Benign vulvar vestibular papillomatosis

An underreported condition in Indian dermatological literature

Sir,

A 26-year-old lady had noticed “small growths” on vulva since one year of her marriage. She had also experienced burning sensation, irritation, and pain in vulva on many occasions over the past one year. She was anxious and depressed because these symptoms interfered with her work and sexual activity. Her husband likened the appearance of her vulval lesions to a “broccoli.” She was in a monogamous relationship and had no past history of sexual contacts. Examination revealed multiple, small, uniformly arranged, soft, smooth-surfaced, monomorphic micropapillae covering the inner aspect of labia minora and the vestibule [Figures 1 and 2]. Color of the lesions was the same as that of the adjacent mucosa. Lesions were tender. A provisional diagnosis of vestibular papillomatosis (VP) with vulvar vestibulitis syndrome (VVS) was made. On vulval biopsy, we could see finger-like protrusions of loosely arranged subdermal tissue covered with normal mucosal epithelium [Figure 3]. No atypical koilocytes were identified. PCR for human papilloma virus (HPV) DNA was negative.

Figure 1: Uniformly arranged, monomorphic, symmetric papillae on inner labia and vestibule (arrows and encircled area)

Figure 2: Vestibular micropapillae with separate bases and symmetric arrangement on inner labia (arrows and encircled area)

Figure 3: Digitate structures of loosely arranged subdermal tissue covered by normal mucosal epithelium (H and E, ×40)

Vestibular papillomatosis (VP) is considered a normal flexibility in topography and morphology of the vulvar epithelium. Prevalence reported in various studies has ranged between 1–33%.[¹²³] In past, papillary projections of the inner labia have been overdiagnosed as caused by HPV infection. Careful identification of clinical parameters of VP—clusters of pink, soft, uniformly arranged tubular papillae on inner labia, hymen, or periurethral area with round tips, separate bases, and lack of circumscribed whitening on 5% acetic acid application—is diagnostic.[⁴] On the other hand, genital warts are skin-colored or pigmented, randomly arranged, firm, acuminate papules—individual papillary projections fuse at the base—with prominent whitening on 5% acetic acid application.[⁴] The fact that VP is distinct from genital warts has also been well-established by PCR and in-situ hybridization studies.

VP is asymptomatic in majority of affected females, however, vulvar pruritus, pain, burning, and dyspareunia may accompany in some patients.[⁵] Coexisting, VVS has also been reported, which is defined as severe pain on vestibular touch or vaginal entry and tenderness located within the vulvar vestibule.[⁶] The feeling of irritation and burning can persist for hours or days following sexual activity, engendering a sense of hopelessness and depression in the patient.[⁶]

A female with VP may be referred to a dermatologist for treatment of suspected genital warts. Therefore, it is imperative that dermatologists are familiar with this condition in order to avoid unnecessary treatment. However, there has been a scarcity of literature about this rare entity in the Indian dermatological scenario, highlighting an apparent disregard for this potentially misdiagnosed entity.

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