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For further information, see CMDT Part 20-21: Carcinoma of the Vulva
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Essentials of Diagnosis
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History of genital warts
Two independent pathways for development: human papillomavirus or chronic inflammation
History of prolonged vulvar irritation, with pruritus, local discomfort, or slight bloody discharge
Early lesions may suggest or include non-neoplastic epithelial disorders
Late lesions appear as a mass, an exophytic growth, or a firm, ulcerated area in the vulva
Biopsy is necessary for diagnosis
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General Considerations
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The majority of cancers of the vulva are squamous lesions that classically occur in women over 50 years of age
Vulvar low-grade squamous intraepithelial lesions (LSIL) are benign and do not require intervention
Vulvar high-grade squamous intraepithelial lesions (HSIL) and differentiated vulvar intraepithelial neoplasia (dVIN) are premalignant conditions
Vulvar HSIL (VIN usual type) is associated with HPV, while dVIN is associated with vulvar dermatoses, eg, lichens sclerosus
About 70–90% of premalignant lesions are vulvar HSIL, but HSIL is the precursor for only 20% of vulvar cancers, while dVIN is the precursor for approximately 80% of vulvar cancers
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Differential Diagnosis
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Vulvar intraepithelial neoplasia
Inflammatory vulvar dermatoses
Psoriasis
Lichen sclerosis
Lichen planus
Chronic granulomatous lesions (eg, lymphogranuloma venereum, syphilis)
Genital warts (condyloma acuminata)
Epidermal inclusion cyst
Papillary hidradenoma
Neurofibroma
Ulcer: herpes simplex virus, chancroid, granuloma inguinale, Behçet syndrome
Hidradenitis suppurativa
Paget disease of the vulva
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Preoperative colposcopy of vulva, vagina, and cervix
CT or MRI of the pelvis or abdomen is generally not required except in advanced cases for planning therapeutic options
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Diagnostic Procedures
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Biopsy is essential for the diagnosis and should be performed with any localized atypical vulvar lesion, including white patches and hyperpigmented lesions
Colposcopy of the vulva, vagina, and cervix can help identify areas for biopsy
Multiple skin-punch specimens can be taken in the office under local anesthesia
Lichen sclerosus and other associated leukoplakic changes in the skin should be biopsied
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A 7:3 combination of betamethasone and crotamiton is particularly effective for itching
After an initial response, fluorinated steroids should be replaced with hydrocortisone because of their skin-atrophying effect
For lichen sclerosus
Apply clobetasol propionate cream, 0.05% twice daily for 2–3 weeks, then once daily until symptoms resolve
Application one to three times a week can be used for long-term maintenance therapy