Sir,
Vulvar vestibular papillomatosis (VVP) is an anatomic or functional variant of the normal genital mucosa commonly mistaken for genital warts. We report this case to highlight the need for dermato-venereologists to become familiar with this rare entity, thus avoiding unnecessary concerns and investigations, and to consider cryotherapy as a treatment modality in symptomatic cases.
A 21-year-old woman married for 1 year presented with small raised lesions on her vulva associated with pruritus of 6-month duration. She and her partner were in a monogamous relationship without any history of extramarital sexual contacts. Examination showed multiple, small, soft, shiny, smooth-surfaced, non-tender monomorphic papules 1–3 mm in diameter with bases separate from each other, colored same as that of adjacent mucosa, symmetrically distributed over inner aspect of labia minora and vestibule with negative acetowhite test [Figure 1]. These were the typical clinical findings of VVP. Dermatoscopy using Heine NC2 Dermatoscope (Heine Optotechnik, Herrsching, Germany; ×10 magnification, polarized mode) showed uniformly sized teardrop-shaped transparent juxtaposed papillae with separate bases with irregular vascular pattern in the core confirming the diagnosis.
Figure 1.
Multiple, small, soft, shiny, smooth-surfaced monomorphic papules with bases separate from each other, colored same as that of adjacent mucosa seen over inner aspect of labia minora
A single course of cryotherapy with liquid nitrogen spray gun consisting of three 15–20s freeze-thaw cycles delivered by open spray successfully removed majority of the lesions [Figure 2] without any long-term sequelae. The patient experienced mild pain and watery discharge after the procedure, which settled in 4–5 days. The patient was symptom free during 6 months of follow-up.
Figure 2.
Majority of the lesions cleared after single sitting of cryotherapy (photograph taken 1 month after treatment)
VVP, also known as pseudocondylomata, is now believed to represent a morphological variant of normal genital epithelium. Due to the clinical resemblance of VVP to genital wart, the former is often misdiagnosed or over diagnosed as human papillomavirus (HPV) infection, leading to inappropriate investigations and treatment. But distinction between the two entities has been well established by in situ hybridization and polymerase chain reaction studies.[1,2] Clinical, dermatoscopic, and histopathological findings differentiating the two conditions have been summarized in Table 1.[1,3,4] Our case satisfied the clinical criteria of VVP suggested by Moyal-Barracco et al.,[1] which was confirmed dermatoscopically; hence, investigations such as biopsy and HPV testing were avoided.
Table 1.
Clinical, dermoscopic, and histopathological differences between vestibular papillomatosis and condylomata acuminata
| Features | Vestibular papillomatosis | Condylomata acuminata |
|---|---|---|
| Sites involved | Confined to the vestibule | Not confined to the vestibule, can occur anywhere on genitalia or in the anal region |
| Distribution | Symmetrical or linearly arranged | Usually asymmetrical and randomly arranged |
| Color | Pink, same as adjacent mucosa | Pink, red, white or hyperpigmented |
| Surface | Smooth and shiny | Rough and irregular |
| Base | Individual lesions remain separate at the base | Individual lesions fuse at the base |
| Shape of individual lesion | Teardrop shaped | Cauliflower or broccoli shaped |
| Consistency | Soft | Firm to hard |
| 5% Acetic acid test | No whitening | Whitening present |
| Dermoscopic findings | Abundant, irregular linear vascular channels in transparent core of uniform-sized cylindrical papillae with bases separate from each other | Conglomerate vascular structures within multiple, irregular projections with tapering ends that are broader and more white than vestibular papillae, arising from a common base |
| Histopathology | Normal mucosal epithelium covering finger-like protrusion of loose connective tissue. Some vacuolated cells resembling koilocytes may occur, as heavily glycogenated epithelial cells in genital mucosa get vacuolated during tissue processing. These cells are confined to upper layers of mucosal epithelium | Hyperkeratosis, parakeratosis, papillomatosis, and acanthosis. Large epithelial cells with perinuclear vacuolization and hyperchromatic, round nuclei extending into the deeper portions of stratum malpighii. Presence of koilocytes |
Asymptomatic and symptomatic variants of VVP have been observed. Latter variant is associated with symptoms such as vulvar pruritus, burning, and dyspareunia, which makes the patient anxious interfering with their sexual activity and work.[5] For patients with asymptomatic lesions, reassurance regarding benign nature of the condition would be sufficient. However, for patients with excessive concern desiring removal or those presenting with symptomatic lesions, we propose cryotherapy as a promising treatment option as our patient gave an encouraging result. Our patient has been kept under follow-up to assess any regrowth or development of new lesions.
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Conflicts of interest
There are no conflicts of interest
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