Some Vulvar Problems Nearly Unique to Girls


SAN FRANCISCO — Girls may present with vulvovaginal skin problems that are seldom or never seen in women, Dr. Libby Edwards said at a meeting sponsored by Skin Disease Education Foundation.

Vulvovaginal aphthae, pseudowarts, and infantile labial agglutination are nearly unique to girls, she said.

Aphthae (canker sores) are extremely common painful lesions in the mouths of adults but seldom appear on adult genitalia. Vulvar aphthae are very common in girls aged 10–18 years, however, whether or not they have oral aphthae.

“This is something that once you recognize it, you see it quite often,” said Dr. Edwards, a dermatologist in Charlotte, N.C., who has developed expertise in vulvovaginal disease.

Vulvar aphthae can be large or small, and typically are 5–20 mm in diameter, larger than oral aphthae that average 1–5 mm in diameter. Vulvar aphthae are well demarcated and red, usually with a white fibrin base. Typically, they are surrounded by significant inflammation, are very painful, and can scar. They usually appear on modified mucous membranes, and sometimes appear on keratinized skin.

Often vulvar aphthae are misdiagnosed as a sexually transmitted disease. They differ from herpes lesions by being deeper ulcerations rather than erosions, and usually are fewer in number than herpes lesions. Individual aphthae typically are much larger than the tiny round erosions of herpes. Aphthae differ from chancres (another sexually transmitted disease to consider) by the painful nature of aphthae and their lack of induration, Dr. Edwards said.

Aphthae often are preceded by fever, malaise, and sore throat, followed quickly by vulvar pain and ulcerations, suggesting that the aphthae are precipitated by a viral syndrome. Epstein-Barr virus may be one of many viral triggers of vulvar aphthae, she said.

The prodrome plus vulvar aphthae “doesn't make it Behçet's disease,” which is a chronic, systemic disease, she added. “Only if they have clinically objective eye, joint, or neurologic disease is it a symptom of Behçet's.”

Prescribe oral prednisone at a dose of 40 mg each morning for vulvar aphthae until pain ceases. If there are occasional, future episodes, parents can be ready to give a short burst of prednisone. Girls with frequent or ongoing vulvar aphthae will need suppressive anti-inflammatory therapy, starting with dapsone and moving to other agents if needed.

Pseudowarts—a unique nodular reaction to chronic irritation of anogenital skin—is also found by far more often in girls rather than women.

Usually caused by chronic incontinence (especially diarrhea), pseudowarts are bilaterally symmetrical, monomorphous, well-demarcated, flat-topped papules. They can be nearly skin colored or red with an eroded surface, Dr. Edwards said.

Also called Jacquet's diaper dermatitis or granuloma gluteale infantum, pseudowarts are diagnosed by appearance and setting. A biopsy in difficult cases will show squamous hyperplasia, spongiosis, hyperkeratosis, and sometimes erosion with associated acute and chronic inflammation.

Treat by removing the irritants, which can be challenging in a patient with chronic diarrhea or incontinence, she said. Don't use corticosteroids, which may cause irritation that contributes to formation of pseudowarts.

Infantile labial agglutination, not an uncommon finding in young girls, usually resolves before puberty as fragile, thin skin matures, Dr. Edwards said.

“It's not the labial minora agglutination we see with adults, where they're absorbed into the labia majora, but it's more midline,” and often more like adhesions than agglutination, she said. Occasionally, this can interfere with urine flow and cause dribbling, which may be misdiagnosed as incontinence.

If the parent insists on treatment, minimize irritants and massage the area with topical estrogen. If that doesn't work, use clobetasol, she said.

The cause of infantile labial agglutination is unknown. “I think it can be from irritation from anything. It's very often from very mild, unrecognized lichen sclerosus,” she said.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

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