The Clinicopathologic Challenge of Nonneoplastic Vulvar Acanthosis.

OBJECTIVE: The aim of the study was to evaluate clinicopathologic features of cases demonstrating an acanthotic tissue reaction not clearly consistent with psoriasis, lichen simplex chronicus, mycosis, or condyloma. MATERIALS AND METHODS: This is a retrospective pathologic case series of biopsies reported as "benign acanthotic lesion" and "acanthotic tissue reaction" that lacked a clear diagnosis on expert review. Cases with nuclear atypia were excluded. Clinical and histopathologic data were collected, immunohistochemistry for p16 and p53 were obtained, and molecular testing for 28 common anogenital human papillomavirus (HPV) genotypes was undertaken. RESULTS: There were 17 cases with a median age of 47 years. Unilaterality and medial location were clinical reasons for diagnostic difficulty. Histopathologic uncertainty often related to lack of papillary dermal fibrosis to support lichen simplex chronicus or psoriasiform lesions without parakeratosis, subcorneal pustules, and/or mycotic elements. Firm pathologic diagnoses were not possible, but 3 groups emerged: favoring chronic dermatitis, favoring psoriasis, and unusual morphologies. p16 results were negative or nonblock positive while p53 was normal or basal overexpressed. Human papillomavirus testing was negative in 12, low positive for HPV 16 in 1, unassessable in 3, and not requested in 1. CONCLUSIONS: There is a group of acanthotic tissue reactions that cannot be classified with standard histopathologic assessment. Further clinicopathologic research into unilateral acanthotic lesions may provide insight into separation of psoriasis and mycosis when organisms are absent. Once nuclear atypia is excluded, immunohistochemistry for p16 and p53 and HPV molecular testing do not assist in diagnostic identification.

Erosive Lichen Sclerosus-A Clinicopathologic Subtype.

OBJECTIVE: The aim of the study was to identify whether erosive lichen sclerosus (LS) is a distinct clinicopathologic subtype. MATERIALS AND METHODS: The pathology database was searched for "erosion," "erosive," "ulcer," and "lichen sclerosus." Inclusion criteria were histopathologic diagnosis of LS and erosion or ulcer overlying a band of hyalinization and/or fibrosis. Exclusions were concurrent neoplasia and insufficient tissue. Histopathologic review documented site, epithelial thickness, adjacent epidermal characteristics, infiltrate, and dermal collagen abnormality. Clinical data included demographics, comorbidities, examination findings, microbiologic results, treatment, and response. RESULTS: Ten examples of erosive LS and 15 of ulcerated LS occurred in 24 women with a mean age of 67 years. Ulcerated LS was associated with diabetes and nontreatment at time of biopsy. Clinicians identified red patches in all but 1 case of erosive LS. Ulcerated LS was documented as fissure, ulcer, or white plaque, with 8 (53%) described as lichenified LS with epidermal breaches. Erosive LS favored hairless skin with normal adjacent stratum corneum sloping gently into erosion, whereas most ulcers in LS had an abrupt slope from hair-bearing skin. All cases were treated with topical steroids; 2 patients with erosive LS and 10 with ulcerated LS also had oral antifungals, topical estrogen, antibiotics, and/or lesional excision. Treatment yielded complete resolution in 50%. CONCLUSIONS: Erosive LS is an unusual clinicopathologic subtype characterized by red patches on hairless skin seen microscopically as eroded epithelium overlying a band of hyalinized or fibrotic collagen. In contrast, ulcerated LS is usually a traumatic secondary effect in an uncontrolled dermatosis.

Vestibulovaginal Sclerosis Versus Lichen Sclerosus.

To determine if vestibulovaginal sclerosis and lichen sclerosus (LS) are 2 distinct entities. Biopsies obtained from the vagina or vulvar vestibule that contained abnormal subepithelial collagen were reviewed. Cases were categorized either as LS or vestibulovaginal sclerosis based on presence or absence of basal layer degeneration and lymphocytic infiltrate. Clinical data collected included examination findings, biopsy site and indication, previous vulvovaginal surgery, medications at time of biopsy, vulvar LS, treatment, and response. There were 15 cases with a mean age of 62 yr (range: 32-86 yr); 12 (80%) specimens were from vestibule and 3 from vagina. Nine cases were categorized as LS because of lymphocytic infiltrate in combination with basal layer degeneration, of these 8 had LS elsewhere on vulvar skin. Six cases were classified as vestibulovaginal sclerosis and had an absent or sparse lymphocytic infiltrate and essentially normal epithelium; none of these had vulvar LS. While vestibulovaginal sclerosis and lichen sclerosus are distinguishable clinically and histopathologically, further studies are needed to determine if vestibulovaginal sclerosis is a subset of LS or a different condition.

Interpretation of Nondiagnostic Vulvar Biopsies.

OBJECTIVE: The aim of the study was to assess clinical and histopathologic characteristics of symptomatic women who underwent a nondiagnostic biopsy of the inner vulva. MATERIALS AND METHODS: Consecutive nondiagnostic biopsies from medial labia minora, posterior fourchette, and vestibule obtained from symptomatic women between 2011 and 2015 were reviewed for this retrospective histopathologic case series. Histopathologic assessment included site, basal layer appearance, lymphocytic infiltrate, and presence of fibrosis or sclerosis. Examination findings, treatment, initial impression, and final clinical diagnosis were recorded. Descriptive statistics were performed; clinical and histopathologic characteristics were compared with Fisher exact test. RESULTS: There were 85 cases; mean age was 53 years. Most women presented with painful erythema and underwent biopsy to confirm (30, 35%) or exclude (43, 51%) lichen planus. After clinical follow-up and histopathologic review, most cases had persistent diagnostic discordance. Final clinical diagnoses were available in 70 women: lichen planus in 27 (38%), vulvodynia in 15 (21%), and the other 28 (40%) had LS (8), plasma cell vulvitis (5), psoriasis (4), dermatitis (4), candidosis (3), estrogen deficiency (3), and aphthosis (1). Histopathologic review highlighted the difficulty in distinguishing mucosa-associated lymphoid tissue from an inflammatory infiltrate in 23 (27%) of cases. Compared with other sites, biopsies from the mucocutaneous junction were more likely to be associated with a positive culture for Candida albicans. CONCLUSIONS: Nondiagnostic biopsies from the inner vulva should prompt thoughtful multidisciplinary review, but more research is required to resolve the problem of clinicopathologic discordance through better understanding of vulvar histology and pathophysiology.

Pathogenicity of non-albicans yeasts in the vagina.

OBJECTIVE: It is hypothesized that vaginal non-albicans yeasts (NAYs) do not require treatment. The objective was to determine whether women (presenting with a range of vulvovaginal complaints) found to be harboring NAY, which is left untreated (no antifungals), have similar clinical outcomes to women with comparable presentations but who do not harbor NAY. DESIGN: This is a case-control study design comparing patient outcomes between women with untreated non-albicans Candida on vaginal swab cultures and those who were swab culture-negative. SETTING: A Melbourne metropolitan, private gynecologic and obstetric practice. POPULATION: Women presenting with vulvovaginal symptoms or management of pregnancy, who attended the above practice between 2001 and 2006. METHODS: Fifty-two women were found to have NAY on culture of their vaginal swabs. They were prospectively studied to determine the effect of leaving the NAY untreated (no antifungals) but with appropriate attention to their other diagnoses. Seventy-eight symptomatic women with negative swab cultures were used as the comparison group, and descriptive statistics was computed to compare patient outcomes between the groups. A subanalysis was also carried out, only looking at women who presented with pruritus. MAIN OUTCOME MEASURE: Proportion of patients self-reporting improvement in symptoms. RESULTS: Of the 44 women with NAY who presented with symptoms, 86% reported experiencing improvement. Approximately 77% of the women in the comparative group reported improvement. CONCLUSIONS: Non-albicans yeasts found on culture of a vaginal swab can probably be ignored. The clinician's efforts should be concentrated on making a correct diagnosis without assuming that NAY are pathogenic.

Cytology in the differential diagnosis of vaginitis.

Vaginal discharge, vulvar pruritus, and dyspareunia are among the most common symptoms that prompt women to seek medical advice. They are frequently assumed to be due to vaginitis resulting from infection and are treated with anti-infective agents without further investigation. Such empirical treatment may be successful, but on the frequent occasions when such treatment is inappropriate, the stage is set for deteriorating genital health. I believe that most cases of "vulvodynia" could be prevented by a correct diagnosis and treatment at the onset of symptoms.