Abstract
Introduction:
Vulval dermatoses may present with varied manifestations ranging from asymptomatic to chronic disabling conditions. Due to the warm, moist, and frictional environment of the vulva and its frequent exposure to irritating substances such as urine, feces, repeated use of napkins, and vaginal secretions, the classic appearance of common dermatoses is modified.
Aim and Objective:
To study the pattern of nonvenereal disease of female external genitalia.
Materials and Methods:
The study involved 50 female participants over a 1-year period, with informed consent obtained from all. A comprehensive history was recorded, including demographic details, skin-related complaints, itching, discoloration, thickening, thinning, darkening, erosion, ulceration, onset, duration, pregnancy, menstrual status, and associated conditions. Sexual exposure history was also noted. A thorough examination of the external genitalia was conducted, along with a full physical assessment for any other body lesions. Relevant investigations were performed to confirm the diagnosis.
Results:
The most common age group was 31–40 years. The most common presenting symptom was itching. The most common noninfectious nonvenereal dermatoses were lichen sclerosus (18%), vitiligo (18%), and lichen simplex chronicus (12%). Other dermatoses included lymphedema, invasive squamous cell carcinoma, psoriasis, lichen planus, lymphangioma circumscriptum, irritant contact dermatitis, melanocytic nevi, and drug reaction.
Conclusion:
Due to the challenging nature of self-examination of the vulva, individuals may delay in seeking medical attention for genital lesions. This hesitation can result in heightened anxiety and fear, significantly affecting the patient’s quality of life by contributing to increased morbidity and disruptions in sexual function.
Keywords: Female genital dermatoses, nonvenereal, vulvar dermatoses
Introduction
Vulvar dermatoses may be asymptomatic or present as persistent, distressing conditions that significantly impact daily life. Due to the warm, moist, and frictional environment of the vulva and its frequent exposure to irritating substances such as urine, feces, and vaginal secretions, the classic appearance of common dermatoses is modified. Although nonvenereal genital dermatoses are not sexually transmitted, they can cause significant psychological impairment and stigma among women and their partners due to fear of acquiring sexually transmitted infections. Due to these reasons, many patients hesitate to get treatment, ended with a poor prognosis. Nonvenereal vulvar dermatoses comprises ulcers (Behcet’s disease, aphthous ulcer, fixed drug eruption, and Lipschutz ulcer), pigmentary disease (vitiligo, melanocytic nevi), eczematous and lichenified disease (contact dermatitis, lichen sclerosus, lichen planus, lichen simplex chronicus, and psoriasis), benign lesions (hemangioma, seborrheic keratosis, milia, lymphangioma, and sebaceous cyst), premalignant lesions (vulvar intraepithelial neoplasia, Paget’s disease), malignant lesions (squamous cell carcinoma, basal cell carcinoma, and melanoma). Although there are various case reports of nonvenereal female genital dermatoses, very few studies have been conducted in developing countries like India. Therefore, this has been conducted to give insight into clinical and epidemiological data.
Materials and Methods
This was a prospective, observational study conducted in the department of dermatology. This study was conducted among 50 female patients with nonvenereal disease of external genitalia over a period of July 2023 to July 2024.
Inclusion criteria
We included all women presenting with nonvenereal vulvar dermatoses in the study.
Exclusion criteria
Patients having a venereal disease (e.g., chancroid, syphilis, herpes genitalis, gonorrhea, Donovanosis, lymphogranuloma venereum, molluscum contagiosum, etc.) were excluded from the study.
Approval from the institutional ethics committee was obtained, and informed consent was collected from all patients. A comprehensive history was recorded, including age, socioeconomic status, skin-related symptoms (such as itching, discoloration, thickening, thinning, and erosion, ulceration), onset, duration, menstrual and pregnancy history, and associated conditions. Sexual history was assessed, and patients with venereal diseases were excluded. A thorough examination of the external genitalia and other body parts was conducted. Relevant investigations, including KOH mount and Gram stain, were performed. When necessary, a biopsy with histopathological analysis was done to confirm the diagnosis. Venereal disease research laboratory and HIV enzyme-linked immunosorbent assay tests were done to rule out sexually transmitted infections.
Results
A total of 50 female patients having nonvenereal disease of external genitalia were included in this study. The age of patients was ranging from 1 year to 60 years. Most of the patients belong to the 31–40 years of age group [Figure 1]. Out of 50 patients, 8 were pregnant, 12 were in the postmenopausal age group, and 4 were in the prepubertal age group.
Figure 1.
Patients presenting with different age groups
Thirty-two patients (64%) were living in rural and 18 patients (36%) were from urban areas. Twenty-seven patients (54%) were housewives, followed by laborers (15 cases, 30%), students (8 cases, 16%). Out of 50 patients, 25 patients (50%) were illiterate, followed by graduates (15 cases, 30%), having high school education (10 cases, 20%).
The most common presenting complaint was itching (26 cases, 52%), followed by redness (17 cases, 34%), and white lesions (14 cases, 28%) [Figure 2]. Duration of symptoms ranged from 1 month to 6 years.
Figure 2.
Number of patients presenting with complaint
The most common affected site was labia majora (19 cases, 38%) followed by labia minora (15 cases, 30%), introitus (8 cases, 16%), and mons pubis (6 cases, 12%). Plaque (52%) was the most common morphology in patients, followed by patch (36%), papule (8%). Majority of lesions were erythematous (15), depigmented (14), hyperpigmented (9), and violaceous gray (6). [Figure 3 and Table 1 shows percentage of patients presenting with different disorders].
Figure 3.
Percentage of patients presenting with each disorder
Table 1.
Nonvenereal diseases
| Dermatoses | Number of patients, n (%) |
|---|---|
| Inflammatory dermatoses (26) | |
| Lichen sclerosus et atrophicus | 9 (18) |
| Lichen simplex chronicus | 6 (12) |
| Lichen planus | 6 (12) |
| Psoriasis | 3 (6) |
| Irritant contact dermatitis | 2 (4) |
| Pigmentary disorder (12) | |
| Vitiligo | 9 (18) |
| Melanocytic nevi | 3 (6) |
| Benign tumor and cyst (4) | |
| Vulvar varicosity | 3 (6) |
| Lymphangioma circumscriptum | 1 (2) |
| Premalignant disorder (6) | |
| Bowenoid papulosis | 4 (8) |
| Vulvar intraepithelial neoplasia | 2 (4) |
| Malignant disorder (2) | |
| Squamous cell carcinoma | 1 (2) |
| Malignant melanoma | 1 (2) |
Three patients had vitiligo in other body areas, one patient had psoriasis in other body areas, and six patients had lesions of lichen planus in other body areas. Eighteen patients had regular menses, followed by postmenopausal (12), pregnant (8), irregular menses (6), and prepubertal (6).
Discussion
In literature, the vulva is referred to as “the forgotten pelvic organ.”[1] Severe psychological trauma and stigma are associated with genital diseases. Therefore, it is important to diagnose and treat nonvenereal diseases to relieve patients’ stress due to fear of sexually transmitted infections. Vulvar diseases are classified as vulvar dermatoses and vulvar dysesthesia by the international society for the study of vulvovaginal disease.[2] Vulvar dermatoses include inflammatory diseases (Lichen sclerosus et atrophicus, lichen simplex chronicus, psoriasis, lichen planus, etc.), autoimmune disease (vitiligo), exogenous (irritant contact dermatitis, drug reaction, etc.), benign, premalignant, and malignant conditions.
On analysis of demographic data, marital status, and occupation, the majority of patients were married (32 cases, 64%), among which it is more in homemakers (27 cases, 54%) followed by laborers (15 cases, 30%) which is similar to study by Pathak et al.[3]
The most common presenting complaint was itching (26 cases, 52%), followed by redness (17 cases, 34%), and white lesions (14 cases, 28%).
Among the inflammatory conditions, lichen sclerosus et atrophicus (9 cases, 18%) was more prevalent, followed by lichen simplex chronicus (6 cases, 12%) and lichen planus (6 cases, 12%), which is comparable to Fischer and Rogers, where lichen simplex et atrophicus (17%) and lichen simplex chronicus (17%) is reported.[4] Among patients having lichen sclerosus et atrophicus, dyspareunia is seen in four cases (44%). Two patients had erosive lichen planus, while the other four patients had hyperpigmented lichen planus.
Among pigmentary disorders, nine patients (18%) had vitiligo and 6% had melanocytic nevi. Among patients having vitiligo, three patients had isolated genital vitiligo, and six patients had involvement of other areas of the body.
Most of thyroid dysfunction is seen in lichen sclerosus et atrophicus (3 cases) and vitiligo (3 cases), followed by psoriasis (2 cases) and lichen planus (2 cases). Out of 50 patients, seven patients had diabetes mellitus. Four patients with psoriasis and three patients with lichen planus had diabetes mellitus.
Bhardwaj et al. showed significance of diagnosing nonvenereal vulvar dermatoses and challenges the common belief that all vulvar dermatoses among sexually active females are sexually transmitted. It also highlights that vulvar dermatoses encompass a broader range of dermatoses beyond sexually transmitted infections.[5]
The study done by Shinde and Popere was useful in understanding epidemiological, clinical, and etiological characteristics of nonvenereal vulvar dermatoses.[6]
Muktamani et al. showed localized genital involvement was found to be significant among nonvenereal dermatoses. This study was useful in diagnosis and management of nonvenereal vulvar dermatoses and differentiating them from venereal disease, which helps in mitigating guilt and fear among women.[7]
Conclusion
This study highlights the importance of the diagnosis of vulvar dermatoses. A multidisciplinary strategy is essential for the diagnosis of vulvar dermatoses. This approach typically involves collaboration between a dermatologist and a gynecologist, ensuring comprehensive evaluation and management for affected patients. The vulva is a difficult site for self-examination and to seek medical care for genital lesions leads to anxiety and fear, and may severely impair the quality of life of the patient in terms of increased morbidity and disturbed sexual function. Increasing awareness among females and encouraging them to seek medical help and avoid self-medication is important.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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