple.Theyaremainlylocated
onthelabiamajora.Whenlargenumbersarepresent,theymaycoalescetoformalarger,bumpyplaque.Pruritusis
common[6].
FoxFordycediseaseisarare,extremelypruritic,eruptionofmonomorphous,1to2mm,closelyset,domeshaped,
follicularpapulesaroundthepubichairs.Thepapulesmaybeskincolored,yellow,red,orbrown.Similarlesionsmay
occurintheaxilla.Theclinicaldiagnosisisbasedonthedistinctiveappearanceofthisdisorder,butconfirmationcan
beobtainedbybiopsy.Differentialdiagnosisincludesfolliculitisandtinymolluscumcontagiosum.
Neurofibromasarebenign,soft,skincoloredtotannodulesthatmayoccurinthepericlitoralareaorlabiamajora.
Theymayappearassolitarynodulesormaybenumerousandwidelydistributedwhentheydevelopaspartof
generalizedneurofibromatosis(vonRecklinghausendisease).(See"Overviewofbenignlesionsoftheskin",section
on'Neurofibroma'.)
Condylomalataistheanogenitalformofsecondarysyphilis.Itappearsassharplymarginated,smooth,flattopped,
1to2cm,moistpapulesandsmallplaques.Theselesionsmaybeskincolored,white,pink,oryellow(picture42
andpicture43).DifferentialdiagnosisincludesHPVinfectionandVIN.Aclinicaldiagnosiscanbesuspected,but
willrequireconfirmationbypositiveserologicaltestsforsyphilis.(See"Syphilis:Epidemiology,pathophysiology,and
clinicalmanifestationsinHIVuninfectedpatients",sectionon'Clinicalmanifestations'.)
EDEMA,SKINCOLOREDORERYTHEMATOUSDifferentialdiagnosis(table9).
PostsurgicalandpostradiationedemaVulvaredemacanfollowanysignificantlymphaticvesseldamagecausedby
surgeryorradiationtherapyofthelowerabdomenandpelvicarea.Itinitiallypresentsassoft,easilypitted,skincolored
swellingofthelabiaminoraandmajora,but,ifpresentformonthstoyears,itwillbecomemorefirmandlesseasilypitted.
Thediagnosisandcauseforthistypeofedemaisestablishedonclinicalexaminationtogetherwithahistoryofpreceding
surgeryorradiationtherapy.Biopsyisnothelpful.
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

15/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

CrohndiseaseCrohndiseaseisinthedifferentialdiagnosisofredpatchesandplaques(table2)andulcerative
disease(table8).However,persistentvulvaredemacanoccurasaresultofintestinaland/orvulvarCrohndisease.
Inflammatorylesionsdonothavetobewithin,orevennear,thesiteoftheedema.(See'Crohndisease'above.)
HidradenitissuppurativaHidradenitissuppurativaisinthedifferentialdiagnosisofredpatchesandplaques(table2)
andulcerativelesions(table8).Persistentvulvaredemaoftenoccurswhenlesionsofhidradenitissuppurativaoccurinthe
anogenitalarea.Theinflammatorylesionscancauseedema,eveniftheyaresomedistancefromtheedema.(See
'Hidradenitissuppurativa'above.)
EdemaduetopregnancyMild,skincolorededemamayoccurinthelatestagesofpregnancyduetofetalpressureon
thelymphaticvesselsandisevenmorelikelytooccurinpreeclampsia.Thediagnosisisapparentwhenvulvaredema
occursinanotherwisewellorpreeclampticpregnantwoman[12].
EdemaduetoinfectionCellulitisofthevulva,usuallyduetoS.aureusor,lessoften,Streptococcuspyogenes,is
accompaniedbyvulvaredema.Theedemaappearspinkorredandmaybepainfuland/ortendertopalpationwhen
infectionisactive.However,persistent,skincolorededemaremainsafteractiveinfectionshavesubsided.Adiagnosisof
cellulitisshouldbestronglyconsideredwhenred,painfuledemaoccursinapatientwithmildfeverandmalaise.Relapsing
episodesofpinktoredvulvaredemashouldalsosuggestcellulitisrelatededema.
Thewhitebloodcellcountmaybeelevated.Bacterialculturesarenothelpful.Thediagnosisisconfirmedifthereisagood
responsetooralantibiotictherapy.Theedemausuallyresolvesafterthefirstepisode,butbecomesmorepermanentwith
repeatedboutsofcellulitis.(See"Cellulitisanderysipelas".)
Vulvaredemamayalsooccurinthesettingofprimaryherpessimplexinfectionandmayaccompanyvulvovaginal
candidiasis.Inbothoftheseinstances,theedemaisusuallyerythematous,andthediagnosisisdependentonrecognition
ofoneortheotherofthesetwoinfections.Followingtreatment,theedemasubsides.(See"Epidemiology,clinical
manifestations,anddiagnosisofgenitalherpessimplexvirusinfection"and"Candidavulvovaginitis".)
PostinfectiousedemaVulvaredemafollowinganinitialepisodeofbacterialcellulitisresolves.However,cellulitis
damagesthelymphaticsystem,and,followingseveralrecurrentepisodesofcellulitis,noninflammatoryvulvaredema
becomesmorepermanent,leadingtoalocusminorisresistentiaeandrepeatedepisodesofcellulitis.Thischronicedema
isskincoloredandgraduallybecomesfirmerandpitslesseasily.
Diagnosisdependsonobtainingahistoryofepisodicrednessandswelling.Thediagnosisisfurthersupportedifthe
recurrentinflammatoryepisodesceasewhilethepatientistakinglongtermprophylacticantibiotics.Biopsyandattempts
toculturepathogenicbacteriafromthesurfaceorfromneedleaspiratesarenothelpful.
BartholinductabscessBartholinductabscessisinthedifferentialdiagnosisofredpapulesandnodules(table4).The
inflammationassociatedwithBartholinductabscesscausesunilateralvulvaredema,whichsubsideswhentheabscessis
successfullytreated.(See'Bartholinductabscesses'above.)
AllergiccontactdermatitisVulvarcontactdermatitisisinthedifferentialdiagnosisofredpatchesandplaques(table
2).However,theinflammationassociatedwithvulvarcontactdermatitisoftheallergictypeisassociatedwithvulvar
edema,whichsubsidesafterappropriatetreatment.(See'Allergiccontactdermatitis'above.)
TraumaEdemacanariseafteranysignificantblunttraumatothevulvartissue.Unlessbloodvesseldamageoccurs,
causingpurpura,theedemaisskincolored,softandeasilypitted.Usually,thediagnosisisapparentbecauseoftheshort
intervalbetweentherecognizedtraumaandthedevelopmentofswelling.Anexceptionislowgrade,chronictraumathat
canoccurfromlongrangebicycleridingor,morerarely,horsebackriding[12].
Rarecauses
Acuteallergicangioedemahasarapid,IgEmediatedonset.Itismostlikelytooccurwhenawomanhasbecome
sensitizedtosemenorlatex.Theedemaisusuallyskincolored,althoughsometimespink.Itisalsosoft,pitting
easily.Angioedemaatdistantsitessuchastheeyelids,lips,andairwayisalsopossible.Theedemaarisesacutely
andresolvesspontaneously,hourslater.Therearenoskinsurfacechangeslikethoseseeninallergiccontact
dermatitis.Thecorrectdiagnosisissuggestedbytheacutecourseoftheedemaandahistoryofcontactwithlatex
orsemenwithinthepreviousminutes.(See"Latexallergy:Epidemiology,clinicalmanifestations,anddiagnosis"and
"Allergicreactionstoseminalplasma".)
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

16/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Localizedlymphangiomacanbecongenitaloracquired.Congenitallymphangiomasareduetofaultylymphvessel
formation.Theinguinalandgenitalarearepresentsafairlyfrequentsiteforthesedeepseatedanaloguesof
hemangiomas.Acquiredlymphangiomasmostoftenoccurfollowingpelvicsurgeryorradiationtherapy.Inbothtypes
oflymphangiomas,theoverlyingskinisnormal.Later,duetoapropensityforbacterialinfection,damageoccursto
thelymphatictissue,causingchronic,firm,noteasilypittedvulvaredema.Sometimes,dilatedcysticstructuresform
pseudoblisters(lymphangiectasis)ontheoverlyingskin.
Milroydiseaseisnotedat,orshortlyafter,birth.Defectsinlymphvesselformationresultinlymphedemainoneor
bothlegs.Skincolored,fairlyfirmvulvaredemamayalsodevelop.
MelkerssonRosenthalsyndromeisanidiopathic,skincolored,fairlyfirmedemaofthefaceand,rarely,thevulva.
Veryfewcaseshavebeenreportedinwhichonlythevulvaisinvolved[13].Thediagnosisisestablishedwhen
granulomas,similartothosethatoccurinCrohndisease,arefoundonbiopsy.
VESICLESANDBULLAEDifferentialdiagnosis(table12)[14].
HerpessimplexvirusGenitalherpessimplexcanpresentineitheroftwoways.Therarelyencountered,primary
episodeoccurswithwidespreadgenitalvesiclesand/orerosionsinapatientwhoisalsoexperiencingfever,malaise,and
dysuria(picture46).Themuchmorecommon,recurrentformofgenitalherpespresentswith5to15small(1to5mm)
vesiclesthatcontainclearorslightlyyellowfluid(picture47).Theseareclusteredoveranareaofapproximately2to5cm.
Thevesiclesquicklybreak,formingsuperficial,welldemarcated,rounderosionsontheskin,mucousmembranes,and
modifiedmucousmembranesofthevulva.Swellingoftheunderlyingskinisvariable.Atypicalprodromeoflocalized
itching,burning,ortinglingsupportsthediagnosis.Eightypercentofindividualswithherpesareunawareoftheirdiagnosis.
Aclinicaldiagnosisoferodedgenitalherpesisusuallypossiblebasedonthepresenceofcollarettescalearoundthe
circumferenceoftheerosions,tightgroupingoftheerosions,agyrateborderiftheerosionshavebecomeconfluent,anda
historyofpreceding,similarlesionsatthesamesite.However,ifthisisthefirstoutbreak,confirmationoftheclinical
diagnosisshouldbeobtained.Confirmationisachievedbyviralcultureand/orimmunofluorescencetestingofmaterial
gentlyswabbedorscrapedfromthebaseoftheerosionspreadontoamicroscopeslide.Polymerasechainreaction(PCR)
techniquebasedtestingisalsoavailable.Thesetestsbecomenegativeapproximatelyfivedaysaftertheerosionshave
developed.Confirmationofherpessimplexinerosionsolderthanfivedaysisdifficult,ifnotimpossible.(See
"Epidemiology,clinicalmanifestations,anddiagnosisofgenitalherpessimplexvirusinfection".)
Theindividualvesiclesofherpeszosterarealmostidenticalinappearance.However,theclustersofvesiclesareusually
arrangedinadermatomalpatternandusuallyappearforthefirsttimeinolderindividuals.Appreciablepainoccurringinthe
involveddermatomeisalsoregularlypresent(see'Herpeszoster'below).Candidiasisismoresuperficial,thelesionsare
pustulesratherthanvesicles,andthelesionsaresmallerinsize(see'Candidiasis'above).Bullousimpetigoismore
superficial,withvesiclesandbullaethatbreakandformdesquamatingedges.(See'Bullousimpetigo'below.)
Insignificantlyimmunocompromisedwomen,theremaynotbeahistoryofavesicularstage.Instead,thepresentationis
oftenthatofnonhealingulcersorulceratednodules.Theseulcersareusuallysomewhatpainful,but,insomeinstances,
thereisnoappreciablepain.Becauseoftheinabilitytomusterasuitableimmuneresponse,theulcersmaypersistfor
weekstomonths.
Adiagnosisofherpessimplexshouldbeconsideredinimmunosuppressedwomenwithnonhealingulcers(especiallyifa
gyrateconfigurationispresent).Asuspecteddiagnosisshouldbeconfirmedbyimmunofluorescence,PCRbasedtesting,
orviralculture.Materialforthesetestsmaybeobtainedbygentlyscrapingtheedgeandthebaseoftheulcer.Ifthese
studiesarenegative,serologicaltestsforsyphilisshouldbeobtained,andbiopsyshouldbeperformedtoruleoutaphthous
ulcers,chancroid,pyodermagangrenosum(see'Pyodermagangrenosum'below),andulceratedmalignancy.(See
"Approachtothepatientwithgenitalulcers".)
HerpeszosterHerpeszosterpresentsasroundtoovaledematouspinkplaquesalongadermatome,withvarying
degreesofitchingand/orpain.Withinadayortwo,groupsofonetofivevesiclesappearonthesurfaceoftheplaques.
Thesevesiclesoftencoalesceintolargerbullaethatmaybepurpuric.Intheanogenitalregion,theblistersusuallyextend
unilaterallyalongthebuttockstothelabiamajoraandminora.Theblisterroofsbreakdownquicklyandeasily,leaving
painful,open,groupederosions(3to7mm).Usually,therearebitsofloosescale(collarettescale)attheperipheryofthe
erosions.Occasionally,thelesionsbecomeconfluent,leavinglargererosionspossessingagyrateconfiguration.
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

17/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Adiagnosiscanusuallybeestablishedclinicallybasedonthemorphology.However,viralculture,immunofluorescent,or
PCRbasedidentificationmaybedesirable,consideringthatapproximately10percentofthepatientswiththeabove
morphologyturnouttohaveherpessimplexvirus(HSV)infection,ratherthanvaricellazostervirusinfection.(See
"Clinicalmanifestationsofvaricellazostervirusinfection:Herpeszoster".)
Thedifferentialdiagnosesincludeherpessimplex,bullousimpetigo,andbullouspemphigoid.HSVisusuallymorelimited
andoftencrossesthemidline,whileherpeszosterisclassicallyunilateralalongadermatome.Bullousimpetigohasthin
walledvesiclesandbullae,whichareculturepositiveforS.aureus.Bullouspemphigoidhasfirm,thickwalledbullae.
Neitherconditionisaspainfulasherpeszoster.
BullousimpetigoImpetigoofthebulloustypeisusuallycausedbyS.aureusandlessoftenbyStreptococcus
species.Thelesionsinitiallyconsistofthinwalled,fragilevesiclesandbullae.Thesebreakdownquickly,leavinground
erosionswithcollarettesofscale.Anogenitalimpetigooccursonthekeratinizedskinofthelabia,labiocruralfolds,upper
innerthighs,andmonspubis.Occasionally,thevesiclesandbullaeremainintactforseveraldays,and,whenthisoccurs,
thegradualaccumulationofwhitebloodcellsresultsinyellowwhiteblisterfluid.Inadditiontovesiclesandbullae,oneor
morefollicularredpapulesorpustules(bacterialfolliculitis)arealsooftenpresent.
Bullousimpetigocanbeconfusedwithblisteringdiseasesastheerosionsinallofthesediseaseshavewelldemarcated,
superficialpeelingedges.DiagnosisismadethroughtherecoveryofS.aureusorStreptococcusspeciesonculturefrom
theblisterfluidorfromthesurfaceoftheerosionthatoccursaftertheblisterroofisgone.(See"Impetigo".)
ContactdermatitisContactdermatitisisinthedifferentialdiagnosisofredpatchesandplaques(table2),butvesicles
andbullaemayoccur.(See'Allergiccontactdermatitis'aboveand'Irritantcontactdermatitis'above.)
PemphigoidBullouspemphigoidisrarelyseeninwomenyoungerthan60yearsofage.Thedistributionpatternis
usuallygeneralized,butthekeratinizedskinofthevulvaisinvolvedin10percentofpatients.Thepresentationis
polymorphousandincludesamixtureoferosions(picture48),redpapulesandplaques(picture49),vesicles,andbullae
(picture50andpicture51).Theblistersmayariseeitheronnormalappearingskinorfromthesurfaceoftheredplaques.
Theyarethickwalled,tense,unilocular,andfilledwithstrawcoloredtohemorrhagicfluid.Theyarelessfragilethanthose
thatoccurinimpetigo,pemphigus,orcontactdermatitis.Becausetheblistersarenotfragile,theclinicalpresentationwill
likelybeamixofintactblistersanderosionswithloosebitsofscale(collarettescale)attheperipheryoftheerosions.The
distributionintheanogenitalareaincludesthemonspubis,buttocks,thighs,andlabiamajora.Whenthelesionsrupture,
theyleaveerosionsthathealwithoutscarring.Itchingisusuallysevere.
Thedifferentialdiagnosesforpemphigoidincludeblisteringerythemamultiforme,drugeruptions,andcontactdermatitis.
Diagnosisissuggestedbytheclinicalpattern,butbiopsiesfromtheedgeofablisterandfromperilesionalskinshouldbe
submittedforbothconventionalhistologyanddirectimmunofluorescenttesting.Indirectimmunofluorescentstudiesofthe
serumshowacharacteristicpatterninmostpatients.(See"Clinicalfeaturesanddiagnosisofbullouspemphigoidand
mucousmembranepemphigoid".)
Pemphigoidgestationis(herpesgestationis)Pemphigoidgestationis(herpesgestationis)isablisteringskineruption
thatoccursinthesecondorthirdtrimesterofpregnancy.Thereisarapidonsetofextremelyitchy,redplaquesonwhich
vesiclesandbullaedevelop.Theblistersareverysimilartothosefoundinconventionalpemphigoid,butthedistributionin
pemphigoidgestationisshowsamarkedpredilectionfortheabdominalregion,especiallytheareaaroundtheumbilicus.
Thevulvaisnotusuallyinvolved.
Thediagnosisissuggestedbytheassociatedpregnancyandclinicalpattern,butitshouldbeconfirmedwithbiopsies
submittedforconventionalhistologyanddirectimmunofluorescence.(See"Dermatosesofpregnancy",sectionon
'Pemphigoidgestationis'.)
PemphigusvulgarisThereareseveraltypesofpemphigus.Themostcommontypeispemphigusvulgaris.The
distributionpatternisgeneralized,butthereisamarkedpredilectionforthemucousmembranesofthemouth,vulva,and
vagina.Technically,itisablisteringdisease,buttheblistersaresofragile,theclinicalpresentationisalmostalwaysthat
oferosions.Earlyon,theseerosionswillhaveloosebitsofscale(collarettescale)attheperiphery,butlaterthescale
disappears.Pemphigusvulgarisisnonscarringonglabrousskin,butscarringandresorptionofthelabiaminoraoftenoccur
whenthevulvaandvaginaareinvolved.

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

18/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Thelistofdifferentialdiagnosesincludesbullouserythemamultiforme(StevensJohnsonsyndrome),bullouspemphigoid,
andcicatricialpemphigoid.
Diagnosisismadebytypicalhistopathology,directimmunofluorescencepattern,andindirectimmunofluorescencetesting
ofthepatientsserum.(See"Pathogenesis,clinicalmanifestations,anddiagnosisofpemphigus",sectionon'Pemphigus
vulgaris'.)
Cicatricialpemphigoid(mucousmembranepemphigoid)Cicatricialpemphigoid(benignmucousmembrane
pemphigoid)isamucosalblisteringdiseasethatischaracterizedbyerosionsandscarringofthemucousmembranesof
theeyes,mouth,andgenitaliainmiddleagedpatients.Shortlivedblistersmarktheonsetofthedisease,butarequickly
replacedbyerosions.
Theusualpresentationispainfulerosionsonthevulvarandvaginalmucousmembranes,resultinginlabiaminora
resorption,adhesions,andscarring.Diagnosisismadebyroutinehistopathologyandthedirectimmunofluorescent
pattern.(See"Clinicalfeaturesanddiagnosisofbullouspemphigoidandmucousmembranepemphigoid",sectionon
'Mucousmembranepemphigoid'.)
Cicatricialpemphigoidofthevulvaandvaginamustbedifferentiatedfrompemphigusvulgaris,erosivelichenplanus,
erosivelichensclerosus,andStevensJohnsonsyndrome.
StevensJohnsonsyndrome(bullouserythemamultiforme)StevensJohnsonsyndrome(bullouserythema
multiforme)presentswithacuteonset(oftenwithaprodromeoffeverandmalaise)offlattopped,redpapulesandplaques.
Theselesionsmaycoalescetoformgeneralizedredness,coveringupto30percentoftheskinsurface.InStevens
Johnsonsyndrome,vesiclesandbullaedeveloponthereddenedskinaswellasallmucosalsurface,includingthevulva
andvagina.Theseblistersbreakdowntoformpainfulerosions.Themucosalerosionsfrequentlyhealwithscarring.
Diagnosisismadebythetypicalclinicalpresentationoftheprodromeandthedisordersrapidprogression.Itinvolves10
to30percentoftheskinssurface,asopposedtogreaterthan30percentintoxicepidermalnecrolysis.Diagnosisis
confirmedbyskinbiopsy.(See"StevensJohnsonsyndromeandtoxicepidermalnecrolysis:Pathogenesis,clinical
manifestations,anddiagnosis".)
Rarediseases
FixeddrugeruptionFixeddrugeruptionisalocalizeddrughypersensitivitythatpresentsasred,brawny,orbrown
patchesthatcanblisterorerode,leavingpostinflammatoryhyperpigmentation.Singleormultiplelesionsmay
developonthevulva.Characteristically,whenthepatienttakesthesamedruginthefuture,thelesionrecursatthe
samelocation.Diagnosisissuggestedclinicallyandisconfirmedbybiopsy.(See"Fixeddrugeruption".)
HaileyHaileydisease[3]andtherelatedpapularacantholyticdyskeratosis[4]usuallypresentasredpatchesand
plaques,oftenwithvaryingdegreesoferosion.Theselesionsmimictheappearanceofthosedescribedfor
extramammaryPagetdisease(table2andtable3).However,ifthereissignificanthyperkeratosis,thesurfaceofthe
lesionmayappearwhitewhenmoist.Thisdiseasefirstappearsinyoungerwomen,andtherearealmostalways
similarplaquesonthechest,back,andaxillae(table2)andapositivefamilyhistoryforsimilarlesions.Intact
vesiclesarerarelyencountered.Biopsyisrequiredfordiagnosis.(See"HaileyHaileydisease(benignfamilial
pemphigus)".)
Lymphangioma/lymphangiectasiaThecloselyset,nonfragile,dilatedlymphaticvessels(pseudovesicles)in
lymphangioma/lymphangiectasiaariseonthesurfaceoftheskin,eitherfromahamartomatousskindefect
(lymphangioma)orsecondarytoanobstructionofthelymphaticsasaresultofpelvictumorradiationtherapy,pelvic
surgery,orsevereinflammatorydisease.Thesegroupedvesiclesaremostoftenfoundonthemonspubisandlabia
majora.Underlyinglymphedemaisgenerallypresent(table9).Aclinicaldiagnosiscanbeconfirmedbybiopsy.
BullouslichensclerosusLichensclerosusisinthedifferentialdiagnosisofwhitepatchesandplaques(table10).
Rarely,lichensclerosuscanbebullous.Thebullaeformonthetypicalwhiteplaquesassociatedwiththedisorder.
Theyeasilybreak,leavingerosions.Thediagnosisismadebybiopsy.(See'Lichensclerosus'above.)
ToxicepidermalnecrolysisToxicepidermalnecrolysisissimilartoStevensJohnsonsyndrome,withwidespread
reddeninginvolvinggreaterthan30percentoftheskinsurface.Peelingoftheskinquicklyoccurs,leavinglarge,
erodedareas.Thevulvaandvaginacanbediffuselyinvolved.Lesionsinvolvingthevulvaalwayspresentas
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

19/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

erosions(table3).Diagnosisissuggestedbyahistoryofmedicationusage(especiallythesulfarelatedantibiotics),
thepresenceoflesionselsewhereontheskinandothermucousmembranesandappreciablesystemictoxicity.
Diagnosiscanbeconfirmedbybiopsy.(See"StevensJohnsonsyndromeandtoxicepidermalnecrolysis:
Pathogenesis,clinicalmanifestations,anddiagnosis".)
EROSIONSDifferentialdiagnosis(table3).
ExcoriationScratchingcausesshallowerosionsthatcanbeidentifiedclinicallybytheirelongated(linear)orangular
configuration.Patientsareusuallyawareoftheirscratching,but,sometimes,itonlyoccursduringsleep,andpatientsmay
beunawarethattheyarecausingtheerosions.Scratchingmostoftenoccurswithlichensimplexchronicusandatopic
dermatitis,butcanbesuperimposedonotherdisorders,notablylichensclerosus,candidiasis,tineacruris,andpsoriasis
(table2andtable10).Muchmorerarely,patientsgougeatthemselves,causingulcersratherthanerosions.Thediagnosis
ofexcoriationisestablishedclinically.
FissuresLinearfissuresmayoccuraserosionsorulcers,dependingonthedepthofthedefect.Theyareencountered
asasecondaryphenomenoninseveraldiseases,notablycandidiasis,markedlylichenifiedlichensimplex,irritantcontact
dermatitis,lichensclerosus,Crohndisease,andhidradenitissuppurativa(table2andtable4andtable10andtable8)
[15].
Primaryfissures,arisingdenovoonpreviouslynormalappearingskin,canoccuraftercoitus.(See'Postcoitalfissures'
below.)
LichensimplexchronicusLichensimplexchronicus(table2)isalmostalwayscharacterizedbythepresenceof
excoriations.(See'Lichensimplexchronicus'above.)
HerpessimplexBecausethevesiclesofherpessimplexareveryfragile,manypatientpresentwitherosionsrather
thanblisters(table12).(See'Herpessimplexvirus'above.)
CandidiasisVulvarcandidiasismaypresentsolelywithredeczematousplaques(table2).Whilepustulesare
commonlypresent,theseverityofpruritus,withconsequentscratching,resultsinbreakageofthepustules(table7)and
anulcerativepresentation,insteadoferosions(table2).(See'Candidiasis'above.)
ErosivelichensclerosusErosionsfrequentlydevelopinlichensclerosus(table10)becausebasementmembrane
damage(inherentinthedisease)allowseasyseparationoftheepidermis.Erosionsalsomayresultfromscratchingor
developonthesurfaceofnodulesandplaquesofunderlyingsquamouscellcarcinoma(SCC).(See'Lichensclerosus'
aboveand"Vulvarlichensclerosus".)
ErosivelichenplanusTheerosiveformoflichenplanusisthemostcommonpresentationanddoesnotusually
coexistwiththepapulosquamousform(table2)ofthedisorder.Theerosionsarefoundinthevestibuleandmayextend
intothevagina(picture52andpicture53).Theyareextremelypainfulandoftenextensive.Scarringoftendevelopsand
canresultinentrapmentoftheclitoris,effacementofthelabiaminora,andvaginalnarrowingorevenocclusion.
Clinicaldiagnosisispossibleifthelacywhitechangesarefoundperipheraltotheerosionsand/orifthesamewhite
lesionsarefoundinthemouth.Iftheselesionsarenotpresent,biopsyfromnormalappearingskinadjacenttothemargin
oftheerosionshouldbeperformed.(See"Vulvarlichenplanus",sectionon'Erosivevulvarlichenplanus'and'Lichen
planus(papulosquamousform)'above.)
ImpetigoTheinitiallesionsinimpetigoareoftenpustules,vesicles,orbullae(table12).However,theroofsofthese
lesionsareextremelyfragile,oftenleadingtoapresentationwitherosions.(See'Bullousimpetigo'above.)
IrritantcontactdermatitisTheprimaryappearanceofirritantcontactdermatitisiseczematous(table2),but
sometimeslinearfissuresareprominent.(See'Irritantcontactdermatitis'above.)
AllergiccontactdermatitisTheprimaryappearanceofallergiccontactdermatitisiseczematous(table2),butitching
andscratchingoftenresultinexcoriation.(See'Allergiccontactdermatitis'above.)
PostcoitalfissuresSomewomendeveloppainfulfissuresattheposteriorfourchettefollowingsexualintercourse
[15,16].Thesefissuresperpendicularlycrossthefoldedtissueofthefourchetteandvaryinwidthfromahairlinecrackto
alineardefectthatisseveralmillimeterswide.

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

20/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Thediagnosisisestablishedclinicallybasedonthehistoryofapainfulfissuredevelopingat,orshortlyafter,penile
intromission.Sincemanyofthesewomendonotcarefullyexaminethemselves,itmaybenecessarytohavethepatient
appearintheofficeonthedayof,orthedayafter,painfulintercoursetodeterminethatafissureispresent.Thiswill
distinguishbetweenpostcoitalfissureandentrancedyspareuniaandprovokedvestibulodynia.(See"Clinical
manifestationsanddiagnosisoflocalizedvulvarpainsyndrome(formerlyvulvodynia,vestibulodynia,vulvarvestibulitis,or
focalvulvitis)"and"Approachtothewomanwithsexualpain".)
HerpeszosterThevesiclesofherpeszostermaybecomeunroofedbythetimeaclinicianexaminesthepatient(table
12).(See'Herpeszoster'above.)
StevensJohnsonsyndrome(bullouserythemamultiforme)StevensJohnsonsyndromefrequentlyisassociated
withamixtureofbullaeanderosions(table12).(See'StevensJohnsonsyndrome(bullouserythemamultiforme)'above.)
PemphigusThebullaeofpemphigusareextremelyfragile,and,therefore,mostpatientspresentprimarilywitherosions
(table12).(See'Pemphigusvulgaris'above.)
PemphigoidOlderbullaeofpemphigoidmayhavedisintegrated,leadingtoamixofbullaeanderosions(table12).
(See'Pemphigoid'above.)
CicatricialpemphigoidPatientswithcicatricialpemphigoidusuallypresentwitherosions,ratherthatwithbullae(table
12).(See'Cicatricialpemphigoid(mucousmembranepemphigoid)'above.)
PemphigoidgestationsOlderbullaeinpemphigoidgestationismayhavedisintegrated,resultinginamixofvesicles,
bullae,anderosions(table12).(See'Pemphigoidgestationis(herpesgestationis)'above.)
MalignancyAsmalignancyadvances,thesurfaceofthenodules(table4)erodeand,eventually,ulcerate.(See
'Squamouscellcarcinoma'above.)
PlasmacellvulvitisPlasmacellvulvitis(Zoonsvulvitis)usuallypresentsasaunilateral,solitary,sharplymarginated,
redpatchwithinthevestibule(picture54andpicture55)[17].Thesurfacemayappearshinyorsomewhateroded.Most
lesionsareasymptomatic,butmilditchingorpainmaybepresent.Biopsyisrequiredfordiagnosis.
Rarecauses
ExtramammaryPagetdiseasepresentsasoneormoreredpatchesorplaques.Theselesionsmaybesharply
marginatedordiffuselymarginated.Forpracticalpurposes,thisdiseaseoccursonlyinwomenovertheageof60
years.Thesurfaceofthelesionsusuallydemonstratesmultipleshallowerosions.Biopsyisrequiredfordiagnosis.
(See"Vulvarcancer:Clinicalmanifestations,diagnosis,andpathology",sectionon'ExtramammaryPagetdisease'.)
HaileyHaileydisease(table12)[3],andtherelatedpapularacantholyticdyskeratosis[4],usuallypresentasred
patchesandplaques,oftenwithvaryingdegreesoferosion.Theselesionsmimictheappearanceofthosedescribed
forextramammaryPagetdisease.However,ifthereissignificanthyperkeratosis,thesurfaceofthelesionmay
appearwhitewhenmoist.Thisdiseasefirstappearsinyoungerwomen,andtherearealmostalwayssimilarplaques
onthechest,back,andaxillaeandapositivefamilyhistoryforsimilarlesions.Biopsyisrequiredfordiagnosis.(See
"HaileyHaileydisease(benignfamilialpemphigus)".)
ToxicepidermalnecrolysisToxicepidermalnecrolysispresentslikeStevensJohnsonsyndrome.Thereis
widespreadinvolvementwithsheetsoferosionsstartingintheskinfoldsaroundtheneck,axillae,andinthegroin.
Vesiclesandbullaeareshortlived,breakingtoformlargeareasofdenuded,red,painfulskininvolvingmorethan30
percentoftheskinsurface.Thevulvaandvaginacanbediffuselyinvolved.Lesionsinvolvingthevulvaalways
presentaserosions.Systemicsymptomsandsignsarepresent.Diagnosisissuggestedbyahistoryofmedication
usage(especiallythesulfarelatedantibiotics),thepresenceoflesionselsewhereontheskinandothermucous
membranesandappreciablesystemictoxicity.Diagnosiscanbeconfirmedbybiopsy.(See"StevensJohnson
syndromeandtoxicepidermalnecrolysis:Pathogenesis,clinicalmanifestations,anddiagnosis".)
ULCERSDifferentialdiagnosis(table8).
Aphthousulcers
IdiopathicVulvaraphthousulcers(Lipschutzulcers,vulvaraphthae)aresimilartothemuchmorecommonoral
aphthousulcers(cankersores)[18].Atbothsites,theulcersarepainfulandsharplymarginated(punchedout)andmay
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

21/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

haveawhitecoagulumoradherent,blackcrustatthebaseoftheulcer.Incontrasttooralulcers,vulvarulcersaremore
likelytobelarge(upto3cm),mayinvolvetheskinaswellasthemodifiedmucousmembranesofthevestibule,assume
agyrateconfigurationwhentwoormoreadjacentulcersgrowintoconfluence,andhealmoreslowly(overtwoorthree
weeks).
Themajorityofpatientshaveflulikesymptomsthatprecedeoraccompanytheulcers.Theyoccuralmostonlyingirlsand
youngwomenbetweentheagesof8and25years.Approximatelyhalfofthepatientshavehad,orwilldevelop,oral
aphthousulcers.Approximatelyonethirdofthepatientshavehad,orwilldevelop,recurrentvulvaraphthousulcers.
Thediagnosisisbasedontheclinicalfindings,butviralculturetoruleoutherpessimplexvirus(HSV)infectionandbiopsy
toruleoutothercausesofvulvarulceration,suchassyphilisandchancroid,areindicatedinmostcases.
Aphthousulcerscanoccurinassociationwithvariousdiseases(seebelow),and,dependingonaccompanyingsymptoms
andsigns,theseshouldbeconsidered.
SecondarytodiseaseAphthousulcersthatoccurinassociationwithdiseasehavethesameappearanceasthose
thatoccurinanidiopathicsetting.Sincetheylookthesameinallsettings,itislikelythattheirappearanceinasecondary
settingoccursasanonspecificreactionratherthanadirectmanifestationoftheassociateddisease.
ThemostcommondiseaseassociatedwithvulvaraphthousulcersisCrohndiseaseaphthousulcershavealsobeen
reportedwithseveralviralinfections,includinghumanimmunodeficiencyvirus(HIV),cytomegalovirus(CMV)andEpstein
Barrvirus(EBV)[18].OralandgenitalaphthousulcersoccurinassociationwithBehetssyndrome,butitisimportantto
notethatalmostnoneoftheseyoungwomenpresentingsolelywithvulvaraphthoushave,orwilldevelop,Behets
syndrome.Oralaphthaehavealsobeenassociatedwithanumberofuncommondiseasesandraresyndromesitisnot
clearwhatproportionofthesepatientshavealsohadvulvaraphthousulcers.
CrohndiseasePatientswithCrohndiseaseoftenpresentwithamixtureofinflammatorylesions(table4),fissures,
and"knifecut"typeulcers.(See'Crohndisease'above.)
HerpessimplexvirusinimmunosuppressedpatientsImmunocompetentpatientswithHSV(table12)presentwith
erosions,butnotulcers.Ontheotherhand,immunocompromisedpatientsmaypresentwithtrueulcers,oftenof
longstandingduration.(See'Herpessimplexvirus'above.)
Primarysyphilis(chancre)Primarysyphilispresentsasoneortwopainlessulcers,1to2cmindiameter(picture56
andpicture57).Theulcerationusuallyhasacleanbase,withlittleornopusorcrust.Onpalpation,thebaseoftheulcer
feelsfirm.Regionallymphadenopathymayormaynotbepresent.
Theclinicalsettingmaybehighlysuggestiveforprimarysyphilis,butthediagnosismustbeconfirmedbylaboratory
testingforsyphilis.(See"Syphilis:Screeninganddiagnostictesting"and"Syphilis:Epidemiology,pathophysiology,and
clinicalmanifestationsinHIVuninfectedpatients",sectionon'Clinicalmanifestations'.)
TraumaTraumaticulcersmaybeaccidentalorintentionallyinduced[5].Theformerisrelativelycommon,whilethe
latterisquiterare.Traumaticulcersarecharacteristicallylinearorangular.Themostcommonformofaccidentaltraumais
deepexcoriation(gouging),usuallyinthesettingoflichensimplex.Occasionally,theyareinducedinotherwisenormal
appearingskinbypsychologicallydysfunctionalindividualsthesehavebeentermedneuroticexcoriations.Ulcerscan
developaftertreatmentwithliquidnitrogenortheapplicationofbiortrichloroaceticacid,imiquimodorfluorouracil.A
diagnosisisbasedonhistoryandphysicalexamination.
Rarely,ulcersarecausedbyintentional,butunacknowledged,selfinducedtrauma[5].Whenthisisencountered,itis
usuallyrelatedtogenitalselfcuttingorinpatientswithdelusionsofbugsorfibersintheirskin.Patientswithsuch
delusionsfeeltheneedtoremovethebugsorfibers,and,insodoing,theyleaveulcersofvarioussizeanddepth.A
correctdiagnosismaybesuspectedclinically,butoftenpsychiatricinterventionwillbenecessary.
MalignancyAsmalignancyadvances,thesurfaceofthetumors(table4)regularlydeveloperosionsandulcers.(See
'Squamouscellcarcinoma'above.)
PyodermagangrenosumTheinitiallesioninpyodermagangrenosumisusuallyapustuleorinflamedpapuleornodule.
Theselesionsquicklyprogresstooneormoreslowlyenlargingulcers,whichmaybeshallowordeep.Deepulcers
characteristicallyhaveaviolaceous,overhanging,circumferentialborder.
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

22/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Adiagnosismaybesuspectedclinically,butbacterialandfungalcultures,aswellasabiopsytakenfromnormal
appearingtissueattheedgeoftheulcer,shouldbeperformedtoruleoutotherformsofulcers.Thisdiseaseisidiopathic
inhalfofthepatients.Intheotherhalfofpatients,associateddiseasesincludeinflammatoryboweldiseaseand
hematopoieticmalignancy.(See"Pyodermagangrenosum:Pathogenesis,clinicalfeatures,anddiagnosis".)
Rarecauses
GranulomainguinaleGranulomainguinaleisasexuallytransmittedinfectionthatpresentswithsoft,painless
ulcersthatareoftenlinearandinvolveskinfolds(picture58).Inthisrespect,itresemblestheulcersofCrohn
disease.Lymphadenopathyisusuallyabsent.ThisdiseaseisextremelyrareinNorthAmericaandEurope,butis
endemicinsomelesswelldevelopedpartsoftheworld.Diagnosisdependsonbiopsy.(See"Approachtothepatient
withgenitalulcers".)
ChancroidChancroidisasexuallytransmitteddiseasethatpresentswithoneorseveralverypainful,roundulcers
1to2cmindiameter.Thebaseoftheulceriscoveredwithapurulentexudate,and,incontrasttotheulcerof
primarysyphilis,thebaseoftheulcerissoftonpalpation.Lymphadenopathyisusuallypresent,and,insome
patients,thenodesaremassiveinsizeandfluctuant.Thediagnosisismadeonaclinicalbasisasthereareno
easilyavailablelaboratoryteststhatcanbeusedforconformation.(See"Chancroid".)
BehetssyndromeBehetssyndromerarelyoccursinNorthAmericanandEuropeanwomen.However,genital
ulcerswiththesameappearanceasaphthousulcersareoftenoneofthefeaturesofthedisease(see'Aphthous
ulcers'above).SincetheInternationalStudyGroupscriteriafordiagnosisofBehetssyndromedonotoffer
sufficientspecificity,greatcaremustbetakennottooverdiagnoseyoungwomenwithoralandvulvaraphthous
ulcersashavingBehetssyndrome.(See"ClinicalmanifestationsanddiagnosisofBehetssyndrome"and
'Aphthousulcers'above.)
SUMMARYANDRECOMMENDATIONS
Awidevarietyoflesionsoccuronthevulva.Someofthedisorderscausingtheselesionsarelimitedtothevulva,
whileothersalsoinvolveskinormucocutaneousmembraneselsewhereonthebody.(See'Introduction'above.)
Useofamorphologybasedclassificationsystem(table1)canhelpclinicianswiththedifferentialdiagnosisofvulvar
lesionsafterperformingahistoryandphysicalexamination.Thisclassificationsystemisalsousefulforguidingthe
choiceofdiagnostictestsandprocedures.(See'Morphologicdefinitionsformucocutaneousvulvarlesions'above
and'Howtousethistopic'above.)
Thefollowingtablesprovidedifferentialdiagnosisusingthismorphologybasedsystem:

Redpatchesandplaques(table2)
Erosions(table3)
Redpapulesandnodules(table4)
Skincoloredlesions(table5)
Whitepapulesandnodules(table6)
Yellowpapulesandpustules(table7)
Ulcerativelesions(table8)
Edematouslesions(table9)
Whitepatchesandplaques(table10)
Brownblueorblacklesions(table11)
Vesiclesandbullae(table12)

ACKNOWLEDGMENTTheauthorsandUpToDatewouldliketoacknowledgeDrs.TMinsueChen,AileenLangston,
andPeterLynch,whocontributedtoearlierversionsofthistopicreview.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

23/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

1.StewartKM.Clinicalcareofvulvarpruritus,withemphasisononecommoncause,lichensimplexchronicus.
DermatolClin201028:669.
2.LynchPJ,MoyalBarraccoM,BogliattoF,etal.2006ISSVDclassificationofvulvardermatoses:pathologicsubsets
andtheirclinicalcorrelates.JReprodMed200752:3.
3.vonFelbertV,HamplM,TalhariC,etal.SquamouscellcarcinomaarisingfromalocalizedvulvallesionofHailey
Haileydiseaseaftertacrolimustherapy.AmJObstetGynecol2010203:e5.
4.PernetC,BessisD,SavignacM,etal.GenitoperinealpapularacantholyticdyskeratosisisallelictoHaileyHailey
disease.BrJDermatol2012167:210.
5.LewisFM,VelangiSS.Anoverviewofvulvarulceration.ClinObstetGynecol200548:824.
6.DuhanN,KalraR,SinghS,RajotiaN.Hidradenomapapilliferumofthevulva:casereportandreviewofliterature.
ArchGynecolObstet2011284:1015.
7.OdobasicA,PasicA,IljazovicLatifagicE,etal.Perinealendometriosis:acasereportandreviewoftheliterature.
TechColoproctol201014Suppl1:S25.
8.CutlanJE,SaundersN,OlsenSH,FullenDR.Whitespongenevuspresentingasgenitallesionsina28yearold
female.JCutanPathol201037:386.
9.IavazzoC,FotiouS,SalakosN,etal.HPVrelatedverrucouscarcinomaofthevulva.Acasereportandliterature
review.EurJGynaecolOncol201132:680.
10.EdwardsL.Pigmentedvulvarlesions.DermatolTher201023:449.
11.VenkatesanA.Pigmentedlesionsofthevulva.DermatolClin201028:795.
12.AmankwahY,HaefnerH.Vulvaredema.DermatolClin201028:765.
13.GhoshD,WoodrowS,MathewJ,etal.Chronicgranulomatousinflammationofthevulva:anunusualpresentation
withdiagnosticandtherapeuticdifficulties.JLowGenitTractDis201115:322.
14.MarrenP,WojnarowskaF,VenningV,etal.Vulvarinvolvementinautoimmunebullousdiseases.JReprodMed
199338:101.
15.EdwardsL.Vulvarfissures:causesandtherapy.DermatolTher200417:111.
16.AhmedE,SyedSA,ParveenN.Femaleconsensualcoitalinjuries.JCollPhysiciansSurgPak200616:333.
17.GurumurthyM,CairnsM,CruickshankM.CaseseriesofZoonvulvitis.JLowGenitTractDis201014:56.
18.RosmanIS,BerkDR,BaylissSJ,etal.Acutegenitalulcersinnonsexuallyactiveyounggirls:caseseries,review
oftheliterature,andevaluationandmanagementrecommendations.PediatrDermatol201229:147.
Topic5412Version18.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

24/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

GRAPHICS
Morphologicdefinitionsformucocutaneousvulvarlesions
Morphology

Definition

Macule

Small(<1cm)areaofcolorchangenoelevationandnonpalpable.

Patch

Large(>1cm)areaofcolorchangenoelevationandnonpalpable.

Papule

Small(<1cm)palpablelesion.

Nodule

Large(>1cm)palpablelesionusuallydomeshapedmarginsmaybedistinct
(sharp)orslopeshouldered.

Plaque

Large(>1cm)flattoppedandpalpablelesion.

Vesicle

Small(<1cm)fluidfilledblisterclearfluid.

Bulla

Large(>1cm)fluidfilledblisterclearfluid.

Pustule

Smallorlargepusfilledblisterwhiteoryellowfluid.

Cyst

Smallorlargenodulewithepitheliallinedcentralcavitycontainingsolid,semisolid,or
fluidfilledmaterial.

Erosion

Shallowdefectlimitedtoepidermisthebaseofthedefectmayberedorcoveredby
yellowcrust.Erosionshealwithoutscarring.

Ulcer

Deepdefectintoorthroughthedermisthebasemayberedorcoveredbyyellow,
blue,orblackcrust.Ulcershealwithscarring.

Fissure

Thin(<2mmwide),linearerosionintoorthroughtheepidermis.

Scale

Greyorsilverkeratinproteinsonthetissuesurfacethatbecomewhitewhenmoist
usuallyfeelsroughonpalpation.

Crust

Yellow,granularmaterialoverlyingerosionsdevelopsduetosolidificationofplasma
proteinswhenthewatercomponentofplasmaevaporatescrustsoverlyingulcers
maybeblueorblackduetohemepigment.

Excoriation

Linearorangularerosionsduetoscratching.

Lichenification

Redorskincoloredplaqueswithexaggeratedskinmarkingsduetochronicrubbing
excoriationsareusuallyalsopresent.Thesurfacemaybewhitewhenmoist.

Eczema

Erythematous,poorlymarginatedpatchesandplaquesthatdemonstrate
lichenificationand/orevidenceofepithelialdisruptionsuchaserosionsorcrust.

Graphic95851Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

25/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofredpatchesandplaquesonthevulva
Common

Uncommon

Rare

Candidiasis

Allergiccontactdermatitis

Plasmacellvulvitis

Atopicdermatitis(eczema)

Irritantcontactdermatitis

ExtramammaryPagetdisease

Lichensimplexchronicus

Lichenplanus

HaileyHaileydisease

Irritantcontactdermatitis

Tineacruris

Tineaversicolor

Psoriasis

Perianalstreptococcal
infection

Pityriasisrosea

Vulvarintraepithelial
neoplasia(Bowen'sdisease)
Graphic95964Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

26/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Candidiasisvulva

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic51710Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

27/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Candidainfectioninvolvingthevulvaandthigh

Candidainfection:Brightredpatchesandplaqueswitherosioninvolving
thevulvaandinnerthigh.Aslightscaleoverliestheredpatchesand
plaques.
Reproducedwithpermissionfrom:HopeKHaefner,MD.
Graphic95804Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

28/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Candidiasisvulva

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic70637Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

29/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Lichensimplexchronicusofthevulva(skin
lichenificationfromchronicscratching)

(A)Lichenificationandswellinginlocalizedplaqueoflichensimplex
chronicus.
(B)Markedlichenification,erosions,andcrustinginlichensimplex
chronicusofleftlabiummajor.
Reproducedwithpermissionfrom:FisherBK,MargessonLJ.GenitalSkin
Disorders:DiagnosisandTreatment.Mosby,St.Louis,Missouri1998.p.158.
Copyright1998ElsevierScience.
Graphic69453Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

30/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarlichensimplexchronicus

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic68426Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

31/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarlichensimplexchronicus

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic81018Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

32/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarlichensimplexchronicus

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic59195Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

33/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarpsoriasis

Erythematousandscalyplaquesinvolvingthelabiamajoraand
perineuminapatientwithinversepsoriasis.
ReproducedwithpermissionfromRidleyCM,NeillSM(Eds),TheVulva,2nded,
BlackwellScience,Oxford1999.Copyright1999BlackwellScience.
http://www.blackwellscience.com.
Graphic56110Version6.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

34/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Contactdermatitisvulva

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic66955Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

35/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Contactdermatitisvulva

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic80139Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

36/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Lichenplanus

Notethethick,violaceous,hyperkeratoticplaquewithawhite,
lacelikepatternonthesurface(Wickhamstriae).
CourtesyofBethGGoldstein,MD,andAdamOGoldstein,MD.
Graphic61523Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

37/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

OrallichenplanusWickham'sstriae

Lacywhiteplaques(Wickham'sstriae)arepresentonthebuccal
mucosa.
Reproducedwithpermissionfrom:www.visualdx.com.CopyrightLogical
Images,Inc.
Graphic76338Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

38/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Tineacruris,involvementofbuttocks

Thispatientwithtineacrurisexhibitedextensionofdiseasetothe
buttocksandglutealcleft.
Reproducedwithpermissionfrom:Goodheart,HP.Goodheart'sPhotoguideof
CommonSkinDisorders,2nded,LippincottWilliams&Wilkins,Philadelphia
2003.Copyright2003LippincottWilliams&Wilkins.
Graphic76169Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

39/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarintraepithelialneoplasia

Redmacularlesionasamanifestationofvulvarintraepithelial
neoplasia.
CourtesyofChristineHolschneider,MD.
Graphic74997Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

40/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarintraepithelialneoplasia(VIN)

VINmanifestingasabrownmacularlesion.
CourtesyofChristineHolschneider,MD.
Graphic75216Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

41/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarintraepithelialneoplasia

Raisedwhitishplaquesasamanifestationofvulvarintraepithelial
neoplasia.
CourtesyofChristineHolschneider,MD.
Graphic72661Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

42/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarintraepithelialneoplasia3

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic78650Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

43/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisoferosionsonthevulva
Common

Uncommon

Rare

Excoriation

Allergiccontactdermatitis

HaileyHaileydisease

Fissures

Postcoitalfissures

ExtramammaryPagetdisease

Lichensimplex

Herpeszoster

Toxicepidermalnecrolysis

Herpessimplex

StevensJohnsonsyndrome

Candidiasis

Pemphigus

Erosivelichensclerosus

Pemphigoid

Erosivelichenplanus

Cicatricialpemphigoid

Impetigo

Pemphigoidgestations

Irritantcontactdermatitis

Erodedmalignancy
Plasmacellvulvitis

Graphic95984Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

44/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

VulvarHaileyHaileydisease

Alargeerythematousplaquewithmultiplesuperficialerosions
involvingthevulvarandgroinareainapatientwithHaileyHailey
disease.
CourtesyofLynneJMargesson,MD.
Graphic80862Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

45/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofredpapulesandnodulesonthevulva
Common

Uncommon

Rare

Folliculitis

Inflamedepidermalcyst

Pyogenicgranuloma

Cherryangioma

Bartholinductabscess

Kaposisarcoma

Angiokeratoma

Prurigonodularis

Hidradenomapapilliferum

Hemangioma

Urethralcaruncle

Vulvarendometriosis

Furunculosis

Urethralprolapse

Pseudowarts

Hidradenitissuppurativa

Crohndisease

Langerhanshistiocytosis

Hemangioma

Vulvarintraepithelial
neoplasiaandsquamouscell
carcinoma

Sarcoidosis

Vestibularpapillomatosis

Amelanoticmelanoma

Molluscumcontagiosum
(inflamed)
Insectbites
Graphic95971Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

46/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Folliculitisvulva

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic68351Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

47/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Keratosispilaris

Acnelikelesionsareseenontheupperouterarms.
Reproducedwithpermission:Goodheart,HP.Goodheart'sPhotoguideof
CommonSkinDisorders,2nded,LippincottWilliams&Wilkins,Philadelphia
2003.Copyright2003LippincottWilliams&Wilkins.
Graphic50290Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

48/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Cherryangioma

CourtesyofLynneJMargesson,MD.
Graphic63468Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

49/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Ulceratedhemangioma

Ulcerationisthemostcommoncomplicationofhemangiomas.Large
segmentallesions,especiallyintraumapronelocations,astheoneof
theperineumdepictedabove,areatincreasedriskforulceration.
CourtesyofDeniseWMetry,MD.
Graphic74768Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

50/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Severehidradenitissuppurativa

Reproducedwithpermissionfrom:FWilliamDanby,MD,FRCPC,FAAD,and
LynneJMargesson,MD.
Graphic65188Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

51/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Moderatehidradenitissuppurativa

Reproducedwithpermissionfrom:FWilliamDanby,MD,FRCPC,FAADand
LynneJMargesson,MD.
Graphic65884Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

52/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Hidradenitissuppurativa

HurleystageIdisease.Aninflamednodule(arrow)andanopencomedo
(arrowhead)arevisible.Sinustractsandfibrosisareabsent.
Graphic90463Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

53/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofskincoloredpapules,nodules,andplaqueson
thevulva
Common

Uncommon

Rare

Vulvarpapillomatosis

Fibroepithelialpolyp

Syringoma

Skintag

Bartholinductcyst

Basalcellcarcinoma

Humanpapillomaviruswart

Intradermalmelanocytic
nevus

Hidradenomapapilliferum

Lichensimplex

Lipoma

Neurofibroma

Scar

Vestibularmucinouscyst

Condylomalata

Vulvarintraepithelial
neoplasia(usualand
differentiated)

Squamouscellcarcinoma

Molluscumcontagiosum

FoxFordycedisease

Epidermalcyst
Graphic95996Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

54/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofwhitepapulesandnodulesonthevulva
Common
Fordycespots

Uncommon

Milium(plural,milia)

Vulvarintraepithelial
neoplasia,differentiatedtype

Epidermalcyst

Squamouscellcarcinoma

Molluscumcontagiosum

Rare
Verrucouscarcinoma
Condylomatalata

Scar

Humanpapillomavirus
infection(wart)
Vulvarintraepithelial
neoplasia,usualtype
Graphic95990Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

55/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofyellowpapulesandpustulesonthevulva
Common

Uncommon

Rare

Candidiasis

Keratosispilaris

FoxFordycedisease

Folliculitis

Epidermalcyst

Pustularpsoriasis

Furunculosis

Bullousimpetigo

Hidradenitissuppurativa

Vestibularmucinouscyst

Subcornealpustular
dermatosis

Molluscumcontagiosum

Condylomalata

Graphic95993Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

56/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Bartholinabscess

Thepatient'sleftlabialareaisswollenanderythematous.
Reproducedwithpermissionfrom:AronSchuftan,MD.CopyrightAron
Schuftan,MD.
Graphic79478Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

57/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Urethralcaruncle

Urethralcarunclesaresoftpinkorred,sessileorpedunculated,
lesionsprotrudingfromtheurethralmeatus.
CourtesyofTobyChai,MD,UniversityofMarylandSchoolofMedicine.
Graphic80179Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

58/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofulcerativelesionsonthevulva
Common

Uncommon

Rare

Aphthousulcers,idiopathic

Primarysyphilis(chancre)

Granulomainguinale

Aphthousulcers2to
infectionorinflammatory
disease

Trauma,accidentalandself
induced

Chancroid

Crohndisease

Pyodermagangrenosum

Behet'sdisease

Ulceratedmalignancy

Herpessimplexvirusin
immunosuppressed
Graphic96017Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

59/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

PerianalCrohndisease

PerianalfistulasandulcersinapatientwithCrohndisease.Thereare
bilateralposteriorperianalfistulas(arrows)andtworightposterior
ulcers(arrowheads).
CourtesyofAlainBitton,MD,FRCPC.
Graphic65699Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

60/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

PerianalCrohndisease

PerineuminawomanwithCrohndiseaseshowsalargeposteriorulcer
(arrow)withanterioredematousfissure(arrowhead).
CourtesyofAlainBitton,MD,FRCPC.
Graphic80569Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

61/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Perianalfistula

PerianalfistulainapatientwithCrohndisease.Scarringand
deformityfrompreviousfistulasisalsoapparent.
CourtesyofDavidASchwartz,MDandMauritsJWiersema,MD.
Graphic78460Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

62/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofskincoloredorerythematousedemaofthevulva
Common

Uncommon

Rare

Postsurgicalandpostradiation
edema

Postinfectiousedema

Acuteallergicangioedema

Bartholinductabscess

Lymphangiomaedema

Crohndisease

Allergiccontactdermatitis

Milroy'scongenitaledema

Trauma

MelkerssonRosenthal
syndrome

Hidradenitissuppurativa
Pregnancy
Edemaduetoinfection
Graphic96008Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

63/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarsquamouscellcancerandlichensclerosus

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic80593Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

64/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Typicalmolluscumbumps

Notethepearlyappearanceandthedimpleinthecenterofthe
bumps.
Reproducedfrom:CentersforDiseaseControlandPrevention.Overviewof
MolluscumContagiosum.
http://www.cdc.gov/ncidod/dvrd/molluscum/overview.htm.AccessedMay30,
2008.
Graphic65763Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

65/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofwhitepatchesandplaquesonthevulva
Common
Vitiligo
Postinflammatory
hypopigmentation

Uncommon

Rare

Vulvarintraepithelial
neoplasia,differentiatedtype

Whitespongenevus

Squamouscellcarcinoma

Verrucouscarcinoma

HaileyHaileydisease

Lichensclerosus
Lichenplanus
Lichensimplex(moist)
Candidiasis
Humanpapillomavirus
infection(wart)
Vulvarintraepithelial
neoplasia,usualtype
Graphic95983Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

66/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarvitiligo

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic80058Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

67/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Lichensclerosuspallor

ReproducedwithpermissionfromRidley,CM,Neill,SM(Eds),TheVulva,2nd
ed,BlackwellScience,Oxford1999.Copyright1999BlackwellScience.
Graphic50972Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

68/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Perianallichensclerosus

ReproducedwithpermissionfromRidleyCM,NeillSM(Eds),TheVulva,2nded,
BlackwellScience,Oxford1999.Copyright1999BlackwellScience.
http://www.blackwellscience.com.
Graphic62753Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

69/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Severelichensclerosus

Longstandingvulvarlichensclerosusina55yearoldwomanwith
severepruritusforeightyears.Shewokeupmostnightsscratching.
Clitorisisalmostburied.Theinnerlabiaminoraandvulvartrigoneare
thick,firm,andwhitewithtwobiopsysitesvisibleontheleftside.
Reproducedwithpermissionfrom:FWilliamDanby,MD,FRCPC,FAAD,and
LynneJMargesson,MD.
Graphic54149Version6.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

70/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Lichensclerosuswithlichensimplexchronicus

Figure8involvementofvulvarlichensclerosuswithscarringofthe
vulvaandlossofallthenormalarchitecture.Allareasarelichenified
withfissuringofthethickpericlitoralareaandlabiocruralfold.
Reproducedwithpermissionfrom:FWilliamDanby,MD,FRCPC,FAAD,and
LynneJMargesson,MD.
Graphic72766Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

71/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Lossofarchitecture

Thedistinctionbetweenthelabiamajoraandminoraislost,andthe
clitorisbecomesburiedunderthefusedprepuce.
ReproducedwithpermissionfromRidleyCM,NeillSM(Eds),TheVulva,2nded,
BlackwellScience,Oxford1999.Copyright1999BlackwellScience.
http://www.blackwellscience.com.
Graphic57562Version5.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

72/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarlichensclerosus

Severelyitchylichensclerosusinafigureof8patternaroundvulva
andperianalareawithlossofclitorisandlabiaminora.Swollen,
irritatedhemorrhoidaltagsareseen.Typicalwhiteshinylichen
sclerosuschangesarevisiblewithpurpuraanderosionsfrom
scratching.
Reproducedwithpermissionfrom:FWilliamDanby,MD,FRCPC,FAAD,and
LynneJMargesson,MD.
Graphic59461Version6.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

73/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Analcondyloma

Photographshowsthecharacteristicverrucous,pinkorskincolored,
papilliformappearanceofanalcondylomaacuminata.
ReproducedbypermissionfromtheAmericanSocietyofColonandRectal
Surgeons.
Graphic74391Version4.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

74/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofbrown,blue,orblackmacules,papules,patches,
plaquesonthevulva
Common

Uncommon

Rare

Physiologic
hyperpigmentation

Vulvarmelanosis/lentiginosis

Pigmentedbasalcellcancer

Lichenplanus

Hidradenomapapilliferum

Postinflammatory
hyperpigmentation

Atypicalmelanocyticnevus

Acanthosisnigricans

Humanpapillomavirus
infection(wart)

Melanoma

Varicosity

Vulvarintraepithelial
neoplasia,usualtype
Melanocyticnevus
Seborrheickeratosis
Angiokeratoma
Skintags
Graphic95978Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

75/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Whitespongenevusoftheoralmucosa

Alarge,whiteplaqueispresentontheoralmucosa.Whitespongenevi
representararegeneticconditioncausedbymutationsinkeratin4orkeratin
13genes.Lesionsusuallyfirstappearduringchildhood.
ImagecreatedbyCarlAllen,DDS,MSD.Reproducedwithpermissionfrom:
www.visualdx.com.CopyrightLogicalImages,Inc.
Graphic86948Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

76/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Condylomatalata

Flatcondylomatalatalesionswhicharemoistinawomanwith
secondarysyphilis.
CourtesyofDavidHMartinandTomaszFMroczkowski.TheSkinand
Infection:AColorAtlasandText,SandersCV,NesbittLTJr(Eds),Williams&
Wilkins,Baltimore,1995.

http://www.lww.com
Graphic56162Version7.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

77/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Condylomalataintheperinealregionofawoman
withsecondarysyphilis

Numerousorganismsaregenerallypresentintheselesions,which
makesthemhighlyinfectious.
CourtesyofCharlesHicks,MD.
Graphic63924Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

78/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarvaricosity

CourtesyofNatashaRJohnson,MD.
Graphic86312Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

79/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Acanthosisnigricans

Hyperpigmented,velvetyplaquesarepresentinthegroin.
Reproducedwithpermissionfrom:www.visualdx.com.CopyrightLogicalImages,Inc.
Graphic76234Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

80/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Differentialdiagnosisofvesiclesandbullaeonthevulva
Common

Uncommon

Rare

Herpessimplex

Pemphigoid

Fixeddrugeruption

Herpeszoster

Pemphigoidgestationis

HaileyHaileydisease

Impetigo

Pemphigus

Lymphangioma/lymphangiectasia

Contactdermatitis

Cicatricialpemphigoid

Bullouslichensclerosus

StevensJohnsonsyndrome

Toxicepidermalnecrolysis
LinearIgAdisease
Epidermolysisbullosa
Acquisita

Graphic95995Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

81/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Primarygenitalherpessimplexinfection

CourtesyofLynneJMargesson,MD.
Graphic61107Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

82/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Femalegenitalherpessimplexvirus

Reproducedwithpermissionfrom:www.visualdx.com.CopyrightLogical
Images,Inc.
Graphic58485Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

83/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Mucousmembranepemphigoid

Erosionsarepresentonthegenitalmucosa.
Reproducedwithpermissionfrom:www.visualdx.com.CopyrightLogical
Images,Inc.
Graphic75723Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

84/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarpemphigoid

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic54032Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

85/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Bullouspemphigoid

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic78207Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

86/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Bullouspemphigoid

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic57255Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

87/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvovaginallichenplanus

Vulvarerosionsandperianalpapulesduetolichenplanusarepresent.
Reproducedwithpermissionfrom:Dr.BethaneeSchlosser.
Graphic86858Version1.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

88/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Vulvarerosivelichenplanus

Erythemaanderosionsonthevulvarlabialmucosainapatientwith
erosivelichenplanus.
ReproducedwithpermissionfromRidleyCM,NeillSM(Eds),TheVulva,2nded,
BlackwellScience,Oxford1999.Copyright1999BlackwellScience.
http://www.blackwellscience.com.
Graphic60224Version5.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

89/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Plasmacellvulvitis

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic75171Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

90/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Plasmacellvulvitis

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic51099Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

91/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Chancre

ReproducedwithpermissionfromLynneJMargesson,MD.
Graphic73119Version2.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

92/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Primarysyphilis

Primarychancreonthelabiamajora.Chancresarepainlessand
frequentlycanbemissed,especiallyinwomen.
CourtesyofLeeTNesbitt,Jr.TheSkinandInfection:AColorAtlasandText,
SandersCV,NesbittLTJr(Eds),Williams&Wilkins,Baltimore,1995.

http://www.lww.com
Graphic50385Version5.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

93/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

Ulcerovegetativegranulomainguinale

Theulcerovegetativeulcersofgranulomainguinalestartaspseudobuboes
thatbreakdowntoformspreadingulcers,typicallyonthegenitaliaandinthe
inguinalregion.
Reproducedwithpermissionfrom:www.visualdx.com.CopyrightLogicalImages,Inc.
Graphic83016Version3.0

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

94/95

8/30/2016

Vulvarlesions:Differentialdiagnosisbasedonmorphology

ContributorDisclosures
LynetteJMargesson,MD,FRCPC,FAADAdvisoryBoards(Spouse):AbbVie[hidradenitissuppurativa(adalimumab)].
HopeKHaefner,MDConsultant/AdvisoryBoards:Merck&Co.,Inc[HPVrelatedlowergenitaltractdisease(HPV
vaccine)].RobertPDellavalle,MD,PhD,MSPHNothingtodisclose.KristenEckler,MD,FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedby
vettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.
AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

https://www.uptodate.com/contents/vulvarlesionsdifferentialdiagnosisbasedonmorphology?topicKey=OBGYN%2F5412&elapsedTimeMs=31&imageId=

95/95