Fig. 19.1 ). Leukocytic infiltration of the dermis is sometimes pronounced. These nonspecific changes are a consequence of chronic irritation, often caused by pruritus related to an underlying inflammatory dermatosis. Lichen simplex chronicus appears as an area of leukoplakia. While no increased predisposition to cancer has been demonstrated when lesions are isolated, lichen simplex chronicus often is present at the margins of established vulvar cancer, suggesting some association with neoplastic disease.
Lichen sclerosus and lichen simplex chronicus may coexist in different areas of the body in the same person, and both lesions may take the form of leukoplakia. Similar white patches or plaques also are seen in a variety of other benign dermatoses, such as psoriasis and lichen planus (Chapter 24), as well as in malignant lesions of the vulva, such as squamous cell carcinoma in situ and invasive squamous cell carcinoma. Thus, biopsy and microscopic examination are often needed to differentiate these clinically similar-appearing lesions.
Lichensclerosusischaracterizedbyatrophicepithelium,sub-epithelialdermalfibrosis,andbandlikechronicinflammation.
Lichensclerosuscarriesaslightlyincreasedriskfordevelopmentofsquamouscellcarcinoma.
Lichensimplexchronicusischaracterizedbythickenedepithelium(hyperplasia),usuallywithadermalinflammatoryinfiltrate.
Thelesionsoflichensclerosusandlichensimplexchronicusmustbebiopsiedtodistinguishthemdefinitivelyfromothercausesofleukoplakia,suchassquamouscellcarcinomaofthevulva.
Condyloma is the name given to any warty lesion of the vulva. Most such lesions can be assigned to one of two distinctive forms. Condylomata lata, not commonly seen today, are flat, minimally elevated lesions that occur in secondary syphilis (Chapter 18). The more common condylomata acuminata may be papillary and distinctly elevated or somewhat flat and rugose. They may occur anywhere on the anogenital surface, sometimes as single but more often as multiple lesions. When located on the vulva, they range from a few millimeters to many centimeters in diameter and are red-pink to pink-brown (
Fig. 19.2 ). On histologic examination, the characteristic cellular feature is koilocytosis (a cytopathic change characterized by perinuclear cytoplasmic vacuolization and a wrinkled nuclear contour), a hallmark of HPV infection (
Fig. 19.2 ). Indeed, more than 90% of condylomata acuminata are positive for HPV subtypes 6 and 11. HPV is sexually transmitted, and identical lesions occur in men on the penis and around the anus in men and women. HPV 6 and 11 are low-risk viral types, and hence, vulvar condylomas do not commonly progress to cancer. However, women with condyloma acuminata are at risk of having other HPV-related lesions in the vagina and cervix.
Fig.19.1Nonneoplasticvulvarepithelialdisorders.(A)Lichensclerosus.Thereismarkedthinningoftheepidermis,fibrosisofthesuperficialdermis,andchronicinflammatorycellsinthedeeperdermis.(B)Lichensimplexchronicusdisplayingthickenedepidermisandhyperkeratosis.
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Fig.19.2(A)Numerouscondylomasofthevulva.(B)Histopathologicfeaturesofcondylomaacuminatumincludeacanthosis,hyperkeratosis,andcytoplasmicvacuolization(koilocytosis,center).(A, Courtesy of Dr.Alex Ferenczy, McGill University, Montreal, Quebec, Canada.)