Persistent Erythematous Lesion of the Vulva: A Diagnostic and Treatment Challenge

January 2012 | Volume 11 | Issue 1 | Case Report | 110 | Copyright © 2012

Elizabeth Lazaridou MD PhD, Christina Fotiadou MD, Christina Giannopoulou MD, Demetrios Ioannides MD PhD

Aristotle University Medical School, Thessaloniki, Greece

Abstract

The painful, erythematous and eroded vulva often proves to be a diagnostic problem both clinically and histologically. Its differential diagnosis includes both non-neoplastic and neoplastic diseases like Bowen's disease and squamous cell carcinoma (SCC). We report the case of a 62-year-old woman diagnosed, after considerable delay, with Bowen's disease of the vulva that eventually progressed to invasive SCC, despite the treatment with imiquimod 5% cream. Our case indicates, on one hand, that dermoscopy could contribute to the accuracy of the pre-operative clinical diagnosis. On the other hand it confirms the fact that treatment of Bowen's disease of the vulva could be rather intriguing. Although imiquimod 5% cream is an effective, non-invasive treatment option for large lesions or poor healing sites, it should be administered with great consideration in carefully selected cases.

J Drugs Dermatol. 2012;11(1):110-112.

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INTRODUCTION

The painful, erythematous, and eroded vulva often poses a serious diagnostic and treatment challenge for medical practitioners who deal with the problems arising in this anatomical region. As such, these disorders may frequently be overlooked and improperly treated.

CASE REPORT

We report a 62-year-old female patient who visited our department for further evaluation of a red, shiny, mildly painful, erosive plaque with a diameter of approximately 2 cm, located on the perineum, involving mainly the left labia majoris (Figure 1). The lesion appeared six years ago without any previous history of an HPV infection. A biopsy at that time could not reach a certain diagnosis. Without any treatment the lesion slowly enlarged. A second biopsy two years later exhibited histologic findings consistent with Bowen's disease of the vulva. Over the last two-year period, the patient was under intermittent treatment with imiquimod cream 5%, three times weekly. The lesion did not show any improvement, and the patient interrupted treatment complaining of intense local irritation.

A dermoscopic evaluation of the lesion was indicative of its neoplastic nature. It revealed multiple polymorphous vessels and an unspecific global pattern, findings consistent with squamous cell carcinoma (SCC) (Figure 2). A third biopsy verified the diagnosis of SCC, showing abnormal acanthosis of the epidermis with an elongation that extended down to the deep dermis and many keratinocytes with "windblown" appearance and atypical, enormous, hyperchromatic nuclei (Figure 3).

The patient was referred to the surgical department for further treatment.

DISCUSSION

Numerous vulvar dermatoses encompass the full spectrum of differential diagnosis of the erythematous vulva including both non-neoplastic epithelial diseases (i.e., lichen planus, lichen sclerosus, lichen simplex chronicus, irritant, and allergic contact dermatitis) and neoplastic ones like Bowen's disease of the vulva, extramammary Paget's disease, and SCC.

Histopathology still holds the key for the definitive diagnosis of all vulvar diseases, although dermoscopy may contribute to the accuracy of the clinical diagnosis.1,2 Up to date, dermoscopy has been applied for the evaluation of skin Bowen's disease but it has not been used for the diagnosis of erythematous genital lesions.3,4 Unfortunately, in our case it was not performed in the first place in order to compare the initial findings which would have been probably consistent with Bowen's disease (i.e., glomerular vessels).4 However, the disclosure of features like the

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