Angiokeratoma of Vulva Mimicking Genital Warts

Abstract

Angiokeratoma of vulva is a relatively rare lesion which is occasionally misdiagnosed as melanoma, pyogenic granuloma, seborrheic keratosis, or genital warts. We report a case of vulvar angiokeratomas which were diagnosed and managed as genital warts. All asymptomatic dull red-colored papules over vulva should be subjected to astute clinical and histological examination to diagnose angiokeratoma and differentiate it from other lesions.

Introduction

Angiokeratomas are benign cutaneous lesions consisting of numerous ectatic blood vessels present in the superficial dermis [1]. Angiokeratoma is usually seen over scrotum and can rarely involve vulva [1, 2]. Majority of these lesions are asymptomatic but occasionally can be associated with pruritus, bleeding or dyspareunia. Asymptomatic angiokeratoma can be managed conservatively, while symptomatic cases can be treated with various destructive modalities [1, 2].

Case Report

A 35-year-old-multiparous woman was referred to the sexually transmitted disease clinic for genital lesions of 6 months duration. She had complaints of occasional pruritus but denied history of chronic constipation or varices. There was no history of high risk behavior in patient or spouse. She reported having had two children by uncomplicated vaginal delivery. She had been treated previously by many physicians as a case of genital warts with multiple topical applications of 25 % podophyllin resin and imiquimod 5 % cream with no improvement.

On examination she had multiple dusky erythematous papules of size <0.5 cm present over labia majora and surrounding perineal region (Fig. 1). On puncturing the papule with sterile needle, there was profuse bleeding that stopped after sustained pressure. The remaining mucocutaneous, genital, and systemic examinations were unremarkable with no evidence of varices or venous hypertension in the patient. She had been subjected to serology for Human Deficiency Virus (HIV 1 and 2), Hepatitis B surface antigen, anti-HCV, herpes serology 1 and 2, and VDRL which were all negative. Excisional biopsy from lesion revealed numerous dilated, thin walled, congested capillaries in the papillary dermis with overlying epidermis showing variable degree of acanthosis, elongation of the rete ridges, and hyperkeratosis (Fig. 2). Thus, the diagnosis of angiokeratoma of fordyce of vulva was made. Patient was counseled about the disease and her lesions were treated with radiofrequency ablation. She had complete resolution with no recurrence observed for 1 year.

Fig. 1.

Multiple dusky erythematous papules size (<0.5 cm) present over labia majora and the surrounding perineal region

Fig. 2.

Histopathological section of lesion revealed hyperkeratotic and acanthotic epidermis with ectatic vascular channels in papillary dermis.( hematoxylin & eosin X 100)

Discussion

Angiokeratomas are benign vascular lesions which may be localized or diffuse. Among the localized forms, angiokeratomas of scrotum are the most common. Analogous to angiokeratoma of scrotum, vulvar lesions present as erythematous papules affecting women between 20 and 40 years [2]. Various factors implicated in the pathogenesis of angiokeratoma of vulva include use of contraceptive pills, localized venous hypertension due to varicocele, obesity, and phlebectasia associated with chronic inflammation, radiotherapy, and hysterectomy [1, 2]. Dermatoscopy and confocal microscopy are useful non-invasive techniques which differentiate angiokeratoma from melanoma, pyogenic granuloma, and angiosarcoma with variable success [1, 2]. Biopsy of angiokeratomas is important for confirmation of diagnosis as these lesions clinically resemble genital warts, malignant melanoma, and seborrheic keratosis. The histopathological examination of these lesions showed varying degree of compact hyperkeratosis, acanthosis, and papillomatosis, and the presence of ectatic vascular channels in papillary dermis [1, 2]. Majority of these lesions are asymptomatic and can be managed conservatively. In the presence of symptoms like bleeding or dyspareunia, these lesions can be treated by cryotherapy, radiofrequency, laser ablation, chemical cauterization, or surgical excision [1, 2].

Angiokeratoma of vulva being rare is commonly misdiagnosed as genital warts or malignant vascular tumor. Patients are usually subjected to multiple examinations and investigations including serological tests to rule out sexually transmitted diseases. Many times these lesions are treated as genital warts, thus subjecting patients to physical, psychological, and financial stress. Thus, it is of great importance to consider angiokeratoma in the differential diagnosis of asymptomatic dull red-colored papules over vulva.